Essentials of Anatomy, 2nd Edition

ESSENTIALS OF ANATOMY
Second Edition
INDERBIR SINGH
Professor Emeritus
52, Sector One, Rohtak 124001
JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD.

New Delhi Ahmedabad Bengaluru Chennai Hyderabad
Kochi Kolkata Lucknow Mumbai Nagpur
Published by
Jitendar P Vij
Jaypee Brothers Medical Publishers (P) Ltd
Corporate Office
4838/24 Ansari Road, Daryaganj, New Delhi - 110002, India
Phone: +91-11-43574357
Registered Office
B-3 EMCA House, 23/23B Ansari Road, Daryaganj, New Delhi - 110 002 India,
Phones: +91-11-23272143, +91-11-23272703, +91-11-23282021
+91-11-23245672, Rel: +91-11-32558559, Fax: +91-11-23276490
+91-11-23245683, e-mail: jaypee@jaypeebrothers.com
Visit our website: www.jaypeebrothers.com
Branches
2/B, Akruti Society, Jodhpur Gam Road Satellite
Ahmedabad 380 015, Phones: +91-79-26926233, Rel: +91-79-32988717, Fax: +91-79-26927094
e-mail: ahmedabad@jaypeebrothers.com
202 Batavia Chambers, 8 Kumara Krupa Road, Kumara Park East
Bengaluru 560 001, Phones: +91-80-22285971, +91-80-22382956, 91-80-22372664
Rel: +91-80-32714073, Fax: +91-80-22281761
e-mail: bangalore@jaypeebrothers.com
282 IIIrd Floor, Khaleel Shirazi Estate, Fountain Plaza, Pantheon Road
Chennai 600 008, Phones: +91-44-28193265, +91-44-28194897, Rel: +91-44-32972089, Fax: +91-44-28193231
e-mail: chennai@jaypeebrothers.com
4-2-1067/1-3, 1st Floor, Balaji Building, Ramkote Cross Road
Hyderabad 500 095, Phones: +91-40-66610020, +91-40-24758498, Rel:+91-40-32940929, Fax:+91-40-24758499
e-mail: hyderabad@jaypeebrothers.com
No. 41/3098, B & B1, Kuruvi Building, St. Vincent Road
Kochi 682 018, Kerala, Phones: +91-484-4036109, +91-484-2395739, +91-484-2395740
e-mail: kochi@jaypeebrothers.com
1-A Indian Mirror Street, Wellington Square
Kolkata 700 013, Phones: +91-33-22651926, +91-33-22276404, +91-33-22276415, Rel: +91-33-32901926
Fax: +91-33-22656075, e-mail: kolkata@jaypeebrothers.com
Lekhraj Market III, B-2, Sector-4, Faizabad Road, Indira Nagar
Lucknow 226 016 Phones: +91-522-3040553, +91-522-3040554
e-mail: lucknow@jaypeebrothers.com
106 Amit Industrial Estate, 61 Dr SS Rao Road, Near MGM Hospital Parel
Mumbai 400 012, Phones: +91-22-24124863, +91-22-24104532, Rel: +91-22-32926896, Fax: +91-22-24160828
e-mail: mumbai@jaypeebrothers.com
KAMALPUSHPA 38, Reshimbag, Opp. Mohota Science College Umred Road,
Nagpur 440 009 (MS), Phone: Rel: +91-712-3245220
Fax: +91-712-2704275, e-mail: nagpur@jaypeebrothers.com
USA Office
1745, Pheasant Run Drive, Maryland Heights (Missouri), MO 63043, USA
Ph: 001-636-6279734 e-mail: jaypee@jaypeebrothers.com, anjulav@jaypeebrothers.com
Essentials of Anatomy
2009, Inderbir Singh
All rights reserved. No part of this publication should be reproduced, stored in a retrieval system, or transmitted in any form or by any means:
electronic, mechanical, photocopying, recording, or otherwise, without the prior written permission of the author and the publisher.
This book has been published in good faith that the material provided by author is original. Every effort is made to ensure accuracy of
material, but the publisher, printer and author will not be held responsible for any inadvertent error(s). In case of any dispute, all legal
matters are to be settled under Delhi jurisdiction only.
First Edition: 2002

Second Edition: 2009
ISBN 978-81-8448-461-8
Typeset at JPBMP typesetting unit
Printed at Gopsons Papers Ltd, A-14, Sector 60, Noida 201 301, India
Preface to the Second Edition
The principles that guided the preparation of the first edition remain valid today. With great squeezing of the
time available for study of anatomy, shorter books are the need of the hour.
In this edition the language has been greatly improved. Errors have been corrected. Almost all the illustrations
have been improved.
I thank the publishers and readers of this book for their support.
2008 INDERBIR SINGH
Preface to the First Edition
This book is a condensed version of the authors three volume Textbook of Anatomy. It has been produced in
response to the reduced time available for the study of Anatomy consequent to the decision of the Medical
Council of India to reduce the period of the first professional MBBS course from 18 months to 12 months.
Different teachers will doubtless have their own views on what to teach (or more importantly, what not to
teach) under the new circumstances. The facts included, or not included, are based on my personal view. The
main features that I have decided to omit are as follows.
1. A great deal of time is spent on the study of osteology. I feel that the practice of enumerating attachments on
individual bones should be done away with as these are considered when the relevant muscles or ligaments are
described. Details of individual bones of the skull, or of small bones of the hand and foot have been omitted.
2. I have excluded all references to ossification of bones. These are necessary for determination of age which
will be required to be done only by experts in forensic medicine.
3. A great deal of time is spent in mugging up lists of relations of various structures. I have included only the
most important relationships.
4. I have omitted all detail that should, in my opinion, be studied only by postgraduate students in Anatomy or
in specific clinical disciplines.
It is obvious that, by its very nature, the selection of contents is likely to generate many objections or suggestions.
I have a very open mind on the issue and will welcome comments and suggestions. My overall effort has been
to present Anatomy in a relatively small volume while retaining all essential facts. I feel that any student who
knows what is given in this book will have no difficulty in doing well in the first professional MBBS examination,
and should have a sufficient knowledge of Anatomy for intelligent study of clinical subjects of the medical
curriculum. However, those who need a more detailed text, or more illustrations, are advised to consult the
authors three volume textbook.
June 2001
INDERBIR SINGH
Contents
PART 1: UPPER EXTREMITY
1. Some Descriptive Terms --------------------------------------------------------------------------- 2

2. Bones of the Upper Extremity -------------------------------------------------------------------- 4
3. Pectoral Region, Axilla and Breast --------------------------------------------------------------- 18
4. The Back and Scapular Region ------------------------------------------------------------------- 26
5. Superficial Nerves and Veins: The Arm and Cubital Fossa ---------------------------------- 33
6. The Forearm and Hand ---------------------------------------------------------------------------- 42
7. Joints of the Upper Limb ------------------------------------------------------------------------- 65
8. Surface Marking of Some Structures
and Clinical Correlations of the Upper Limb -------------------------------------------------- 71
PART 2: LOWER EXTREMITY
9. Bones of the Lower Limb ------------------------------------------------------------------------- 78

10. Front and Medial Side of Thigh ---------------------------------------------------------------- 100
11. Gluteal Region, Back of Thigh, Popliteal Fossa --------------------------------------------- 117
12. Front and Lateral Side of Leg: Dorsum of Foot --------------------------------------------- 130
13. Back of Leg and Sole ----------------------------------------------------------------------------- 139
14. Joints of the Lower Limb ----------------------------------------------------------------------- 152
15. Surface Marking and Clinical Correlations of Lower Limb -------------------------------- 160
PART 3: THORAX
16. Bones and Joints of the Thorax ---------------------------------------------------------------- 165

17. Walls of the Thorax ------------------------------------------------------------------------------ 174
18. The Thoracic Cavity, Trachea, Bronchi and Lungs ----------------------------------------- 184
19. The Heart and Pericardium --------------------------------------------------------------------- 194
20. Blood Vessels of the Thorax -------------------------------------------------------------------- 202
21. The Oesophagus, The Thymus. Lymphatics and Nerves of the Thorax ---------------- 209
22. Surface Marking and Clinical Correlations of the Thorax ---------------------------------- 218
PART 4: ABDOMEN AND PELVIS
23. Introduction to the Abdomen: Bones and Joints -------------------------------------------- 223

24. Anterior Abdominal Wall ------------------------------------------------------------------------ 230
25. The Perineum and Related Genital Organs --------------------------------------------------- 241
26. Oesophagus, Stomach and Intestines --------------------------------------------------------- 250
27. The Liver, Pancreas and Spleen ---------------------------------------------------------------- 258
28. Blood Vessels of Stomach, Intestines, Liver, Pancreas and Spleen ----------------------- 265
29. Kidney, Ureter, Suprarenal Gland ------------------------------------------------------------- 269
30. Posterior Abdominal Wall and Some Related Structures ----------------------------------- 273
31. Walls of the Pelvis ------------------------------------------------------------------------------- 282
32. Pelvic Viscera and The Peritoneum ------------------------------------------------------------ 287
33. Lymphatics and Autonomic Nerves of Abdomen and Pelvis ------------------------------ 298
34. Surface Marking and Clinical Correlations of Abdomen and Pelvis ---------------------- 304
PART 5: HEAD AND NECK
35. Bones of the Head and Neck ------------------------------------------------------------------- 315

36. Scalp, Face, Parotid Region and Lacrimal Apparatus --------------------------------------- 333
37. Temporal and Infratemporal Regions --------------------------------------------------------- 339
38. The Submandibular Region and Tongue ------------------------------------------------------- 344
39. Cranial Cavity and Vertebral Canal: Joints of the Head and Neck ------------------------ 350
40. Muscles and Triangles of the Neck: Deep Cervical Fascia -------------------------------- 358
41. Blood Vessels of Head and Neck -------------------------------------------------------------- 366
42. Nerves of Head and Neck ---------------------------------------------------------------------- 382
43. Orbit, Eye and Ear ------------------------------------------------------------------------------- 402
44. Oral Cavity, Nasal Cavity, Pharynx, Larynx, Trachea, Oesophagus --------------------- 416
45. Endocrine Glands of Head and Neck ---------------------------------------------------------- 429
46. Lymphatics of Head and Neck ----------------------------------------------------------------- 433
47. Surface Marking and Some Clinical Correlations -------------------------------------------- 437
PART 6: CENTRAL NERVOUS SYSTEM
48. Gross Anatomy of the Brain ------------------------------------------------------------------- 444

49. Tracts of Spinal Cord and Brainstems: Cerebellar Connections -------------------------- 458
50. Internal Structure of Brainstem ---------------------------------------------------------------- 467
51. Diencephalon, Basal Ganglia, Olfactory Region and Limbic System -------------------- 474
52. Internal Capsule, Commissures: Pathways for Special Senses ---------------------------- 482
53. The Ventricles of the Brain and Cerebrospinal Fluid --------------------------------------- 488
54. Blood Supply of the Brain ---------------------------------------------------------------------- 493
Index ------------------------------------------------------------------------------------------------------ 499

2
PART 1:UPPER EXTREMITY
1 : Some Descriptive Terms

MAIN SUBDIVISIONS OF
THE HUMAN BODY
For convenience of description the human body is divided

into a number of major parts. Many of the parts bear names
with which the student would be already familiar, but even
some of these may require more precise definition.
The uppermost part of the body is the head. The face is
ESSENTIALS OF ANATOMY : UPPER EXTREMITY
part of the head (and includes the region of the forehead,

the eyes, the nose, the cheeks and the chin). Below the
Fig. 1.1. Scheme to explain the terms anterior, posterior,
head there is the neck. Note that the junction of the head
superior, and inferior.
with the neck is oblique because the neck extends higher
up on the back than in front. Below the neck, there is the
region that a lay person calls the chest. In anatomical
terminology the chest is referred to as the thorax. The thorax
is in the form of a bony cage within which the heart and
lungs lie. Below the thorax, there is the region commonly
referred to as stomach or belly. Its proper name is
abdomen. The abdomen contains several organs of vital
importance to the body. Traced downwards, the abdomen
extends to the hips. A part of the abdomen present in the
region of the hips is called the pelvis.
The head and neck, the thorax and the abdomen together
form the trunk. Attached to the trunk there are the upper Fig. 1.2. Scheme to explain the terms medial, lateral
and lower limbs, or the upper and lower extremities. In and median.
relation to the upper limb the terms shoulder, elbow, wrist,
hand, palm, fingers and thumb will be familiar. A lay
person frequently refers to the entire upper limb as the arm,
but in anatomy we use this term only for the region between
the shoulder and elbow. The region between the elbow and
wrist is the forearm. The fingers and thumb are also called
digits.
In the lower limbs the terms hip, knee, ankle, foot and
toes will be familiar. The region between the hip and the
knee is the thigh, and that between the knee and the ankle
is the leg. Like the fingers the toes are also called digits.
The innermost, and largest toe, is the great toe.
Fig. 1.3. Scheme showing median and paramedian planes.

SOME COMMONLY USED We have seen that a plane passing vertically through the
SOME DESCRIPTIVE TERMS

DESCRIPTIVE TERMS midline of the body, so as to divide it into right and left
halves, is called the median plane. It is also called the mid-
sagittal plane. Vertical planes to the right or left of the median
In the study of Anatomy special terms are used for precise
descriptions of the mutual relationships of various structures plane, and parallel to the latter, are called paramedian or
within the body. In describing such relationships the lay person sagittal planes (Fig. 1.3). A vertical plane placed at right
uses terms like in front, behind, above, below etc. angles to the median plane (dividing the body into anterior
However, in a study of anatomy, such terms are found to be and posterior parts) is called a coronal plane or a frontal
inadequate; and the students first task is to become familiar plane. Planes passing horizontally across the body (i.e., at
with the specialised terms used. right angles to both the sagittal and coronal planes) and
The relationships within the body are always described dividing it into upper and lower parts, are called transverse
presuming that the person is standing upright, looking directly or horizontal planes.
forwards, with the arms held by the sides of the body, and with
the palms facing forwards. This posture is referred to as the STRUCTURES CONSTITUTING THE
anatomical position. Some descriptive terms are as follows.
HUMAN BODY
1. When structure A lies nearer the front of the body as
compared to structure B, A is said to be anterior to B (Fig.1.1).
The opposite of anterior is posterior. In the above example, it When we dissect up any part of the body we encounter
follows that B is posterior to A. various elements. The basic framework of the body is
2. When structure C lies nearer the upper end of the body as provided by a large number of bones that collectively form
compared to structure D, C is said to be superior to D (Fig. the skeleton. Bones meet each other at joints, many of which
1.1). The opposite of superior is inferior. In the above example allow movements to be performed. At joints bones are united
D is inferior to C. to each other by fibrous bands called ligaments. Overlying
3. The body can be divided into two equal halves, right and (and usually attached to) bones we see muscles. Muscles
left, by a plane passing vertically through it. The plane provide power for movements. A typical muscle has two
separating the two halves is called the median plane (Fig. 1.2). ends one called the origin, and the other called the insertion.
When structure E lies nearer the median plane than structure Quite often the muscle fibres end in cord like structures
F, E is said to be medial to F. The opposite of medial is lateral. called tendons. Sometimes a muscle may end in a flat fibrous
In the above example F is lateral to E. When a structure lies membrane. Such a membrane is called an aponeurosis.
exactly in the median plane it is said to be median in position Muscles are separated from skin, and from each other, by a
(e.g., G in figure 1.2). tissue which is referred to as fascia. Immediately beneath
Various combinations of the descriptive terms mentioned
the skin the fibres of the fascia are arranged loosely and this
above are frequently used. For example, a structure may be
loose tissue is called superficial fascia. The muscles are
anteromedial or inferolateral to another.
covered by a much better formed and stronger membrane
The term ventral is often used as equivalent to anterior. The
called deep fascia.
opposite of ventral is dorsal. In the hand the palm is on the
Running through the intervals between muscles (usually in
anterior or ventral aspect. This aspect of the hand is often called
the palmar aspect. The back of the hand is the dorsal aspect, relation to fascial septa) there are blood vessels, nerves.
or simply the dorsum, of the hand. In the case of the foot the lymphatic vessels and lymph nodes.
surface towards the sole is ventral: it is called the plantar In many parts of the body there are specialized organs, also
aspect. The upper side of the foot is the dorsum of the foot. commonly called viscera. Some of the viscera are solid (e.g.
While referring to structures in the trunk the term cranial the liver, or the kidney), while others are tubular (e.g. the
(= towards the head) is sometimes used instead of superior; intestines) or sac like (e.g. the stomach). Viscera are grouped
and caudal (= towards the tail) in place of inferior. In the limbs together to form various organ systems.
the term superior is sometimes replaced by proximal (= nearer) From the discussions in the previous paragraphs it will be
and inferior by distal (= more distant). In the case of the forearm clear that in the study of the anatomy of any part of the
(or hand) the medial side is often referred to as the ulnar side, body we have to consider the following:
and the lateral side as the radial side. Similarly, in the leg (or 1. The skeletal basis of the part including bones and joints.
foot) we can speak of the tibial (= medial) or fibular (= lateral) 2. The muscles and fasciae.
sides. 3. The blood vessels and nerves.
In addition to the terms described above there are some terms 4. The lymph nodes and their areas of drainage.
that are used to define planes passing through the body. 5. Viscera present in the region.
3
4
2 : Bones of the Upper Extremity

Introduction
The skeleton of each upper limb (Fig. 2.1) consists of the bones of the
pectoral girdle (or shoulder girdle) that lie in close relation to the
upper part of the thorax, and those of the free limb.
The pectoral girdle consists of the collar bone or clavicle, and the
scapula. The bone of the arm is called the humerus. There are two
bones in the forearm: the bone that lies laterally (i.e. towards the thumb)
is called the radius; and the bone that lies medially (i.e. towards the
little finger) is called the ulna. The humerus, radius and ulna are long
bones each having a cylindrical middle part called the shaft, and
expanded upper and lower ends.
In the wrist there are eight small, roughly cuboidal, carpal bones. The
skeleton of the palm is made up of five rod like metacarpal bones,
while the skeleton of the fingers (or digits) is made up of the phalanges.
There are three phalanges, proximal, middle and distal, in each digit
except the thumb that has only two phalanges (proximal and distal).
The upper end of the humerus is joined to the scapula at the shoulder
joint, and its lower end is joined to the upper ends of the radius and
ulna to form the elbow joint. The wrist joint is formed where the lower
ends of the radius and ulna meet the carpal bones. The upper and lower
ends of the radius and ulna are united to one another at the superior
and inferior radioulnar joints. There are numerous small joints in the
hand: the intercarpal between the carpal bones themselves; the
carpometacarpal between the carpal and metacarpal bones; the
metacarpo-phalangeal between each metacarpal bone and the proximal
phalanx; and the inter-phalangeal joints between the phalanges
themselves.
THE CLAVICLE
The clavicle is a long bone having a shaft, and two ends (Figs 2.2, 2.3).
The medial end is much thicker than the shaft and is easily distinguished
from the lateral end that is flattened. The anterior and posterior aspects
of the bone can be distinguished by the fact that the shaft (that has a
gentle S-shaped curve) is convex forwards in the medial two-thirds,
and concave forwards in its lateral one-third. The inferior aspect of the
bone is distinguished by the presence of a shallow groove on the shaft,
Fig. 2.1. Skeleton of the right upper limb. The
and by the presence of a rough area near its medial end. The side to
manubrium is included for orientation
which a clavicle belongs can be determined using the information given
above.
For purposes of description it is convenient to divide the clavicle into The medial two-thirds of the shaft has four surfaces:
the lateral one-third that is flattened, and the medial two-thirds that are anterior, posterior, superior and inferior, that are not
cylindrical. clearly marked off from each other. The large rough
The lateral one-third has two surfaces, superior and inferior. These area present on the inferior aspect of the bone near
surfaces are separated by two borders, anterior and posterior. The the medial end forms part of the inferior surface. The
anterior border is concave and shows a small thickened area called the middle-third of the inferior aspect shows a
deltoid tubercle. The lower surface (of the lateral one-third) shows a longitudinal groove.
prominent thickening near the posterior border; this is the conoid The lateral or acromial end of the clavicle bears a
tubercle. Lateral to the tubercle there is a rough ridge that runs obliquely smooth facet that articulates with the acromion of
up to the lateral end of the bone, and is called the trapezoid line. the scapula to form the acromioclavicular joint.
BONES OF THE UPPER EXTREMITY
Fig. 2.2. Right clavicle seen from above.
Fig. 2.3. Right clavicle seen from below.
Fig. 2.4. Right clavicle, showing attachments, seen from above.
Fig.2.5. Right clavicle showing attachments, seen from below.
The medial or sternal end of the clavicle articulates with Some Attachments on the Clavicle
the manubrium sterni, and also with the first costal cartilage. 1. The pectoralis major (clavicular head) arises from the
The articular area extends on to the inferior surface of the anterior surface of the medial-half of the shaft.
bone. The uppermost part of the sternal surface is rough for 2. The deltoid arises from the anterior border of the lateral one-
ligamentous attachments. third of the shaft.
5
6
3. The sterno-cleidomastoid (clavicular head) arises
from the medial part of the upper surface.
4. The sternohyoid (lateral part) arises from the lower
part of the posterior surface just near the sternal end.
5. The trapezius is inserted into the posterior border of
the lateral one-third of the shaft.
6. The subclavius is inserted into the groove on the
inferior surface of the shaft.
THE SCAPULA
The greater part of the scapula consists of a flat triangular

plate of bone called the body (Figs 2.6 to 2.8). The upper
part of the body is broad, representing the base of the
triangle. The inferior end is pointed and represents the
apex. The body has anterior (or costal) and posterior
(or dorsal) surfaces that can be distinguished by the fact
that the anterior surface is smooth, but the upper part of
the posterior surface gives off a large projection called
the spine. At its lateral angle the bone is enlarged and
bears a large shallow oval depression called the glenoid
cavity that articulates with the head of the humerus. The

side to which a given scapula belongs can be determined
from the information given above. Fig. 2.6. Right scapula seen from the front.
In addition to its costal and dorsal surfaces the body has
three angles: superior, inferior and lateral; and three
borders: medial, lateral and superior. Arising from the
body there are three processes. In addition to the spine
already mentioned there is an acromion process and a
coracoid process.
The lateral border runs from the glenoid cavity to the
inferior angle. The medial border extends from the
superior angle to the inferior angle. The superior border
passes laterally from the superior angle, but is separated
from the glenoid cavity (representing the lateral angle)
by the root of the coracoid process. A deep
suprascapular notch is seen at the lateral end of the
superior border.
The costal surface lies against the posterolateral part
of the chest wall. It is somewhat concave from above
downwards. The dorsal surface gives attachment to the
spine. The part above the spine forms the supraspinous
fossa, along with the upper surface of the spine. The
area below the spine forms the infraspinous fossa (along
with the lower surface of the spine). The supraspinous
and infraspinous fossae communicate with each other
through the spinoglenoid notch that lies on the lateral
side of the spine.
The glenoid cavity is pear shaped and forms the shoulder
joint along with the head of the humerus. Just below the
cavity the lateral border shows a rough raised area called
the infraglenoid tubercle. Immediately above the
glenoid cavity there is a rough area called the Fig. 2.7. Right scapula seen from behind
supraglenoid tubercle. The region of the glenoid cavity is
often regarded as the head of the scapula. Immediately medial
to it there is a constriction which constitutes the neck.
The spine of the scapula is triangular in form. Its anterior
border is attached to the dorsal surface of the body. Its
posterior border is free: it is greatly thickened and forms the
crest of the spine. The medial end of the spine lies near the
medial border of the scapula: this part is referred to as the
root of the spine. The lateral border of the spine is free and
forms the medial boundary of the spino-glenoid notch.
The acromion is continuous with the lateral end of the spine.

It forms a projection that is directed forwards and partly
overhangs the glenoid cavity. The lateral border meets the
crest of the spine at a sharp angle termed the acromial angle.
The medial border of the acromion shows the presence of a
small oval facet for articulation with the lateral end of the
clavicle.
The coracoid process is shaped like a bent finger. The root

of the process is attached to the body of the scapula just above
the glenoid cavity. The lower part of the root is marked by
the supraglenoid tubercle. The tip of the coracoid process is
directed straight forwards.
Some Attachments on the Scapula

(Figs 2.8, 2.9) Fig. 2.8. Right scapula, showing attachments, seen
from the front.
1. The deltoid takes origin from the lower
border of the crest of the spine; and from
the lateral margin, tip and upper surface of
the acromion.
2. The trapezius is inserted into the upper
border of the crest of the spine, and into the
medial border of the acromion.
3. The short head of the biceps brachii arises
from the (lateral part of the) tip of the
coracoid process; and the long head from
the supraglenoid tubercle.
4. The coracobrachialis arises from (the
medial part of) the tip of the coracoid
process.
5. The long head of the triceps arises from
the infraglenoid tubercle.
6. The pectoralis minor is inserted into the
superior aspect of the coracoid process.
7. The inferior belly of the omohyoid arises
from the upper border near the suprascapular
notch.
8. The subscapularis arises from the whole
of the costal surface, but for a small part near
the neck.
9. The serratus anterior is inserted on the
costal surface along the medial border.
10. The supraspinatus arises from the
medial two-thirds of the supraspinous fossa,
including the upper surface of the spine. Fig. 2.9. Right scapula, showing attachments,
seen from behind
7
8
Fig. 2.10. Right humerus seen from the front Fig. 2.11. Right humerus seen from behind.
11. The infraspinatus arises from the greater part of the 15. The rhomboideus minor is inserted into the dorsal aspect
infraspinous fossa, but for a part near the lateral border and a of the medial border, opposite the root of the spine.
part near the neck. 16. The rhomboideus major is inserted into the dorsal aspect
12. The teres minor arises from the upper two-thirds of the of the medial border, from the root of the spine to the inferior
rough strip on the dorsal surface, near the lateral border. angle.
13. The teres major arises from the lower one-third of the 17. The capsule of the shoulder joint and the glenoidal labrum
rough strip along the dorsal aspect of the lateral border are attached to the margins of the glenoid cavity. In its upper
14. The levator scapulae is inserted into a narrow strip along part the attachment of the capsule extends above the
the dorsal aspect of the medial border, extending from the supraglenoid tubercle so that the origin of the long head of
superior angle to the level of the root of the spine. the biceps is within the capsule.
THE HUMERUS rounded and is called the capitulum. It articulates with the
head of the radius. The medial part of the articular surface is
shaped like a pulley and is called the trochlea. The trochlea
The humerus has a shaft, and upper and lower ends (Figs.
articulates with the upper end (trochlear notch) of the ulna.
2.10, 2.11). The upper end is easily distinguished from the
The anterior aspect of the lower end of the humerus shows
lower by the presence of a large rounded head. The medial
two depressions: one just above the capitulum and another
and lateral sides can be distinguished by the fact that the head
is directed medially. The anterior aspect of the upper end above the trochlea. The depression above the capitulum is
shows a prominent vertical groove called the intertubercular called the radial fossa and that above the trochlea is called
sulcus. The side to which a given bone belongs can be the coronoid fossa (Fig. 2.10). Another depression is seen
determined from the information given above. above the trochlea on the posterior aspect of the lower end
The head is rounded and has a smooth convex articular (Fig. 2.11). This depression is called the olecranon fossa.
surface. It is directed medially, and also somewhat backwards Some Attachments on the Humerus (Figs 2.12 and 2.13)
and upwards. It forms the shoulder joint along with the glenoid 1. The supraspinatus is inserted into the upper impression on
cavity of the scapula. It may be noted that the articular area the greater tubercle.
of the head is much greater than that of the glenoid cavity. 2. The infraspinatus is inserted into the middle impression
In addition to the head, the upper end of the humerus shows on the greater tubercle.
two prominences called the greater and lesser tubercles (or 3. The teres minor is inserted into the lower impression on
tuberosities). These two tubercles are separated by the the greater tubercle.
intertubercular sulcus. 4. The subscapularis is inserted into the lesser tubercle.
The lesser tubercle lies on the anterior aspect of the bone
5. The pectoralis major is inserted into the lateral lip of the
medial to the sulcus, between it and the head.
intertubercular sulcus.
The greater tubercle is placed on the lateral aspect of the
6. The latissimus dorsi is inserted into the floor of the
upper end. The tubercle shows three areas (or impressions)
where muscles are attached (Fig. 2.14).
7. The teres major is inserted into the medial lip of the
The junction of the head with the rest of the upper end is
called the anatomical neck, while the junction of the upper
Of the three insertions into the intertubercular sulcus that of
end with the shaft is called the surgical neck.
the pectoralis major is the most extensive, and that of the
The shaft of the humerus has three borders: anterior, medial
and lateral. These are easily distinguished in the lower part latissimus dorsi is the shortest.
of the bone. When traced upwards the anterior border 8. The deltoid is inserted into the deltoid tuberosity.
becomes continuous with the anterior margin of the greater 9. The coracobrachialis is inserted into the rough area on the
tubercle. The medial border reaches the lesser tubercle. The middle of the medial border.
lower part of the lateral border can be seen from the front, 10. The brachialis arises from the lower halves of the
but its upper part runs upwards on the posterior aspect of the anteromedial and anterolateral surfaces of the shaft. Part of
bone. the area of origin extends onto the posterior aspect.
The three borders divide the shaft into three surfaces. The 11. The pronator teres (humeral head) arises from the
anterolateral surface lies between the anterior and lateral anteromedial surface, near the lower end of the medial
borders; the anteromedial surface between the anterior and supracondylar ridge.
medial borders, and the posterior surface between the medial 12. The brachioradialis arises from the upper two-thirds of
and lateral borders. the lateral supracondylar ridge.
We may now note certain additional features of the shaft. 13. The extensor carpi radialis longus arises from the lower
The anterolateral surface has a V-shaped rough area called one-third of the lateral supracondylar ridge.
the deltoid tuberosity that is present near the middle of this 14. The superficial flexor muscles of the forearm arise from
surface. When the shaft is observed from behind we see that the anterior aspect of the medial epicondyle. This origin is
its upper part is crossed by a broad and shallow radial groove called the common flexor origin.
that runs downwards and laterally across the posterior and 15. The common extensor origin for the superficial extensor
anterolateral surfaces. muscles of the forearm is located on the anterior aspect of the
The lower end of the humerus is irregular in shape and is also lateral condyle.
called the condyle. The lowest parts of the medial and lateral 16. The lateral head of the triceps arises from the oblique
borders of the humerus form sharp ridges that are called the ridge on the upper part of the posterior surface, just above the
medial and lateral supracondylar ridges respectively. Their radial groove. The medial head of the muscle arises from the
lower ends terminate in two prominences called the medial posterior surface below the radial groove. The upper end of
and lateral epicondyles. Between the two epicondyles the the area of origin extends on to the anterior aspect of the shaft.
lower end presents an irregular shaped articular surface that 17. The anconeus arises from the posterior surface of the
is divisible into medial and lateral parts. The lateral part is lateral epicondyle.
9
10
Fig. 2.13. Right humerus showing attachments, seen

Fig. 2.12.Right humerus, showing attachments, seen from behind.
from the front.
18. The capsular ligament of the shoulder joint is attached

on the anatomical neck except on the medial side where
the line of attachment dips down by about a centimetre to
include a small area of the shaft within the joint cavity.
19. The capsular ligament of the elbow joint is attached
to the lower end of the bone.
Fig. 2.14. Upper end of right humerus, showing

attachments, seen from above.
Important relations
1. The intertubercular sulcus
lodges the tendon of the long
head of the biceps brachii.
2. The surgical neck of the
bone is related to the axillary
nerve and to the anterior and
posterior circumflex humeral
vessels.
3. The radial nerve and the
profunda brachii vessels lie in
the radial groove between the
attachments of the lateral and
medial heads of the triceps.
THE RADIUS
The radius is a long bone

having a shaft and two ends
(Figs 2.15, 2.16). The upper
end bears a disc shaped head.
In contrast the lower end is
much enlarged. The lateral
and medial sides of the bone
can be distinguished by
examining the shaft that is
convex laterally and has a
sharp medial (or intero-
sseous) border. The anterior
and posterior aspects of the
bone may be identified by
looking at the lower end: it is
smooth anteriorly, but the
posterior aspect is marked by
a number of ridges and
grooves. The side to which a
given radius belongs can be
determined from the
information given above.
The upper end of the bone
consists of a head, a neck and Fig. 2.15. Right radius seen from . Fig. 2.16. Right radius seen
a tuberosity. The head is disc the front from behind.
shaped. Its upper surface is
slightly concave and articulates with the capitulum of the The interosseous or medial border forms a sharp ridge that
humerus. The circumference of the head (representing the extends from just below the tuberosity to the lower end of the
edge of the disc) articulates with a notch on the ulna to form shaft. The anterior border begins at the radial tuberosity and
the superior radioulnar joint. runs downwards and laterally across the anterior aspect of
The region just below the head is constricted to form the neck. the shaft. This part of the anterior border is called the anterior
Just below the medial part of the neck there is an elevation oblique line. It then runs downwards and forms the lateral
called the radial tuberosity. boundary of the smooth anterior aspect of the lower part of
The shaft of the radius has three borders (anterior, posterior, the shaft. The upper part of the posterior border runs
and interosseous) and three surfaces (anterior, posterior and downwards and laterally from the posterior part of the
lateral) . tuberosity. The lower part of the posterior border runs
11
12
downwards along the middle of the
posterior aspect of the shaft to the
lower end. The anterior surface lies
between the interosseous and anterior
borders; the posterior surface between
the interosseous and posterior borders;
and the lateral surface between the
anterior and posterior borders.
The lower end of the radius has
anterior, lateral and posterior surfaces
continuous with the corresponding
surfaces of the shaft. In addition it has
a medial surface and an inferior
surface. The lateral surface is
prolonged downwards as a projection
called the styloid process. The medial
aspect of the lower end has an articular
area called the ulnar notch. It
articulates with the lower end of the
ulna to form the inferior radioulnar
joint. The posterior aspect of the lower
end is marked by a number of vertical
grooves separated by ridges. The most
prominent ridge is called the dorsal

tubercle. The inferior surface of the
lower end takes part in forming the
wrist joint.
Attachments on the Radius

A. The following muscles are
inserted into the radius (Figs 2.17,
2.18).
1. The biceps brachii is inserted into
the rough posterior part of the radial
tuberosity.
2. The supinator is inserted into the
upper part of the lateral surface. The
area of insertion extends on to the
anterior and posterior aspects of the
shaft.
Fig. 2.17. Right radius showing Fig. 2.18. Right radius showing 3. The pronator teres is inserted into
attachments seen from the front. attachments seen from behind. the rough area on the middle of the
lateral surface, at the point of
maximum convexity of the shaft.
4. The brachioradialis is inserted into the lowest part of the lateral
surface just above the styloid process.
5. The pronator quadratus is inserted into the lower part of the
anterior surface, and into the triangular area on the medial side of
the lower end.
B. The following muscles take origin from the radius.
1. The flexor digitorum superficialis (radial head) arises from the
upper part of the anterior border (oblique line).
2. The flexor pollicis longus arises from the upper two-thirds of
Fig. 2.19. Lower end of right radius seen
from below. The related tendons are shown. the anterior surface.
3. The abductor pollicis longus arises from the upper part of small. The upper end has a large trochlear notch on its anterior
the posterior surface. aspect. The medial and lateral sides of the bone can be
4. The extensor pollicis brevis arises from a small area on the distinguished by examining the shaft: its lateral margin is sharp
posterior surface below the area for the abductor pollicis and thin, while its medial side is rounded. The side to that an
longus. ulna belongs can be determined from these facts.
The upper end of the ulna consists of two prominent
projections called the olecranon process and the coronoid
THE ULNA process. The olecranon process forms the uppermost part of
the ulna. The coronoid process projects forwards from the
The ulna has a shaft, an upper end and a lower end (Figs anterior aspect of the ulna just below the olecranon process.
2.20 and 2.21). The upper end is large, while the lower end is The trochlear notch covers the anterior aspect of the olecranon
process and the superior aspect
of the coronoid process. It takes
part in forming the elbow joint
and articulates with the trochlea
of the humerus.
The coronoid process has an
upper surface that forms the
lower part of the trochlear
notch. In addition it has anterior,
medial and lateral surfaces. The
lower part of the anterior
surface shows a rough
projection called the tuberosity
of the ulna. The upper part of
the lateral surface of the
coronoid process shows a
concave articular facet called
the radial notch. The radial
notch articulates with the head
of the radius forming the
superior radioulnar joint. The
bone shows a depression just
below the radial notch. The
posterior border of this
depression is formed by a ridge
called the supinator crest.
The lower end of the ulna
consists of a disc-like head and
a styloid process. The head has
a circular inferior surface. This
surface is separated from the
cavity of the wrist joint by an
articular disc. The head has
another convex articular surface
on its lateral side: this surface
articulates with the ulnar notch
of the radius to form the inferior
radioulnar joint. The styloid
process is a small downward
projection that lies on the
posteromedial aspect of the
head. The tip of the styloid
process of the ulna lies at a
higher level than the styloid
process of the radius.
Fig. 2.20. Right ulna seen from the front Fig. 2.21. Right ulna seen from behind.
13
14
Important Attachments on
the Ulna (Figs 2.22, 2.23)
1. The brachialis is inserted into
the anterior surface of the
coronoid process including the
tuberosity.
2. The triceps is inserted into the
posterior part of the superior
surface of the olecranon process.
3. The flexor digitorum
profundus arises from the upper
three-fourths of the anterior and
medial surfaces.
4. The supinator arises from the
supinator crest and from the
triangular area in front of it.
5. The flexor pollicis longus
(occasional ulnar head) arises
from the lateral border of the
coronoid process.
6. The flexor digitorum
superficialis (ulnar head) arises
from the tubercle at the upper
end of the medial margin of the

coronoid process.
7. The pronator teres (ulnar
head) arises from the medial
margin of the coronoid process.
8. The pronator quadratus
arises from the oblique ridge on
the lower part of the anterior
surface of the shaft.
9. The flexor carpi ulnaris
(ulnar head) arises from the
medial side of the olecranon
process, and from the upper two-
thirds of the posterior border
through an aponeurosis common
to it, the extensor carpi ulnaris
and the flexor digitorum
profundus.
10. The extensor carpi ulnaris
(ulnar head) arises from the
Fig. 2.22. Right ulna, showing Fig. 2.23. Right ulna, showing posterior border by an
attachments, seen from the front. attachments, seen from behind. aponeurosis common to it, the
flexor carpi ulnaris and the
flexor digitorum profundus.
The shaft of the ulna has a sharp lateral or interosseous border, and less prominent anterior 11. The posterior surface of the
and posterior borders. It has anterior, posterior and medial surfaces. The upper part of the ulna is divided into medial and
interosseous border is continuous with the supinator crest mentioned above. The anterior lateral parts by a vertical ridge.
border begins at the tuberosity of the ulna. Its lower end lies in front of the styloid process. The lateral part lies between the
The posterior border begins on the posterior aspect of the olecranon process and ends at vertical ridge and the
the styloid process. The anterior surface of the ulna lies between the interosseous and interosseous border. This part of
anterior borders The medial surface lies between the anterior and posterior borders. The the posterior surface may be
posterior surface is bounded by the interosseous and posterior borders. divided into four parts.
a. The uppermost part gives origin to
the abductor pollicis longus.
b. The next part gives origin to the
extensor pollicis longus.
c. The third part gives origin to the
extensor indicis
d. The lowest part is devoid of
attachments.
THE SKELETON OF THE

HAND
The skeleton of the hand consists of

the bones of the wrist, the palm, and
of the digits.
The skeleton of the wrist consists of
eight, small, roughly cuboidal carpal
bones. The skeleton of the palm is
made up of five metacarpal bones.
These are miniature long bones. The
skeleton of the fingers is made up of
the phalanges. There are three
phalanges (proximal, middle and
distal) in each digit except the thumb
that has only two phalanges (proximal Fig. 2.24. Skeleton of the hand seen from the front.
and distal).
The Lunate Bone
The lunate bone can be distinguished because it is shaped like
THE CARPAL BONES a lunar crescent.
Proximally, the bone has a convex articular facet that takes
The carpal bones are arranged in two rows, proximal and part in forming the wrist joint. The bone articulates laterally
distal (Fig. 2.24). The proximal row is made up (from lateral with the scaphoid; medially with the triquetral; and distally
to medial side) of the scaphoid, lunate, triquetral and with the capitate. Between the areas for the capitate and for
pisiform bones. The distal row is made up (from lateral to the triquetral the lunate may articulate with the hamate bone.
medial side) of the trapezium, trapezoid, capitate and hamate
bones.
The Triquetral Bone
The carpal bones of the proximal row (except the pisiform)
The triquetral bone is a small and roughly cuboidal. The distal
take part in forming the wrist joint. The distal row of carpal
part of its palmar surface articulates with the pisiform bone. It
bones articulate with the metacarpal bones. Each carpal bone
takes part in forming the wrist joint: it comes into contact
articulates with neighbouring carpal bones to form intercarpal
with the articular disc of the inferior radioulnar joint.Its lateral
joints. surface articulates with the hamate bone. The proximal surface
articulates with the lunate bone.
The Scaphoid Bone
The scaphoid bone can be distinguished because of its The Pisiform Bone
distinctive boat-like shape. The proximal part of the bone is This bone is shaped like a pea. Its dorsal aspect bears a single
covered by a large, convex, articular surface for the radius. facet for articulation with the triquetral bone.
Distally and laterally the palmar surface of the bone bears a
projection called the tubercle. The Trapezium
The medial surface of the scaphoid articulates with the lunate This bone bears a thick prominent ridge on its palmar aspect.
bone (proximally) and with the capitate (distally). The distal This ridge is called the tubercle. The trapezium articulates
surface of the scaphoid articulates with the trapezium proximally and medially with the scaphoid; distally and
(laterally) and with the trapezoid bone (medially). laterally with the first metacarpal bone; medially with the
15
16
trapezoid bone; and distally and medially with the base of the
second metacarpal bone.
The Trapezoid Bone

This bone is of small size and is irregular shape. It articulates
distally with the base of the 2nd metacarpal bone, laterally
with the trapezium, medially with the capitate, and proximally
with the scaphoid.
The Capitate Bone

The capitate bone is the largest carpal bone, and bears a
rounded head at one end. Fig. 2.25. Schematic section across the distal row of
The capitate lies right in the middle of the carpus. Proximally, carpal bones.
it articulates with the lunate bone. Distally the capitate bone
articulates mainly with the third metacarpal bone, but it also
articulates with the second and fourth metacarpal bones.
Its lateral aspect articulates with the scaphoid (proximally) and
the first metacarpal, and that related to the little finger is the
with the trapezoid (distally). Medially it articulates with the
fifth. Each metacarpal is a miniature long bone having a
hamate bone.
shaft, a distal end and a proximal end.
The Hamate Bone The distal end forms a rounded head. It bears a large convex
The hamate has a prominent hook-like process attached to its articular surface for articulation with the proximal phalanx
palmar aspect. The hamate is triangular in shape, the apex of of the corresponding digit. The shaft is triangular in cross
the triangle being directed proximally. The apex may articulate section and has medial, lateral and dorsal surfaces. The bases
with the lunate bone. Distally the hamate articulates with the (or proximal ends) of the metacarpal bones are irregular in
4th and 5th metacarpal bones. Medially and proximally the shape. They articulate with the distal row of carpal bones.
hamate articulates with the triquetral bone, and laterally with The first metacarpal articulates with the trapezium; the
the capitate. second mainly with the trapezoid; the third mainly with the
capitate; and the fourth and fifth with the hamate bone.
Numerous other smaller articulations exist.
The Carpal Tunnel
The bases of the second and third, third and fourth, and fourth
The carpal bones are so arranged that the dorsal, medial and
and fifth metacarpal bones also articulate with each other.
lateral surfaces of the carpus form one convex surface. On the
other hand the palmar surface is deeply concave with
overhanging medial and lateral projections. This concavity is
converted into the carpal tunnel by a band of fascia called the THE PHALANGES OF THE HAND
flexor retinaculum (Fig. 2.25).
Each digit of the hand, except the thumb, has three phalanges:
The retinaculum is attached, medially to the pisiform bone proximal, middle and distal. The thumb has only two
and to the hook of the hamate; and laterally to the tubercle of phalanges, proximal and distal. Each phalanx has a distal
the scaphoid and to the tubercle of the trapezium. end or head, a proximal end or base, and an intervening shaft
or body.
THE METACARPAL BONES Attachments on the Skeleton of the Hand

The skeleton of the hand gives attachment to numerous
The hand has five metacarpal bones. They are numbered from muscles and other structures. Details of these will be
lateral to medial side so that the bone related to the thumb is mentioned when we study these structures.
PECTORAL REGION, AXILLA AND BREAST
3 : Pectoral Region, Axilla and Breast
THE PECTORAL REGION
The pectoral region lies on the front of the thorax. In the These branches descend over the posterior triangle of the neck.
mature female the most conspicuous feature of this region They pierce the deep fascia a little above the clavicle and then
is the presence of the breasts. Even though the breasts have run downwards across this bone to reach the pectoral region.
no functional connection with the upper limbs it is usual to The medial supraclavicular nerve supplies the skin of the upper
consider them along with other structures of the pectoral and medial part of the thorax. A branch from the nerve supplies
region. In the male the breasts are represented by the sternoclavicular joint. The intermediate supraclavicular
rudimentary nipples. nerve supplies the skin over the upper part of the pectoralis
major. The area of supply of the medial and intermediate
supraclavicular nerves extends up to the level of the second rib.
The lateral supraclavicular nerve supplies the skin over the
CUTANEOUS NERVES OF THE shoulder.
PECTORAL REGION 2. Skin below the level of the sternal angle is supplied by anterior
cutaneous branches of the 2nd to 6th intercostal nerves; and
The skin of the upper part of the pectoral region is supplied more laterally by lateral cutaneous branches of the 3rd to 6th
by nerves derived from spinal segments C3 and C4 (up to intercostal nerves.
the level of the sternal angle). The area just below the level
of the sternal angle is supplied by segment T2. The
intervening nerves (C5 to T1) get pulled away into the MUSCLES OF THE PECTORAL REGION
limb leaving the area for segment C4 in direct continuity
with that for segment T2.
The cutaneous nerves of the pectoral region are as follows:
Platysma
1. The supraclavicular nerves (derived from segments C3
and C4) arise in the neck from the cervical plexus.They
This muscle lies in superficial fascia. It arises from the deep
enter the pectoral region by crossing in front of the clavicle.
fascia over the upper part of the pectoralis major and the anterior
The main trunk divides into three branches called the
part of the deltoid. The fibres pass upwards and forwards across
medial, intermediate and lateral supraclavicular nerves.
the clavicle, and then over the neck to reach the lower border of
the mandible.
Pectoralis Major
Origin:
The pectoralis major takes origin from the following (Fig. 3.2):
a. Medial half of the anterior surface of the clavicle .
b. The anterior surface of the sternum.
c. The medial parts of the upper seven costal cartilages.
d. The aponeurosis of the external oblique muscle.
Insertion:
The fibres of the muscle converge towards the anterior aspect
of the upper end of the humerus. They are inserted into the lateral
lip of the intertubercular sulcus (e in figure). The tendon of
insertion is bilaminar, and consists of an anterior and a posterior
lamina. The anterior lamina receives the clavicular and upper
Fig. 3.1. Dermatomes on the front of the thorax. sternocostal fibres. The posterior lamina receives the fibres from
17
18
the lower costal cartilages and from
the aponeurosis of the external
oblique muscle.
Nerve Supply:
Lateral and medial pectoral nerves
(C 5, 6, 7, 8 T1).
Actions:
The muscle is an adductor, medial
rotator and flexor of the arm.
Pectoralis Minor
Origin (Fig. 3.3):

The pectoralis minor takes origin
mainly by slips from the 3rd, 4th and
5th ribs (near their junctions with
the costal cartilages).
Insertion:
The muscle ends in a tendon which
is inserted into the coracoid process
of the scapula.
Fig. 3.2. Attachments of the

pectoralis major.
Nerve Supply:
Medial and lateral pectoral nerves (C6, 7, 8).
Actions:
a) The muscle helps the serratus anterior in
moving the scapula forwards around the chest wall
(in protracting the arm).
b) The muscle helps the levator scapulae and the
rhomboids to rotate the scapula backwards.
The muscle lies in front of the axillary artery and
is used to divide the artery into its first, second
and third parts.
Subclavius
Origin:
The subclavius arises from the junction of the first
rib with its costal cartilage (Fig. 3.3).
Insertion:
The muscle is inserted into a groove on middle
pectoralis major. one-third of the inferior surface of the clavicle
(Fig. 2.5).
Nerve Supply:
The nerve to the subclavius (C5, 6) arises from the upper
trunk of the brachial plexus (Erbs point).
Actions:
The subclavius depresses the clavicle.
Clavipectoral fascia
This fascia fills the gap between the clavicle (above) and the
medial edge of the pectoralis minor (below) (Fig. 3.4). Near
its upper end the fascia splits to enclose the subclavius. At
the medial edge of the pectoralis minor its splits to enclose
the pectoralis minor. At the lower (lateral) edge of the
pectoralis minor the fascia becomes continuous with the
axillary fascia (forming the floor of the axilla). The
clavipectoral fascia is pierced by the thoracoacromial artery
and vein, the cephalic vein, and the lateral pectoral nerve.
Some lymphatics of the breast and pectoral region passing to
the apical lymph nodes of the axilla also pass through it.
Serratus Anterior
Fig. 3.4. Schematic sagittal section through the axilla to show
The serratus anterior does not belong to the pectoral region.
its anterior and posterior walls, and the clavipectoral fascia.
However, it is encountered in the lateral part of the pectoral
region and takes part in forming the medial wall of the axilla.
It is therefore described here.
Origin: Nerve Supply:
The serratus anterior takes origin, by several digitations from The nerve to the serratus anterior is a branch of the branchial
the outer surfaces of the upper eight (or nine) ribs, and from plexus and arises from the roots C5, 6, 7.
the fascia covering the intercostal muscles.
Actions:
Insertion: (a) The muscle pulls the scapula forwards around the chest
The fibres of the muscle run backwards round the wall of the wall to protract the upper limb.
thorax. They pass deep to the scapula to reach its medial border (b) It rotates the scapula (alongwith the trapezius) so that the
(Fig. 3.5). The entire muscle is inserted into the costal surface glenoid cavity is turned upwards (See Fig. 3.6).
of the scapula along its medial border (Fig. 3.6).
Fig. 3.5. Schematic diagram to show the position of

the serratus anterior in relation to the thoracic wall Fig. 3.6. Scapula showing insertion of the
and to the scapula. serratus anterior
19
20
THE AXILLA
The axilla is the region of the armpit. The

boundaries of the axilla are as follows.
The anterior wall is formed by the
pectoralis major, the pectoralis minor and
the clavipectoral fascia. The posterior wall
is formed by muscles lying in front of the
scapula. In the upper part there is the
subscapularis (Fig. 3.4), and lower down
there are the teres major and the latissimus
dorsi. The latissimus dorsi winds round the
lower margin of the teres major, the two
together forming the thick posterior fold
of the axilla. The medial wall is formed
by the upper few ribs and intercostal
spaces. They are covered by the upper part
of a large muscle called the serratus
anterior. The lateral wall is formed by the
Fig. 3.7. Transverse section through the axilla to show its walls..
humerus in the region of the

intertubercular sulcus. The sulcus is
occupied by the tendon of the long head of the biceps brachii. A. Relationship to muscles (Fig. 3.8)
The short head of the same muscle, and the coracobrachialis (a) The first part of the artery rests (posteriorly) on the
lie just medial to it. The floor of the axilla is formed by axillary muscles of the first intercostal space and the upper part of
fascia, covered by skin. The axillary fascia has an aperture the serratus anterior.
through which the axillary tail of the breast enters the axilla. (b) The second part and the upper portion of the third part
The apex of the axilla faces upwards and somewhat medially of the artery lie on the subscapularis muscle. The lower
and lies at the level of the outer border of the first rib. Behind portion of the third part lies on the teres major muscle and
the apex there is the upper border of the scapula, and in front the tendon of the latissimus dorsi.
of it there is the clavicle. These three structures form the (c) The entire artery except its lowermost part is overlapped
boundaries of an opening through which the axillary vessels by the pectoralis major. The second part is also covered by
and the brachial plexus pass from the neck into the axilla. the pectoralis minor. The first part is also covered by the
The opening is, therefore, called the cervicoaxillary
canal.
The contents of the axilla are the axillary artery and
vein, cords and some branches of the brachial plexus
and the axillary lymph nodes. The remaining space is
filled with fat. We will consider these contents one by
one.
THE AXILLARY ARTERY
The axillary artery is a continuation of the subclavian

artery. It begins at the outer border of the first rib and
ends at the lower border of the teres major (by becoming
the brachial artery). The artery is crossed by the pectoralis
minor which divides it into first, second and third parts.
The artery has numerous relationships.
Fig. 3.8. Some muscles related to the axillary artery

clavipectoral fascia (which extends from the
pectoralis minor to the clavicle).
(d) The coracobrachialis is lateral to the
second and third parts of the artery.
B. Relationship to veins:
The axillary artery is accompanied by the
axillary vein: the vein lies anteromedial to the
artery. The first part of the artery is crossed
by two tributaries of the axillary vein, namely
the cephalic vein and the thoracoacromial vein
.
C. Relationship to brachial plexus (Fig. 3.9):
The first and second parts of the artery are
related to the cords of the plexus; and the third
part of the artery to their branches.
The first part of the artery is also related to
the lateral pectoral nerve which crosses
anterior to the artery; and to the medial
pectoral nerve which lies behind it. A loop
passing in front of the artery joins the two
nerves. The third part of the artery is crossed Fig. 3.9. Relations of axillary artery to cords and branches
anteriorly by the medial root of the median of the brachial plexus.
nerve as the latter passes laterally to join the
lateral root.
Fig. 3.10. Branches of the axillary artery.
21
22
This branch winds round the lateral border
of the scapula passing backwards through
the triangular space (Fig. 4.8). It takes part in
forming the anastomoses round the scapula
(Fig. 4.11).
The anterior circumflex humeral artery (Fig.
3.10) runs laterally in front of the surgical
neck of the humerus: it anastomoses with
the posterior circumflex humeral artery (see
below) to form an arterial circle round the
neck.
The posterior circumflex humeral artery
(Fig. 3.10) runs backwards (accompanied by
the axillary nerve) through the quadrangular
Fig. 3.11. Axillary lymph nodes seen from the front
Branches of the
Axillary Artery
The first part of the artery

gives rise to one branch: the
superior thoracic (Fig. 3.10).
The second part of the artery
gives two branches: the
thoracoacromial and the
lateral thoracic. The third part
gives off three branches: the
subscapular and the anterior
and posterior circumflex
humeral.
The superior thoracic artery
arises from the first part of the
axillary. It supplies the
pectoral muscles and part of
the thoracic wall.
The thoracoacromial artery
arises from the second part of
the axillary. It divides into
four branches, pectoral,
acromial, clavicular and
deltoid.
The lateral thoracic artery
runs downwards near the
lateral margin of the pectoralis
minor. In the female it gives
off branches to the breast.
The subscapular artery runs
downwards along the lateral
border of the scapula. The
artery gives off a large
circumflex scapular branch. Fig. 3.12. Scheme to show the areas drained by the axillary lymph nodes.
space (Fig. 4.8). It then passes laterally behind the The roots of the plexus are the ventral rami of spinal nerves C5, C6, C7,
surgical neck of the humerus to anastomose with C8 and T1. The roots from C5 and C6 join to form the upper trunk. The
the anterior circumflex humeral artery. root from C7 continues as the middle trunk. The roots from C8 and T1
join to form the lower trunk. Each trunk divides into an anterior and a
posterior division. The anterior divisions of the upper and middle trunks
join to form the lateral cord. The anterior division of the lower trunk
THE AXILLARY VEIN continues as the medial cord. The posterior divisions of all the three
trunks join to form the posterior cord.
The axillary vein accompanies the axillary artery The main branches of the brachial plexus are the median, the ulnar and
through the axilla. It is formed at the lower border the radial nerves. The median nerve is formed by union of lateral and
of the teres major by joining together of the venae medial roots arising from the lateral and medial cords, respectively. The
comitantes of the brachial artery and the basilic ulnar nerve arises from the medial cord; and the radial nerve from the
vein. It ends at the outer border of the first rib by posterior cord.
becoming continuous with the subclavian vein . The brachial plexus lies partly in the neck and partly in the axilla. In the
The vein lies medial to the axillary artery. neck the plexus lies in the posterior triangle. It passes behind the medial
part of the clavicle to enter the axilla through the cervico-axillary canal.
In the axilla the cords and their main branches are closely related to the
axillary artery.
AXILLARY LYMPH NODES
The chief lymph nodes of the upper limb are Branches of the Brachial Plexus
located in the axilla: these axillary lymph nodes
are considered below. The only other nodes of the
limb are one or two supratrochlear nodes lying Branches arising from roots:
just above the medial epicondyle of the humerus,
along the basilic vein; one or two infraclavicular (1) Each root of the plexus gives branches to some muscles lying in the
nodes that lie just below the clavicle, along the neck (scalene muscles and longus colli).
cephalic vein. (2) Root C5 gives a contribution to the phrenic nerve. The phrenic nerve
The axillary lymph nodes are divided into the descends into the thorax to supply the diaphragm.
following groups (Figs 3.11 and 3.12):
1) The lateral group of nodes lies along the
axillary vein.
2) The anterior (or pectoral) group of nodes lies
along the lateral thoracic vessels, i.e. along the
lower border of the pectoralis minor.
3) The posterior (or subscapular) group of nodes
lies along the course of the subscapular vessels.
4) The central group of nodes lies in the centre
of the axilla.
5) The apical group lies near the apex of the axilla.
The areas of drainage of these groups are shown
in Figure 3.12.
THE BRACHIAL PLEXUS

AND ITS BRANCHES
Basic Plan of the Brachial Plexus
The basic plan of the brachial plexus is shown in

Figure 3.13. The plexus consists of roots, trunks
(and their divisions) and cords. The main branches
arise as continuations of the cords: branches also Fig. 3.13. Basic plan of the brachial plexus.
arise from other parts of the plexus .
23
24
(3) The dorsal scapular nerve arises from root C5. The thoracodorsal nerve is the nerve to the latissimus dorsi.
(4) The long thoracic nerve is the nerve to the serratus anterior. The nerve arises from the posterior cord between the upper
It arises from roots C5, C6 and C7. and lower subscapular nerves.
The axillary nerve (Fig. 3.9) supplies the deltoid and teres
minor..
Branches arising from trunks:
The musculocutaneous nerve is a branch of the lateral cord.
It descends into the arm..
The only branches arising from the trunks of the brachial plexus
The medial cutaneous nerve of the arm is a branch of the
are the nerve to the subclavius and the suprascapular nerve.
medial cord.
Both of these nerves arise from the upper trunk.
The medial cutaneous nerve of the forearm is a branch of
The nerve to the subclavius passes behind the clavicle to reach
the medial cord..
the subclavius.
The ulnar nerve is the main continuation of the medial cord.
The suprascapular nerve runs laterally and backwards over
In the axilla the nerve lies medial to the third part of the axillary
the shoulder.
artery (Fig. 3.9). It passes through the arm and forearm. to
enter the hand. It has an extensive distribution in the upper
Branches arising from cords: limb.
The radial nerve is the main continuation of the posterior cord.
The lateral pectoral nerve arises from the lateral cord. It is In the axilla it lies posterior to the third part of the axillary
the main nerve supplying the pectoralis major. It also gives artery (Fig. 3.9). It passes through the arm and forearm. to
some fibres to the pectoralis minor. enter the hand. It has an extensive distribution in the upper
The medial pectoral nerve arises from the medial cord. It is limb.
the main nerve of supply for the pectoralis minor. It also sends
a few fibres to the pectoralis major. The median nerve is a continuation of the lateral cord and
The upper subscapular nerve arises from the posterior cord lies lateral to the third part of the axillary artery. It also receives
and supplies the subscapularis muscle. a root from the medial cord. It passes through the arm and
The lower subscapular nerve arises from the posterior cord. forearm. to enter the hand. It has an extensive distribution in
It supplies the teres major and subscapularis. the upper limb.
THE MAMMARY GLANDS
Each breast (right or left) is a rounded elevation present on the Langer). This extension is called the axillary tail. The greater
front of the upper part of the thorax, over the pectoral region. part of the breast lies over the pectoralis major. More laterally
Over the centre of the breast the skin shows a dark circular it lies on the serratus anterior. Inferiorly, it overlaps the
area which is called the areola. In the centre of the areola external oblique muscle of the abdomen, and its aponeurosis.
there is a conical projection called the nipple (or papilla) (Fig. The glandular tissue of the breast consists of acini that are
3.15). aggregated to form lobules. Several lobules collect to form
Deep to the skin the breast lies in the superficial fascia (i.e. a lobe. There are about fifteeen to twenty such lobes in each
between the skin and the deep fascia). It consists of a mass of breast.
glandular tissue embedded in connective tissue and fat. The acini of each lobe are drained by small ducts which
The breast extends upwards to the level of the second rib, and ultimately end in one lactiferous duct for each lobe. The
downwards to the sixth rib (Fig. 3.14). Medially it extends to ducts open on the surface of the nipple. A little proximal to
the right or left margin of the sternum . Laterally its extent is the opening each duct shows a dilation called a lactiferous
variable, but it may reach the midaxillary line. sinus.
From the upper lateral part of the gland an extension of glandular Breast tissue is held in place by bundles of fibrous tissue
tissue passes through an aperture in the deep fascia over the that connect it to the skin and to the underlying deep fascia.
axilla to enter the latter (The aperture is the foramen of These bands are referred to as the suspensory ligaments.
Blood vessels, lymphatics and nerves of the
breasts:
The breast is supplied by perforating branches of the
internal thoractic artery. It also receives branches from
the lateral thoracic branch of the axillary artery and from
the intercostal arteries. The blood is drained by
corresponding veins.
Lymphatic Drainage of the Breast
1. Most of the vessels from the breast end in the axillary
lymph nodes (mainly in the anterior group).
2. Some vessels drain into the parasternal nodes present
within the thorax near the lateral margins of the sternum.
3. Some vessels reach the intercostal nodes lying within
the thorax near the posterior ends of the intercostal
spaces.
4. Some vessels reach the infraclavicular and
supraclavicular lymph nodes
Fig. 3.14. Schematic vertical section through

the breast.
Fig. 3.15. Scheme to show the lymphatic drainage of the breast.
25
26
4 : The Back and Scapular Region

The muscles of the upper limb, to be seen on the back, are concerned
with movements of the scapula. It is important to understand these
movements as they, in turn, affect movements of the arm.
Movements of the scapula
The scapula is held in position by muscles attached to it and its position

depends upon the relative degree of contraction of different muscles.
In protraction the entire bone slides forwards over the chest wall.
Reversal of this movement is retraction. In elevation the entire bone
Fig. 4.1. Neutral position of the scapula
moves upwards (as in shrugging the shoulders); and the opposite and position after forward rotation.
movement is called depression.
In addition to these simple movements
the scapula can undergo rotation. To
understand rotation imagine that the
scapula is transfixed by an imaginary
nail passing through the centre of its
body (Fig. 4.1). Rotation is described

in terms of movement of the inferior
angle of the scapula.
In forward rotation (also called lateral
rotation) the inferior angle passes
forwards and somewhat laterally (Fig.
4.1B). Simultaneously, the superior
angle and the acromion pass
backwards and medially. The glenoid
cavity comes to face upwards. This
movement takes place during
abduction of the arm, and is essential
for raising the arm above the head.
Reversal of this movement constitutes
backward (or medial) rotation.
MUSCLES OF
THE UPPER LIMB
SEEN ON THE BACK
These are the trapezius, the latissimus

dorsi, the levator scapulae, the
rhomboideus major and the
rhomboideus minor (Fig. 4.2).
Trapezius (Figs 4.2 and 4.3)
Origin: Fig. 4.2 Structures belonging to the upper limb seen on the back. On the
The muscle has a long linear origin right side the trapezius, and the greater parts of the latissimus and
deltoid have been removed.
from the following structures.
BACK AND SCAPULAR REGION
1. Medial one-third of superior nuchal line. 4. The muscles of the two sides acting together draw the
2. External occipital protuberance. head backwards. Each muscle acting alone draws the head
3. Ligamentum nuchae. backwards and laterally to its own side.
4. Spine of 7th cervical vertebra.
5. Spines of all thoracic vertebrae and intervening supraspinous
Latissimus Dorsi (Figs 4.2 and 4.4)
ligaments.
Insertion:
Origin:
The muscle is inserted into:
The latissimus dorsi has a long origin from the following:
1. The posterior border of the lateral one-third of the clavicle.
1) The spines of the lower six thoracic vertebrae and the
2. The medial margin of the acromion.
intervening supraspinous ligaments.
3. The spine of the scapula.
2) The lumbar fascia.
Nerve Supply: 3) The iliac crest.
The muscle is supplied by the spinal part of the accessory nerve The fibres of the muscle converge towards the axilla. Here
and by branches from the third and fourth cervical nerves. the muscle winds round the lower border of the teres major
to reach its anterior aspect. These two muscles together form
Actions:
the posterior fold of the axilla.
The trapezius takes part in performing the following
movements: Insertion:
1. Forward rotation of the scapula, along with the serratus The muscle ends in a tendon that is inserted into the anterior
anterior. aspect of the upper end of the humerus, in the floor of the
2. Elevation of the scapula, along with the levator scapulae. intertubercular sulcus.
3. Retraction of the scapula, along with rhomboids.
Nerve Supply:
The muscle is supplied by the thoraco-dorsal nerve (C6,
C7, C8).
Actions of Latissimus dorsi:
1. Adduction of the arm.
2. Medial rotation of the arm.
3. Extension of the arm.
Levator Scapulae (Fig. 4.2)
Origin:
From the transverse processes of the upper four cervical
vertebrae.
Insertion:
Medial margin of the scapula from the superior angle to
the root of the spine.
Nerve Supply:
Branches from spinal nerves C3 and C4 and from the
dorsal scapula nerve (C5).
Actions: See under rhomboideus major.
Rhomboideus minor (Fig. 4.2)
Origin:
From lowest part of ligamentum nuchae and from the
spines of vertebrae C7 and T1.
Fig. 4.3. Scheme to show the attachments Insertion:
of the trapezius. Medial margin of the scapula opposite the root of the
spine.
27
28
NERVES OF THE BACK
Cutaneous nerves of the back

The skin of the back is supplied mainly by
cutaneous branches arising from dorsal rami
of spinal nerves (Fig. 4.5). The lateral parts
of the back are innervated by cutaneous
branches from ventral rami. Note that dorsal
rami make no contribution to the cutaneous
supply of the free upper limb.
Nerves supplying muscles of the upper

limb seen on the back
Spinal part of accessory nerve

The accessory nerve is the eleventh cranial
nerve. It has a cranial part, and a spinal part.
The spinal part of the nerve reaches the
trapezius in the lower part of the neck and
descends into the back deep to this muscle,
supplying it.
Dorsal scapular nerve

The dorsal scapular nerve arises from root
C5 of the brachial plexus. It passes
Fig. 4.4. Scheme to show backwards and downwards through the lower
the attachments part of the neck to reach the anterior aspect
of the latissimus dorsi.
of the levator scapulae. It then descends into
the back to reach the anterior (i.e. deep)
aspect of the rhomboideus muscles. The
dorsal scapular nerve supplies the
rhomboideus major and minor and may give
a branch to the levator scapulae.
Nerve supply: Dorsal scapular nerve.

Actions: See under rhomboideus major
Rhomboideus major (Fig. 4.3)
Origin:
From spines of vertebrae T2 to T5.
Insertion:
Into medial margin of scapula (from the level of the root of the
spine to the inferior angle).
Nerve supply: Dorsal scapular nerve (C5).
Actions of levator scapula and rhomboideus muscles:

The levator scapulae elevates the scapula, while the
rhomboideus muscles retract it. Acting together they steady
the scapula during movements of the upper limb. They also Fig. 4.5. Areas of skin of the back supplied
produce backward rotation of the scapula. by dorsal rami of spinal nerves.
THE SCAPULAR REGION
In the scapular region we see several muscles that take origin Insertion:
from the scapula and gain insertion into the humerus. These Into uppermost impression on greater tubercle of humerus.
are the deltoid, the supraspinatus, the infraspinatus, the teres
major, the teres minor, and the subscapularis. Actions:
1. The supraspinatus, acting along with other muscles, around
the shoulder joint, stabilises it.
Deltoid (Figs 4.3 and 4.6) 2. It is an abductor of the arm.
Origin:
The deltoid has one continuous origin from the following. Infraspinatus (Figs 4.2 and 4.8)
1. Upper surface and anterior border of the lateral one-third of
the clavicle. Origin:
2. Lateral margin and upper surface of the acromion. From medial two-thirds of the infraspinous fossa, of the
3. Lower lip of crest of spine of scapula. scapula.
Insertion:
Insertion:
Deltoid tuberosity on the lateral aspect of the shaft of the Into middle impression on greater tubercle of humerus .
humerus.
Actions:
Nerve Supply:
These are described along with those of the teres minor.
By the axillary nerve (C5, C6).
Nerve Supply:
Actions:
The supraspinatis and the infraspinatus are supplied by the
1. The anterior fibres cause flexion and medial rotation of the suprascapular nerve (C4, 5, 6) arising from Erbs point.
humerus.
2. The posterior fibres cause extension and lateral rotation.
3. The acromial part of the muscle produces abduction of the
arm at the shoulder joint (See below).
Mechanism of abduction of the arm:

Abduction of the arm is a complicated movement and
the deltoid is one of the most important muscles for it.
Abduction of the arm takes place partly at the shoulder
joint, and partly by rotation of the scapula. The first
few degrees of abduction at the shoulder joint are
produced by the supraspinatus. Abduction up to 90
degrees is produced by the deltoid. Further abduction
is produced by forward rotation of the scapula
produced by the serratus anterior and the trapezius
acting together.
Supraspinatus (Fig. 4.2)
This muscle covers the posterior aspect of the scapula

above the spine, and passes to the uppermost part of
the humerus.
Origin:
From medial two-thirds of supraspinous fossa of
scapula.
Fig. 4.6. Attachments of the deltoid muscle.
29
30
Teres Minor (Figs 4.2 and 4.8) Along with other muscles surrounding the shoulder joint
these muscles strengthen the capsule and stabilise it. During
abduction of the arm (by the deltoid and the supraspinatus)
Origin:
these two muscles pull the head of the humerus downwards,
From dorsal surface of scapula along the upper two-thirds of
and thus prevent it from getting stuck under the coraco-
the lateral border.
acromial arch.
Insertion:
Important relations:
Into lowest impression on greater tubercle of humerus.
The subscapularis and the teres major form the posterior wall
Nerve suppply: Axillary nerve.
of the axilla, and are related to the contents of the axilla.
Actions common to infraspinatus and teres minor:
1. These muscles are adductors and lateral rotators of the
Musculotendinous cuff of shoulder
humerus.
The tendons of the subscapularis, teres minor, supraspinatus
2. They stabilise the shoulder joint and strengthen the posterior
and infraspinatus unite to form a cuff (covering) for the
part of its capsule.
shoulder joint.
3. During abduction of the arm (by the deltoid and the
supraspinatus) their downward pull prevents the head of the
humerus from getting stuck under the coraco-acromial arch.
This allows abduction to take place smoothly. Quadrangular and Triangular Spaces
These spaces are present just below the medial border of the
scapula (Fig. 4.8). Their boundaries are as follows:
Teres Major (Figs 4.2, 4.7 and 4.8)
The quadrangular space is bounded above by the teres minor
and the subscapularis, below by the teres major, medially by
Origin: the long head of the triceps, and laterally by the surgical neck
From dorsal surface of scapula; the area of origin overlies the of the humerus. The axillary nerve and the posterior
inferior angle and the lower one-third of the lateral border. circumflex humeral artery pass backwards through this space.
The upper and lower boundaries of the triangular space are
Insertion:
the same as those of the quadrangular space. Its lateral
On anterior aspect of humerus, into the medial lip of
boundary is formed by the long head of the triceps. The
circumflex scapular branch of the subscapular artery passes
Nerve supply: through this space.
Lower subscapular nerve (C6, 7).
Actions:
These are described along with those of the
subscapularis.
Subscapularis (Fig. 4.7)
Origin:
Medial two-thirds of the subscapular fossa
(on costal surface of scapula).
Insertion
Lesser tubercle of humerus.
Nerve supply:
Upper and lower subscapular nerves (C5, 6,
7).
Actions of teres major and subscapularis:

Both the teres major and the subscapularis
are adductors and medial rotators of the arm.
In addition the teres major can extend the arm. Fig. 4.7. Attachments of the subscapullaris. The teres major is also shown.
NERVES OF SCAPULAR
REGION
The nerves of the scapular region are the upper

and lower subscapular nerves (already
described), the suprascapular nerve and the
axillary nerve.
The Suprascapular Nerve
The suprascapular nerve runs laterally and

backwards over the shoulder (Fig. 4.9), deep to
the trapezius. Reaching the upper border of the
scapula it passes backwards through the
suprascapular notch (below the transverse
scapular ligament) to enter the supraspinous
fossa. After supplying the supraspinatus the
nerve enters the infraspinous fossa where it ends
by supplying the infraspinatus. The nerve also
gives branches to the shoulder joint and to the
acromioclavicular joint.
Fig. 4.8. Diagram to show the triangular space (A) and the quadrangular
space (B), of the scapular region.
The Axillary Nerve
The axillary nerve (Fig. 4.10) supplies the deltoid and the The nerve ends by dividing into an anterior and a posterior
teres minor. It is a branch of the posterior cord of the brachial branch. The anterior branch passes round the surgical neck of
plexus. At its origin it lies behind the axillary artery. It the humerus and ends by supplying the deltoid. Some
descends over the subscapularis, and reaching its lower ramifications reach the skin. The posterior branch supplies the
border it passes backwards through the quadrangular space. posterior part of the deltoid and also the teres minor. Its terminal
part becomes the upper lateral cutaneous nerve of the arm:
this nerve supplies the skin over the lower part of the deltoid
muscle.
Fig. 4.10. Scheme to show the course and distribution of

the axillary nerve. a - anterior branch; b - posterior
Fig. 4.9. Scheme to show the course of the branch; c - branch to shoulder joint; e - cutaneous twig
suprascapular nerve, and the nerve to the subclavius. from anterior branch.
31
32
ARTERIES OF SCAPULAR REGION The Transverse Cervical Artery (Fig. 4.11)
This artery divides into superficial and deep branches. The

In the back and scapular region we see some arteries that begin superficial branch runs laterally across the posterior triangle
in the neck as (direct or indirect) branches of the subclavian of the neck to reach the trapezius. It then ascends deep to
artery. Like the axillary artery, the subclavian artery is divided the trapezius, supplying it and neighbouring structures. The
into first, second and third parts (by a muscle called the scalenus deep branch of the transverse cervical passes laterally and
anterior). A short artery called the thyrocervical trunk arises backwards in the lower part of the posterior triangle of the
from the junction of the first and third parts of the subclavian neck to reach the upper angle of the scapula. It then runs
artery (Fig. 4.11). The thyrocervical trunk divides into three along the medial border of this bone up to the inferior angle
arteries: inferior thyroid, suprascapular and transverse cervical. (deep to the levator scapulae and rhomboideus muscles). It
The suprascapular and transverse cervical arteries are supplies these muscles and the trapezius. It gives branches
encountered in the scapular region. that anastomose with the suprascapular and subscapular
arteries (See below).
Fig. 4.11. Anastomoses around the scapula.

The Suprascapular artery (Fig. 4.11) Anastomosis around the scapula (Fig. 4.11)
SUPERFICIAL NERVES AND VEINS : THE ARM AND CUBITAL FOSSSA

This artery arises in the neck from the thyrocervical trunk. It 1. On the back of the body of the scapula the suprascapular
passes downwards to reach the superior border of the artery anastomoses with the deep branch of the transverse
scapula: here it passes above the transverse scapular cervical artery and with the circumflex scapular branch of
ligament and enters the supraspinous fossa (on dorsal the subscapular artery.
surface of scapula above the spine). After giving some 2. On the ventral surface of the body of the scapula branches
branches to the supraspinatus it passes into the infraspinous of the suprascapular artery anastomose with the subscapular
fossa by passing through the spinoglenoid notch. In the artery and with the deep branch of the transverse cervical
infraspinous fossa it divides into a number of branches that artery.
supply the infraspinatus. Branches are also given to some 3. Over the acromion branches of the suprascapular artery
other muscles, to the shoulder joint, the acromioclavicular anastomose with the thoracoacromial and posterior
joint and skin. circumflex humeral arteries.
The anastomoses described above connect the first part of
the subclavian artery to the third part of the axillary artery.
5 : Superficial Nerves and Veins

The Arm and Cubital Fossa
In this chapter we will consider (1) the cutaneous
nerves and superficial veins of the free part of the
upper limb (arm, forearm, hand); (2) the muscles,
blood vessels and nerves of the arm, and (3) the
cubital fossa.
CUTANEOUS NERVES OF THE

ARM AND FOREARM
These are listed below. Their areas of distribution

are indicated by their names, and are shown in Figs
5.1 and 5.2.
1. Lateral supraclavicular nerve supplies skin over

the upper part of the deltoid muscle.
2. Upper lateral cutaneous nerve of arm (branch
of axillary nerve) supplies skin over the lower part
of the deltoid muscle.
3. Lower lateral cutaneous nerve of arm (branch
of radial nerve) supplies the lateral side of the arm.
4. Posterior cutaneous nerve of arm (branch of
radial nerve) supplies an area on the back of the arm.
5. Intercostobrachial nerve (lateral cutaneous
branch of second intercostal nerve) supplies skin of
axilla and upper part of medial side of arm. Fig. 5.1. Cutaneous nerve Fig. 5.2. Cutaneous nerve
6. Medial cutaneous nerve of arm (branch of medial supply of front of upper supply of back of upper
cord of brachial plexus) supplies skin over medial extremity. extremity.
side of lower part of arm.
33
34
7. Medial cutaneous nerve of forearm
(branch of medial cord of brachial plexus)
supplies skin over medial side of forearm; and
on the front of the arm.
8. Lateral cutaneous nerve of the forearm
(continuation of musculocutaneous nerve)
supplies skin on lateral side of the forearm,
and the thenar eminence.
9. Posterior cutaneous nerve of forearm
(branch of radial nerve) supplies skin on the
back of the forearm, and the lower part of the
back of the arm.
CUTANEOUS NERVES OF THE HAND

Fig. 5.3. Cutaneous nerve supply of the hand. A. Palmar aspect.
The skin on the palmar aspect of the hand is B. Dorsal aspect.
supplied mainly by branches of the ulnar and
median nerves (Fig. 5.3). The ulnar nerve
supplies the medial one and half digits and the corresponding part of
the palm. The rest of the palmar aspect is supplied by branches of the
median nerve. Small parts of the hand near the wrist are supplied by
cutaneous nerves of the forearm.

The nerve supply of the skin on the dorsum of the hand is shown in
Figure 5.3B. Note that the dorsal aspects of the terminal phalanges of
each digit are supplied by nerves that wind round from the palmar
aspect. Over the medial one and half fingers the supply is by the
ulnar nerve, and over the other digits it is by the median nerve. The
rest of the dorsum of the hand is supplied in its lateral half (or so) by
the radial nerve, and in its medial half (or so) by the ulnar nerve.
Details of the branching pattern of these nerves will be considered
when the hand is described.
VEINS OF THE UPPER LIMB
The venous drainage of the limbs is carried out through two separate
sets of veins. Most of the blood is returned through superficial veins
that lie in the superficial fascia and have no relationship to arteries of
the limb. The other set, the deep veins, run along the arteries.
A. Superficial Veins
The dorsal digital veins from the fingers end in dorsal metacarpal
veins which in turn join each other to form a dorsal venous network
over the dorsum of the hand (Fig. 5.4). The palmar digital veins
drain into a superficial plexus in the palm. The veins of the hand are
further drained by two main superficial veins. These are the cephalic
and basilic veins.
The cephalic vein begins from the lateral side of the hand. It first
ascends along the radial side of the forearm, but higher up it lies on
the anterior surface. Crossing the lateral part of the elbow it runs Fig. 5.4. Superficial veins of the upper limb.
upwards into the arm. Here it lies along the lateral side of The median cubital vein (Fig. 9.14) lies in front of the elbow

the biceps brachii. In the upper part of the arm it comes to lie joint. It passes upwards and medially from the cephalic vein to
in the groove between the anterior margin of the deltoid the basilic vein.
muscle and the pectoralis major. A little below the clavicle Some other superficial veins seen in the limb are shown in
it pierces the clavipectoral fascia and ends in the axillary Figure 5.4.
vein. The cephalic vein is connected to the basilic vein by
the median cubital vein (See below).
B. Deep Veins
The basilic vein begins from the ulnar side of the venous
network on the dorsum of the hand. It ascends along the
The deep veins accompany the arteries of the limb. Such veins
ulnar side of the forearm, first on its posterior aspect and
are called venae comitantes. They are found in relation to the
then winding round the ulnar border to reach the anterior
radial and ulnar arteries, and to the brachial artery. The veins
aspect. Crossing in front of the medial part of the elbow it
accompanying the brachial artery are joined (near the lower
runs upwards along the medial side of the biceps brachii
border of the teres major) by the basilic vein to form the axillary
muscle. At about the middle of the arm it pierces the deep
vein.
fascia and comes to lie medial to the brachial artery. It
ascends in this position up to the lower border of the teres
major where it becomes the axillary vein.
ARM: ANTERIOR COMPARTMENT
Compartments of the Arm
For purposes of description the arm can be divided into anterior Nerve Supply:
and posterior compartments that are partially separated by the Musculocutaneous nerve (C5, C6).
humerus and by the medial and lateral intermuscular septa.
Actions:
The structures in each compartment are considered below.
1. The muscle is a flexor of the forearm (at the elbow joint).
2. The biceps supinates the forearm at the superior and inferior
radio-ulnar joints.
3. The short head is a flexor of the shoulder joint. The long
MUSCLES OF THE ANTERIOR head helps to maintain the head of the humerus in its normal
COMPARTMENT OF THE ARM position during movements at this joint.
Bicipital aponeurosis
The tendon of the biceps brachii gives off an extension called
Biceps Brachii (Fig. 5.5) the bicipital aponeurosis. This aponeurosis passes medially
and downwards (covering the brachial artery and the median
Origin: nerve).
The biceps brachii arises from the scapula by two heads, long
and short.
The long ahead arises from the supraglenoid tubercle. Coracobrachialis (Fig. 5.6)
The short head arises from the tip of the coracoid process
(together with the coracobrachialis).
The tendon of the long head arches over the head of the Origin:
humerus to enter the intertubercular sulcus. This part of the From tip of coracoid process of the scapula.
tendon lies within the cavity of the shoulder joint. Insertion: Into the medial border of the humerus near the
The two heads fuse to form a large belly which ends in a middle of the shaft.
tendon.
Insertion: Nerve Supply: Musculocutaneous nerve (C5, 6, 7).
The tendon crosses in front of the elbow joint and dips
backwards to be inserted into the posterior part of the Action: It is a flexor of the arm.
tuberosity of the radius.
35
36
Fig. 5.5. Scheme to show the attachments of the Fig. 5.6. Scheme to show the attachments of the
biceps brachii. coracobrachialis and brachialis muscles.
Brachialis (Fig. 5.6) Nerve Supply:

The muscle receives its main supply from the
Origin: musculocutaneous nerve (C5, 6). The lateral part of the
The brachialis arises from the front of the lower half of the muscle is supplied by the radial nerve (C7).
humerus (i.e. from the anteromedial and anterolateral Action:
surfaces). Flexor of the elbow joint.
Insertion:
Into the anterior surface of the coronoid process of the ulna,
including the tuberosity of the ulna.
THE BRACHIAL ARTERY

The brachial artery begins at the
lower border of the teres major as
the continuation of the axillary
artery. Its upper part lies on the
medial aspect of the arm. As it
descends it gradually passes
forwards, so that its lower end lies
in front of the elbow (cubital fossa).
Here it terminates (at the level of the
neck of the radius) by dividing into
the radial and ulnar arteries. The
relations of the artery are considered
below.
Relationship to muscles:
From above downwards the artery
lies successively on the long head of
the triceps, the medial head of the
triceps and the brachialis.
Anterolaterally it is related to the
coracobrachialis and the biceps
brachii. Its lowest part lies medial
to the biceps tendon. The bicipital
aponeurosis, passes medially across
the artery.
Relationship to nerves:
a) The radial nerve lies behind the
uppermost part of the brachial artery.
b) The median nerve descends along
the lateral side of the upper half of
the artery. It then crosses in front of
the artery and comes to lie along its
medial side.
c) The ulnar nerve lies medial to the
upper half of the artery. Lower down
it parts company from the artery as
it pierces the medial intermuscular
septum to enter the posterior
compartment of the arm.
Relationship to veins:
The brachial artery is accompanied
by venae comitantes. The basilic
vein comes to lie medial to the artery
a little above the elbow, but is
separated from it by deep fascia. The Fig. 5.7. Scheme to show the arteries of the arm.
vein pierces the deep fascia near the
middle of the arm, and thereafter lies
close to the artery. At the upper end Branches of the Brachial Artery (Fig. 5.7)
of the brachial artery the venae
comitantes join the basilic vein to The profunda brachii artery arises a little below the upper end of the brachial
form the axillary vein. artery. Accompanying the radial nerve it enters the posterior compartment of the
arm. Here it passes laterally and downwards behind the humerus, where it lies in
the radial groove. It gives off the following branches.
37
38
(a) A nutrient artery is given off to the humerus. brachial plexus. Its upper end lies in the axilla, lateral to
(b) The ascending branch anastomoses with the descending the axillary artery. It continues into the arm lateral to the
branch of the posterior circumflex humeral artery. brachial artery. Near the middle of the arm it crosses
(c) The posterior descending (or middle collateral) branch superficial to the artery to reach its medial side, and
anastomoses with the recurrent branch of the posterior descends in this position to the cubital fossa. The nerve
interosseous artery. leaves the cubital fossa by passing between the superficial
(d) The anterior descending (or radial collateral) artery pierces and deep heads of the pronator teres. and descends into
the lateral intermuscular septum and enters the anterior the forearm.
compartment of the arm. It runs along the radial nerve in the The only branch given off by the median nerve in the
lower lateral part of the arm and ends by anastomosing with the arm descends to supply the pronator teres. All other
recurrent branch of the radial artery. branches arise in the forearm and hand.
The superior ulnar collateral artery arises from the brachial

artery near the middle of the arm. Accompanying the ulnar nerve
this artery pierces the medial intermuscular septum to enter the
posterior compartment of the arm. It runs downwards to reach
the back of the medial epicondyle. The artery ends by
anastomosing with the posterior recurrent branch of the ulnar
artery and with the supratrochlear artery.
The supratrochlear artery arises from the brachial artery a little

above the elbow. It pierces the medial intermuscular septum
and enters the posterior compartment of the arm. Branches of
the artery anastomose with the anterior recurrent branch of the

ulnar artery (in front of the elbow); and with the posterior
descending branch of the profunda brachii artery, and the
interosseous recurrent artery (behind the elbow).
In Figure 5.7, note the arteries helping to form the arterial
anastomoses around the elbow joint.
NERVES OF THE ARM
The main nerves to be seen in the arm are the musculocutaneous

nerve, the median nerve, the ulnar nerve and the radial nerve.
The musculocutaneous and median nerves lie in the anterior
compartment; while the ulnar and radial nerves pass through
both anterior and posterior compartments.
Musculocutaneous nerve
The musculocutaneous nerve is a branch of the lateral cord (Fig.
5.8). The nerve runs downwards and laterally through the front
of the arm. It then crosses in front of the elbow to enter the
forearm. Here the nerve becomes superficial and is called the
lateral cutaneous nerve of the forearm.
The musculocutaneous nerve supplies the coracobrachialis, the
biceps brachii (both heads) and the brachialis. As the lateral
cutaneous nerve of the forearm it supplies the skin of the lateral
half of the front of the forearm. Its lowest part supplies the skin
of the thenar eminence.
Fig. 5.8. Scheme to show the course and distribution of

Median nerve the musculocutaneous nerve. For areas of skin supplied
The median nerve (Fig. 5.9) is formed by union of lateral and by the lateral cutaneous nerve of the forearm, see Fig. 5.1.
medial roots that arise from the corresponding cords of the
Ulnar nerve

arch joining the humeral and ulnar heads of the flexor carpi
The ulnar nerve is a branch of the medial cord of the brachial
ulnaris.. The ulnar nerve does not give any branch in the
plexus (Fig. 5.9). It extends from the axilla to the hand. At
arm.
its origin it lies medial to the axillary artery (between it and
the axillary vein). It runs down into the front of the arm
where it lies medial to the brachial artery. At the middle of Radial nerve (Fig. 5.10)
the arm the nerve passes into the posterior compartment by The radial nerve is the main continuation of the posterior
piercing the medial intermuscular septum. It descends and cord of the brachial plexus. At its upper end (i.e. in the
passes behind the medial epicondyle of the humerus. The axilla) it lies behind the third part of the axillary artery. In the
nerve enters the forearm by passing deep to the tendinous upper part of the arm it lies behind the upper part of the
Fig. 5.10. Scheme to show the course and distribution of the radial
Fig. 5.9. Scheme to show the main nerves of the arm. nerve as seen from the front. The parts of the nerve placed on the
dorsal aspect of the limb are shown in brown.
39
40
brachial artery. It leaves the front of the arm by passing (and while within the muscle) winds round the radius to
backwards (between the long and medial heads of the triceps). reach the back of the forearm.
In the posterior compartment the nerve passes downwards
Branches of radial nerve in the arm:
and laterally lying in the radial groove. Near the elbow, the
1. Near its upper end, the nerve gives branches to the medial
nerve pierces the lateral intermuscular septum and enters the
and long heads of the triceps.
cubital fossa. Here it passes forwards in the interval between
2. In the radial groove, the nerve gives branches to the medial
the brachialis (medially) and the brachioradialis (laterally).
and lateral heads of the triceps; and to the anconeus.
Finally it divides into superficial and deep branches. The
3. After piercing the lateral intermuscular septum, the nerve
superficial branch descends into the front of the forearm. The
gives branches to the brachialis, the brachioradialis, and the
deep branch enters the substance of the supinator muscle
extensor carpi radialis longus. It divides into superficial and
deep terminal branches.
THE CUBITAL FOSSA
CUBITAL FOSSA of the pronator teres muscle. The median nerve leaves the
fossa by passing through the interval between the superficial

and deep heads of this muscle. This nerve gives off several
The region where the front of the arm becomes continuous branches in the cubital fossa that supply some muscles of
with the front of the forearm is marked by a triangular the front of the forearm. The radial nerve enters the cubital
depression called the cubital fossa. (Cubit = elbow). For fossa by passing forwards in the interval between the
descriptive purposes the fossa can be said to have a roof, a
floor, and superior, medial and lateral boundaries.
The superior boundary of the fossa is formed by an imaginary

line connecting the medial and lateral epicondyles of the
humerus (Fig. 12.12).
The lateral boundary of the fossa is formed by the medial
border of the brachioradialis.
The medial boundary of the fossa is formed by the lateral
margin of the pronator teres.
The apex of the fossa lies inferiorly and is formed by crossing
of the brachioradialis across the front of the pronator teres.
The floor of the fossa is formed by the lower end of the
brachialis, above, and by the supinator muscle, below.
The roof of the fossa is formed by overlying fascia.. The
cephalic vein, the basilic vein, and the median cubital vein lie
in this fascia. The medial and lateral cutaneous nerves of the
forearm also lie in the roof.
The contents of the fossa are:

1. The tendon of the biceps brachii (along with the bicipital
aponeurosis).
2. The lower end of the brachial artery (medial to the tendon),
dividing into radial and ulnar arteries.
3. The median nerve (medial to the artery).
4. The radial nerve (in lateral part of fossa).
The radial artery runs downwards to reach the apex of the fossa. Fig. 5.11. Boundaries of the cubital fossa.
The ulnar artery leaves the fossa by passing deep to both heads
brachialis (medially) and the brachioradialis (laterally). Here it carpi radialis longus. The radial nerve then divides into

gives branches to both these muscles, and also to the extensor superficial and deep branches.
ARM:POSTERIOR COMPARTMENT
The structures to be seen in the posterior compartment of

the arm are (1) the triceps muscle, (2) parts of the radial and
ulnar nerves, and (3) the profunda brachii artery and part of
the supratrochlear arteries.
The nerves and arteries have been described above. The
triceps muscle is described below.
Triceps (Fig. 5.12)
Origin:
As indicated by its name the muscle has three heads of origin.
1. The long head arises from the infraglenoid tubercle of
the scapula.
2. The lateral head arises from a ridge on the posterior aspect
of the humerus (See Fig. 2.13). The ridge corresponds to the
upper part of the lateral border of the bone. The upper end of
the ridge reaches the greater tubercle; the lower end lies near
the deltoid tuberosity.
3. The medial head arises from the posterior surface of the
humerus below the radial groove; and also from the medial
and lateral intermuscular septa.
Insertion:
The muscle is inserted into the posterior part of the superior
surface of the olecranon process of the ulna.
Nerve supply:
Radial nerve .
Actions:
The triceps extends the forearm at the elbow joint.
Radial groove
This is a shallow groove on the posterior aspect of the shaft
of the humerus (see Fig. 2.13). It runs downwards and laterally,
just above the attachment of the medial head of the triceps.
Fig. 5.12. Scheme to show the attachments of the The radial nerve and the profunda brachii artery lie in the
triceps muscle groove. These structures are overlapped by the lateral head
of the triceps.
41
42
6 : The Forearm and Hand

FRONT OF FOREARM AND PALM
The forearm contains a large

number of muscles. Most of them
end in long tendons that enter the
hand to gain insertion there. It is
for this reason that we will
consider the forearm and hand
together. For convenience of
description the structures in the
forearm can be divided into those
seen on the front and those seen
on the back. At the wrist the front
of the forearm becomes conti-
nuous with the palmar (anterior)
aspect of the hand, while the back

of the forearm becomes conti-
nuous with the dorsum of the hand.
The cutaneous nerve supply, and
the superficial veins, of the
forearm and hand have already
been described.
MUSCLES OF FRONT
OF FOREARM
Pronator Teres (Figs 6.1

and 6.2)
Origin:
The pronator teres has two heads
of origin. The humeral head (that
is superficial) arises from (1) the
lowest part of the medial
supracondylar ridge, and (2) from
the medial epicondyle (common
flexor origin) of the humerus. The
ulnar head (or deep head) arises
from the medial side of the
coronoid process of the ulna.
Insertion:
Into the lateral surface of the shaft
of the radius at about the middle
of the bone.
Fig. 6.1. Muscles of front of forearm seen after removal of superficial structures.
THE FOREARM AND HAND
Flexor Carpi Radialis (Figs 6.1 and 6.3)
Origin:
From medial epicondyle of humerus (common flexor origin).
The muscle ends in a tendon that passes anterior to the wrist
in its lateral part. Here the tendon passes through a tunnel
bounded laterally by a groove in the trapezium, and medially
by two slips of the flexor retinaculum (Fig. 6.8B).
Fig. 6.2. Attachments of pronator teres and

pronator quadratus.
Nerve Supply:
Median nerve (C6, 7).
Actions:
As indicated by its name it pronates the forearm. It is also a
weak flexor of the elbow.
Notes:
1. The lateral border of the pronator teres forms the medial
boundary of the cubital fossa.
2. The median nerve passes between the humeral and ulnar
heads.
3. The ulnar artery passes deep to the ulnar head. In other
words, the ulnar head separates the ulnar artery from the
median nerve.
Fig. 6.3 Attachments of the flexor carpi radialis.
43
44
Insertion: Bases of the second and third metacarpal bones. Flexor Carpi Ulnaris (Figs 6.1 and 6.4)
Nerve Supply: Median nerve (C6, 7).
Origin:
Actions: Flexion and abduction of the wrist. This muscle has two heads of origin. The humeral head
Important Relation: arises from the medial epicondyle. The ulnar head arises
The radial artery lies just lateral to the tendon of this muscle from (a) the medial side of the olecranon process; and (b)
(between it and the brachioradialis). from the upper two-thirds of the posterior border of the
ulna (through an aponeurosis that also gives origin to the
extensor carpi ulnaris and to the flexor digitorum
profundus).
Some fibres of the muscle arise from a tendinous arch
passing from the medial epicondyle of the humerus to the
olecranon process of the ulna.
The muscle ends in a tendon that crosses the medial part
of the wrist.
Insertion:
Into pisiform bone.
Nerve Supply:
Ulnar nerve (C7, 8).
Actions:
Flexion and adduction of the hand (at the wrist joint).
Note:
1. The ulnar nerve enters the forearm by passing deep to
the tendinous arch connecting the humeral and ulnar heads
of origin.
2. At the wrist the ulnar artery and nerve lie lateral to the
tendon of this muscle.
Flexor Digitorum Superficialis (Figs 6.1 and 6.5)
Origin:
The muscle has two heads of origin.
A B
The humero-ulnar head arises from
a. the medial epicondyle of the humerus (common flexor
origin).
b. the anterior part of the ulnar collateral ligament of the
elbow joint, and
c. the medial margin of the olecranon process of the ulna.
The radial head arises from the anterior border of the
radius (from the radial tuberosity above, up to the insertion
of the pronator teres below (i.e. from the oblique line).
Insertion:
The muscle ends in a tendon that splits into four smaller
tendons, one for each digit except the thumb. Opposite
the proximal phalanx the tendon for each digit splits to
form two slips, medial and lateral that are attached to the
sides of the middle phalanx.
Nerve Supply:
Median nerve (C7, 8, T1).
Fig. 6.4. A. Attachments of flexor carpi ulnaris. B. Humerus and
ulna viewed from the medial side to show origin of ulnar head
of the muscle.
Fig. 6.6. A. Attachments of the flexor digitorum

profundus.
Fig. 6.5. Attachments of the flexor digitorum
B. Medial view of ulna to show area of origin of the
superficialis.
muscle.
45
46
Actions:
Flexion of the middle and proximal phalanges of the digits
concerned.
Flexor Digitorum Profundus (Fig. 6.6)
Origin:
The muscle arises from an extensive area extending on to
the following parts of the ulna:
a. the medial surface of the coronoid process;
b. the upper three fourths of the anterior surface; and
c. the upper three fourths of the medial surface; and
d. the upper three fourths of the posterior border, by an
aponeurosis that also gives origin to the flexor carpi ulnaris
and the exterior carpi ulnaris .
The muscle also takes origin from the medial half of the
interosseous membrane.
Fig. 6.7. Drawings to show the arrangement of tendons on the
palmar aspect of a typical finger. A. Areas of insertion of flexor
digitorum superficialis and profundus. B. View with both tendons
in place. C. View with profundus tendon removed.
Fig. 6.8A. Scheme to show synovial

sheaths in the palm and digits.
Insertion:
The muscle ends in a tendon that splits into four parts, one Over the digits the tendons are surrounded by a common digital
for each digit except the thumb. Each tendon passes through synovial sheath, that lines the inside of the fibrous flexor sheath.
the interval between slips of the flexor digitorum Each digital sheath extends from the level of the metacarpo-
superficialis to be inserted into the base of the distal phalanx. phalangeal joint (proximally) to the insertion of the profundus
tendon (distally). The digital sheath of the little finger is
Nerve Supply:
continuous proximally with the ulnar bursa. For description of
The muscle has a double supply: the medial part by the
the radial bursa see below.
ulnar nerve and the lateral part by the median (through its
anterior interosseous branch) (C8, T1).
Actions:
Flexor Pollicis Longus (Fig. 6.9)
Flexion of the distal phalanges.
Origin:
Some additional facts about Flexor Digitorum
The muscle arises from:
Superficialis and Profundus
a. the anterior surface of the radius (below the oblique line, and
(1) Fibrous flexor sheaths: excluding the lower one fourth of the bone; and
During their course over the ventral aspect of the digits, b. the lateral part of the interosseous membrane (anterior aspect).
the tendons of the flexor digitorum superficialis and The muscle ends in a tendon that runs across the front of the
profundus (for that digit) lie in a common canal bounded wrist (lateral part). Here it lies in the carpal tunnel. The tendon
posteriorly, by the phalanges and anteriorly (and on the then passes into the thumb. Here it is surrounded by a synovial
sides) by a fibrous membrane. This membrane is called the sheath, and a fibrous flexor sheath, just like tendons of the digital
fibrous flexor sheath (Fig. 6.8). It holds the tendons in flexors.
place.
Insertion:
(2) Synovial sheaths:
Base of the distal phalanx of the thumb on its ventral aspect.
At the wrist the four tendons of the flexor digitorum
superficialis lie superficial to the four tendons of the Nerve Supply:
profundus (Fig. 6.8B). All the eight tendons pass through Median nerve through its anterior interosseous branch (C8, T1).
the carpal tunnel that is bounded, in front by the flexor
Action
retinaculum; and behind by the carpal bones. Here the
The muscle flexes the phalanges of the thumb.
tendons are surrounded by a common synovial sheath (also
called the ulnar bursa)(Fig. 6.8). Proximally, the sheath
extends into the forearm for about 2.5 cm proximal to the
flexor retinaculum. Distally it extends to the middle of the
palm.
Fig. 6.8B. Transverse section through the wrist to show related tendons and their synovial sheaths.
47
48
Radial bursa:
The synovial sheath surrounding the tendon is called the
radial bursa (Fig. 6.8). Proximally the bursa extends into the
forearm for about 2.5 cm above the flexor retinaculum. It
surrounds the tendon as it passes through the carpal tunnel
and extends up to the insertion of the tendon.
Pronator Quadratus (Fig. 6.2)
Origin:
Oblique ridge on lower part of the anterior surface of the ulna.
Insertion:
Anterior surface of the shaft of the radius (lower one fourth).
Nerve Supply:
Median nerve through its anterior interosseous branch (C8,
T1).
Actions:
It is the chief pronator of the forearm.
Fascia on front of the wrist and hand
Flexor Retinaculum
This is a strong band of fascia stretching across the ventral
aspect of the carpus. The space between the retinaculum and
the carpal bones is called the carpal tunnel. It transmits the
tendons of the flexor digitorum superficialis and profundus,
Fig. 6.9. Attachments of the flexor pollicis longus.
Fig. 6.11. Diagram to show attachments of lumbrical

Fig. 6.10. Attachments of the flexor retinaculum. muscles.
the tendon of the flexor pollicis longus and the median nerve Nerve Supply:
(Fig. 6.8). The attachments of the flexor retinaculum are shown The first and second lumbricals receive branches from the
in Figure 6.10. median nerve (C8, T1); and the third and fourth from the
deep branch of the ulnar (C8, T1).
Palmar aponeurosis
This is a triangular structure consisting of thickened deep fascia Actions:
that covers the central part of the palm. The apex of the triangle The lumbrical muscles flex the metacarpo-phalangeal joints,
is directed proximally. It is continuous with the tendon of the and extend the interphalangeal joints of the digit into which
palmaris longus. Distally, the aponeurosis is broad. It divides they are inserted.
into four processes, one for each finger.
THE THENAR AND HYPOTHENAR MUSCLES

MUSCLES OF THE HAND
The thenar muscles are present in relation to the thumb and
form the thenar eminence. They produce movements of the
Palmaris Brevis thumb. They are the abductor pollicis brevis, the flexor
This is a subcutaneous muscle lying along the medial border of pollicis brevis, the opponens pollicis, and the adductor
the hand. brevis.
The hypothenar muscles are present in relation to the little
finger and form the hypothenar eminence. They produce
Lumbrical Muscles
movements of the little finger. The hypothenar muscles are
These are four small muscles that take origin from the tendons
the abductor digiti minimi, the flexor digiti minimi, and the
of the flexor digitorum profundus. They are numbered from
opponens digiti minimi
lateral to medial side. Some details of their origin are shown in
Note the following important points about them:
Figure 6.11.
a. The action of each muscle is indicated by its name.
Insertion: b. Remember that movements of the thumb take place at
The tendons of each muscle passes backwards on the radial right angles to those of other digits.
side of a metacarpo-phalangeal joint, to be inserted into the c. The opponens muscles are responsible for bringing the
lateral basal angle of the extensor expansion. thumb and little finger in contact with each other. The
opponens pollicis also brings the thumb into opposition with
other digits.
Fig. 6.12. Attachments of the abductor pollicis brevis and abductor digiti minimi.
49
50
Fig. 6.13. Attachments of the flexor pollicis brevis and flexor digiti minimi.
Fig. 6.14. Attachments of the opponens pollicis and the opponens digiti minimi.
d. Each abductor muscle, and each flexor muscle, arises in
the region of the carpus and is inserted into the proximal
phalanx of the digit concerned.
e. Each opponens muscle arises in the region of the carpus
and is inserted into the shaft of the corresponding
metacarpal bone.
f. All hypothenar muscles are supplied by the deep branch
of the ulnar nerve. The thenar muscles are supplied partly
by the median nerve and partly by the deep branch of the
ulnar nerve.
For details about each muscle, see Figures 6.12 to 6.15.

Palmar Interossei
These are four small muscles placed between the shafts of
the metacarpal bones. They are numbered from lateral to
medial side. There is one muscle each for the 1st, 2nd, 4th
and 5th digits, there being none for the 3rd digit (Fig. 6.16).
Each muscle arises from one metacarpal bone and is
inserted into the dorsal digital expansion of the same digit
(see below).
All palmar interossei adduct the digit to which they are
Fig. 6.15. Attachments of adductor pollicis.
attached, towards the middle finger. In addition they flex
the digit at the metacarpo-phalangeal joint and extend the
digit at the interphalangeal joints. Dorsal Interossei
All palmar interossei are supplied by the deep branch of Like the palmar interossei the dorsal interossei are four small
the ulnar nerve (C8, T1). For details of attachment of each muscles placed between the metacarpal bones, and numbered
muscle, see Figure 6.16. from the lateral to the medial side (Fig. 6.17). Each muscle arises
from the contiguous sides of two metacarpal bones. It is inserted
(a) into a dorsal digital
expansion, and (b) into one
side of the base of a proximal
phalanx.
All dorsal interossei are
abductors of the digit, i.e.
they move the digits, away
from the line of the middle
finger. In addition (like the
palmar interossei) they flex the
metacarpo-phalangeal joint
and extend the interphalangeal
joint.
All dorsal interossei are
supplied by the deep branch
of the ulnar nerve (C8, T1).
Fig. 6.16. Attachments of palmar interossei.
51
52
Fig. 6.17. Attachments of dorsal interossei. Each insertion is partly into the dorsal digital expansion and partly into
the base of the proximal phalanx of the digit concerned.
NERVES OF FOREARM AND HAND

The main nerves of the forearm are the median, ulnar and interosseous membrane. The muscles supplied through it
radial nerves. These are described below. are the flexor pollicis longus, the lateral part of the flexor
digitorum profundus and the pronator quadratus.
THE MEDIAN NERVE (Fig. 6.18) 4. A muscular branch arising in the palm supplies three thenar
muscles namely the flexor pollicis brevis, the abductor
The course of the median nerve in the arm has been described pollicis brevis and the opponens pollicis.
on page 38. We have seen that the nerve leaves the cubital 5. The first and second lumbrical muscles of the hand are
fossa by passing between the superficial and deep heads of supplied by branches from the digital nerves (see below).
the pronator teres. Its further course in the forearm is B. Cutaneous branches:
described below. 1. The palmar cutaneous branch (superficial palmar
The median nerve runs down the forearm in the plane branch) arises in the lower part of the forearm. It supplies
between the flexor digitorum superficialis and the flexor the skin over the thenar eminence and over the middle of
digitorum profundus. At the wrist the nerve lies between the palm.
the tendons of the flexor digitorum superficialis (medially) 2. The median nerve ends by dividing into a variable number
and the flexor carpi radialis (laterally). The nerve enters the of palmar digital branches that subdivide so that ultimately
hand by passing deep to the flexor retinaculum. seven proper palmar digital nerves are formed: two each
The nerve is distributed as follows (Fig. 6.18): (one medial and one lateral) for the thumb, the index and
A. Muscular branches: the middle fingers, and one for the lateral-half of the ring
1. The pronator teres is supplied by a branch that arises in finger. Through these branches the median nerve supplies
the lower part of the arm. the palmar surface of the lateral three and a half digits
2. Direct branches arising in the upper part of the forearm (See Fig. 5.3). It also supplies the dorsal surfaces of the
supply the flexor carpi radialis, the palmaris longus and the terminal parts of the same digits including the nail beds, the
flexor digitorum superficialis. skin over the terminal phalanx of the thumb, and over the
3. The anterior interosseous nerve arises from the median middle and terminal phalanges of the index and middle
nerve as the latter passes between the two heads of the fingers and the lateral-half of the ring finger (See Fig. 5.3 B).
pronator teres. It runs down the forearm in front of the
THE ULNAR NERVE (Fig. 6.19)
The course of the ulnar nerve in the arm has been considered
on page 39. Its further course is described below.
The ulnar nerve enters the forearm by passing deep to the
tendinous arch joining the humeral and ulnar heads of the
flexor carpi ulnaris (See Fig. 6.4). The nerve runs down the
medial side of the front of the forearm lying superficial to the
flexor digitorum profundus. In the lower two-thirds of the
forearm the nerve is accompanied by the ulnar artery that
lies lateral to it. In the upper part of the forearm the nerve is
deep to the flexor carpi ulnaris and to the flexor digitorum
superficialis.
The nerve becomes superficial in the lower one-third of the
forearm: here it lies between the tendons of the flexor carpi
ulnaris (medially) and that of the flexor digitorum
superficialis (laterally). The nerve enters the hand by passing
between the superficial and deep layers of the flexor
retinaculum, lying just lateral to the pisiform bone.
The ulnar nerve is distributed to skin, muscle and joints
through the following branches (Figs 6.19 and 6.20):
A. Cutaneous branches:
1. The palmar cutaneous branch supplies the skin of the
medial one-third of the palm.
2. The dorsal branch reaches the back of the wrist and hand.
It supplies the skin of the medial part of the dorsum of the
hand and gives two or three dorsal digital branches. The
most medial digital branch supplies the medial side of the
little finger. The next supplies the adjoining sides of the little
and ring fingers. A third branch is present occasionally: when
present it supplies the adjacent sides of the ring and middle
fingers. The area of skin supplied by the dorsal digital
branches extends only up to the middle phalanx: the skin
over the distal phalanx (and over part of the middle phalanx)
is supplied by the ventral branches (Figs 5.3 B).
3. The superficial terminal branch of the ulnar nerve arises
after the nerve enters the hand. It divides into two palmar
digital branches: one for the medial side of the little finger;
and the other for the contiguous sides of the little and ring
fingers. These nerves supply the skin on the palmar surfaces
of the digits. They also supply the nail bed and the skin over
the dorsal surface of the distal phalanx and part of the middle
phalanx of the digit concerned (See Figs 5.3 A and B).
B. Muscular branches:
1. Two main branches arising directly from the ulnar nerve
Fig. 6.18. Scheme to show the course and branches of supply the flexor carpi ulnaris and the medial part of the
the median nerve.
flexor digitorum profundus.
2. The deep terminal branch of the ulnar nerve arises in the
C. Articular branches: hand. It supplies several muscles as follows (Fig. 6.20):
1. Articular branches arising directly from the median nerve a. The proximal part of the nerve supplies the hypothenar
near the elbow supply the elbow joint and the superior muscles, namely the abductor digiti minimi, the opponens
radioulnar joint. digiti minimi and the flexor digiti minimi.
2. The distal radioulnar joint and the wrist joint are supplied After supplying the hypothenar muscles the nerve runs
through the anterior interosseous nerve. transversely across the palm deep to the flexor tendons, along
3. The metacarpophalangeal and interphalangeal joints are the deep palmar arch. Here it supplies the following:
supplied through the digital branches. b. All the palmar and dorsal interossei of the hand;
53
54
Fig. 6.20. Distribution of the deep terminal branch of the

ulnar nerve.
THE RADIAL NERVE (Fig. 5.10)
The course of the radial nerve in the arm and cubital fossa
has been described on page 39. We have seen that the nerve
divides into superficial and deep branches. The further course
of these branches is described below.
The superficial terminal branch runs downwards in front
of the lateral part of the forearm (See Fig. 5.10). In the lower-
third of the forearm the nerve passes backwards round the

lateral side of the radius to reach the dorsum of the hand
where it ends by dividing into four or five digital branches.
The deep terminal branch is also called the posterior
interosseous nerve. It enters the substance of the supinator
muscle. Within the substance of the muscle it runs
downwards winding round the lateral side of the radius. It
appears in the back of the forearm through the lower part of
the supinator muscle and gives several branches that supply
the muscles of this region.
A. Muscular branches (See Fig. 5.10):
We have already seen that the brachioradialis and the
extensor carpi radialis longus receive branches arising from
the main stem of the radial nerve in the lower part of the
arm.
Muscles supplied by the deep terminal branch as follows:
1. Extensor carpi radialis brevis.
2. Supinator.
3. Extensor digitorum
4. Extensor digiti minimi.
Fig. 6.19. Scheme showing the course and branches of
the ulnar nerve.
5. Extensor carpi ulnaris
6. Extensor pollicis longus.
7. Extensor indicis.
c. the third and fourth lumbrical muscles;
8. Abductor pollicis longus.
d. the adductor pollicis, and frequently the flexor pollicis
9. Extensor pollicis brevis.
brevis.
Note that all extensor muscles of the arm and forearm are
3. The palmaris brevis is supplied either by the palmar
supplied by the radial nerve directly or through its deep
cutaneous branch, or by the superficial terminal branch.
terminal branch.
C. Articular branches:
B. Cutaneous branches to forearm and hand (See Fig. 5.10):
Branches arising from the ulnar nerve or from its branches
These are as follows:
supply the elbow joint, the wrist joint, and various joints in
1. The posterior cutaneous nerve of the forearm arises from
the medial part of the hand.
the radial nerve while the latter lies in the radial groove. It
supplies an extensive area of skin on the back of the arm
and on the back of the forearm (See Fig. 5.2).
2. Four to five dorsal digital branches arise from the
superficial terminal branch of the radial nerve. The first
(most lateral) supplies the skin of the lateral side of the
thumb; the second the medial side of the thumb. The third
branch supplies the lateral side of the index finger. The
fourth branch supplies the contiguous sides of the index
and middle fingers; while the fifth (when present) supplies
the contiguous sides of the middle and ring fingers. The
dorsal digital branches do not extend to the distal ends of
the digits. The skin over the distal phalanges, and the
whole or part of the middle phalanges is supplied by
palmar digital branches of the median nerve.
1. Direct branches from the radial nerve help to supply
the elbow joint.
2. Joints in the region of the wrist are supplied by branches
from the lower end of the deep terminal branch.
ARTERIES OF THE FOREARM
The main arteries of the forearm are the radial and ulnar
branches of the brachial artery. They are described below.
The Radial Artery Fig. 6.21. Some muscles related to the radial artery.
The radial artery begins in front of the elbow at the level

of the neck of the radius (Fig. 6.21). It first passes
downwards and laterally reaching the lateral border of
the forearm about its middle. It then descends along the
lateral margin of the forearm to the wrist. Thereafter, it
winds round the lateral side of the carpus to reach the
back of the hand (Fig. 6.22). It passes forwards through
the space between the first and second metacarpal bones
to reach the palm. Finally it runs transversely across the
palm as the deep palmar arch, and ends by anastomosing
with the deep palmar branch of the ulnar artery.
Relations of the radial artery:

The artery is related laterally to the brachioradialis.
Medially it is related to the pronator teres (Fig. 6.21A),
and (lower down) to the flexor carpi radialis and its tendon.
The superficial branch of the radial nerve is lateral to the
artery in the middle-third of the forearm. Posteriorly the
artery lies over several muscles that are shown in Figure
6.21B. Just above the wrist the artery lies on the anterior Fig. 6.22. Course of radial artery at the
surface of the radius. At the wrist (Fig. 6.22) the artery wrist and in the hand.
runs backwards deep to the tendons of the abductor
pollicis longus and the extensor pollicis brevis and the
tendon of the extensor pollicis longus (Fig. 6.23). The of the first dorsal interosseous muscle to enter the palm. In
artery reaches the interval between the first and second the palm (Fig. 6.22) the artery forms the deep palmar arch.
metacarpal bones where it passes between the two heads The artery ends by joining the deep branch of the ulnar artery.
55
56
3. The dorsal carpal branch passes medially behind the
carpus to anastomose with a corresponding branch from the
ulnar artery to form the dorsal carpal arch.
4. The superficial palmar branch often joins the ulnar artery
to complete the superficial palmar arch.
5. The first dorsal metacarpal artery arises on the dorsum
of the hand. It divides into two branches, one for the medial
side of the thumb and the other for the lateral side of the
index finger.
6. The princeps pollicis artery arises just as the radial artery
enters the palm after passing forwards between the first and
second metacarpal bones. It supplies the lateral side of the
thumb.
7. The radialis indicis artery arises near the princeps pollicis
and runs along the lateral side of the index finger.
Fig. 6. 23. Structures on the lateral side of the wrist related

to the radial artery. The Ulnar Artery
The ulnar artery begins in front of the elbow, at the level of

the neck of the radius (See Fig. 5.7). It passes downwards
and medially to reach the medial margin of the forearm (at
about its middle) and then runs vertically along this margin
(Fig. 6.25). It runs across the wrist superficial to the flexor

retinaculum. Entering the palm it runs laterally across it as
the superficial palmar arch (Fig. 6.24). This arch is completed
laterally by anastomosis with a branch of the radial artery
that is usually the superficial palmar, but may be the princeps
pollicis or the radialis indicis.
Relations of the ulnar artery:

The upper-half of the artery is deep, the lower-half relatively
superficial. Posteriorly the artery lies (from above
downwards) on the brachialis, the flexor digitorum profundus
and the flexor retinaculum (Fig. 6.25). It lies deep to the
flexor digitorum superficialis and to the flexor carpi ulnaris.
In the lower one-third of the forearm it is covered only by
skin and fascia.Here the tendon of the flexor carpi ulnaris is
medial to it and the tendons of the flexor digitorum
Fig. 6.24. Schematic diagram to show branches of the superficialis are lateral to it.
radial artery in the hand. Some branches of the ulnar artery
are also shown. The various arches are formed by
corresponding branches of the radial and ulnar arteries. Branches of ulnar artery (Fig. 6.26):
1. The anterior ulnar recurrent artery arises near the upper
end of the ulnar artery. It passes upwards in front of the
elbow to anastomose with the supratrochlear artery (Also
Branches of radial artery: see Figure 5.7).
1. The radial recurrent artery arises near the upper end of the 2. The posterior ulnar recurrent artery also arises near the
radial artery (Fig. 5.7). It ascends to anastomose with the radial upper end of the ulnar artery. It passes upwards behind the
collateral (anterior descending) branch of the profunda brachii medial epicondyle and anastomoses with the superior ulnar
artery. collateral artery (Also see Figure 5.7).
All other branches of the radial artery arise near the wrist and 3. The common interosseous artery divides into anterior
hand (Fig. 6.24). and posterior interosseous branches.
2. The palmar carpal branch passes medially in front of the
carpus to anastomose with a corresponding branch from the The anterior interosseous artery descends in front of the
ulnar artery to form the palmar carpal arch. interosseous membrane. Near the upper border of the
pronator quadratus it pierces the membrane and runs
downwards behind it to the back of the wrist. The anterior
interosseous artery also gives off a branch that accompanies
the median nerve.
The posterior interosseous artery passes backwards above the
upper margin of the interosseous membrane and then descends
between muscles of the back of the forearm supplying them.
Near its origin the posterior interosseous artery gives off an
interosseous recurrent artery that runs upwards behind the
elbow to anastomose with the posterior descending branch of
the profunda brachii artery and with the supratrochlear artery
(Also see figure 5.7).
Fig. 6.26. Scheme to show branches of the ulnar artery.

Fig. 6.25. Some relations of the ulnar artery.
completed laterally by a branch of the radial artery: usually

4. The palmar and dorsal carpal branches of the ulnar artery the superficial palmar, but sometimes the radialis indicis or
arise at the wrist. They anastomose with the palmar and dorsal the princeps pollicis.
carpal branches of the radial artery to form the palmar and
dorsal carpal arches.
5. The deep palmar branch of the ulnar artery arises just distal
to the pisiform bone. It ends by anastomosing with the radial
ARTERIES OF THE HAND
artery to complete the deep palmar arch.
6. After giving off its deep branch the ulnar artery continues The palm and digits receive a series of branches from the
into the palm as the superficial palmar branch. This branch various arterial arches formed in the region. They are:
runs transversely across the palm forming the superficial palmar 1. Four dorsal metacarpal arteries. Each dorsal metacarpal
arch: this arch lies distal to the deep palmar arch. The arch is artery ends by dividing into two dorsal digital arteries.
57
58
2. Four palmar metacarpal arteries end by joining the superficial palmar arch. Each artery divides into two palmar
common palmar digital arteries (see below) of the corres- digital branches.
ponding intermetacarpal space. Arteries on the dorsal and ventral aspect of the hand are
3. The common palmar digital arteries arise from the united by a series of perforating arteries.
MUSCLES OF BACK OF FOREARM
Brachioradialis (Fig. 6.27)
Origin:
The muscle arises from:
a. upper two-thirds of lateral supracondylar ridge of
humerus, and
b. lateral intermuscular septum.
Insertion:
Lateral side of the radius just above the styloid process.

Nerve Supply:
Radial nerve (C5, 6, 7).
Notes:
1. The fleshy part of the brachioradialis forms the lateral
boundary of the cubital fossa. Here the radial nerve is deep
to it (between it and the brachialis).
2. Near its insertion its tendon is crossed by tendons of
the abductor pollicis longus and the extensor pollicis brevis
(Fig. 6.23).
3. At the wrist the radial artery is medial to the tendon
(between it and the tendon of the flexor carpi radialis).
Actions:
1. The muscle is a flexor of the forearm.
2. It supinates the fully pronated forearm; and pronates
the fully supinated forearm.
Fig. 6.27. 1. Attachments of the brachioradialis. 2. Lower end

of humerus seen from the lateral side to show area of origin of
the brachioradialis and of the extensor carpi radialis longus.
3. Lower end of radius showing insertion.
Extensor Carpi Radialis Longus (Fig. 6.28) Extensor Carpi Radialis Brevis (Fig. 6.29)
Origin: Origin:
a. Lower one-third of lateral supracondylar ridge of humerus; a. Lateral epicondyle of the humerus (i.e. common extensor
b. Some fibres arise from the common extensor origin (i.e. lateral origin), and from
epicondyle). b. Radial collateral ligament of the elbow joint.
Insertion: Insertion:
Lateral side of the base of the second metacarpal bone. Base of the second and third metacarpal bones.
Nerve Supply: Radial nerve (C6, C7). Nerve Supply: Deep branch of radial nerve (C7, C8).
Actions: Extension and abduction of wrist. Actions: Extension and abduction of wrist.
Fig. 6.28. Fig. 6.29.

Attachments of Attachments of
extensor carpi radialis extensor carpi radialis
longus brevis.
59
60
Extensor Digitorum (Fig. 6.30)
Origin:
Lateral epicondyle of the humerus (common extensor
origin).
The muscle ends in a tendon that passes deep to the extensor
retinaculum. The tendon splits into four parts: one for each
digit other than the thumb.
Insertion:
Each tendon is inserted into the base of the middle phalanx,
and the base of the distal phalanx of the digit. (See Figure
6.31 for details of insertion).
Nerve Supply:
Deep branch of radial n. (C7, 8).
Actions:
The muscle produces extension at the:
a. interphalangeal joints,
b. metacarpophalangeal joints, and
c. wrist joint.
Notes:
1. As the tendons of the muscle pass under cover of the Fig. 6.30. Attachments
extensor retinaculum they are surrounded by a common of the extensor

synovial sheath (see Fig. 6.8 B). digitorum.
2. The tendon for the index finger is joined by the tendon
of the extensor indicis.
3. The tendon for the little finger is joined by the tendon of
the extensor digiti minimi.
4. Over the proximal phalanx the tendon (of that digit)
becomes embedded in a triangular membrane called the
dorsal digital expansion.
Dorsal digital expansion and insertion of the

extensor digitorum
The dorsal digital expansion is an aponeurosis present on
the dorsal aspect of the proximal phalanx, and the
metacarpo-phalangeal joint. The expansion is triangular
(Fig. 6.31). It has an apex directed distally, and a broad
base that lies dorsal to the metacarpo-phalangeal joint. The
tendon of the extensor digitorum joins the central part of
the the expansion. The expansion also gives attachment to
the lumbrical and interosseous muscles of the digit. In
addition to these muscles the expansion for the index finger
receives the tendon of the extensor indicis and that of the
little finger receives the tendon of the extensor digiti
minimi.
Extensor Digit Minimi (Fig. 6.32)

The tendon runs across the back of the wrist deep to the
extensor retinaculum where it occupies a separate
Origin: compartment just behind the radioulnar joint (Fig. 6.39).
Lateral epicondyle of the humerus (common extensor Here the tendon is surrounded by a synovial sheath).
origin).
Fig. 6.31. Dorsal digital expansion and insertion of the
external digitorum.
Insertion:
The tendon joins the tendon from the extensor
digitorum for the little finger.
Nerve supply: Deep branch of radial nerve.
Action: Extension of little finger.
Extensor Carpi Ulnaris (Fig. 6.33)
Origin:
a. Lateral epicondyle of the humerus (common
extensor origin); and from
b. Posterior border of the ulna (by an aponeurosis
common to it and to the flexor carpi ulnaris and the
flexor digitorum profundus).
The muscle ends in a tendon that descends across the Fig. 6.32. Attachments of extensor digiti minimi.
back of the wrist, lying deep to the extensor
retinaculum. Here the tendon is surrounded by a
synovial sheath. Actions:
Insertion: 1. Extension of the wrist.
Medial side of the base of the fifth metacarpal bone. 2. Adduction of the hand.
Nerve Supply:
Deep branch of radial nerve (C7, C8).
61
62
Fig. 6.34. Attachments of the anconeus muscle.
Supinator (Fig. 6.35)
Origin:
The muscle has one continuous origin from the following

structures:
1. Lateral epicondyle of the humerus.
2. Radial collateral ligament of the elbow.
3. Annular ligament.
4. Supinator crest of the ulna.
Insertion:
Upper one-third of the lateral surface of the radius.
Fig. 6.33. Attachments of extensor carpi ulnaris.
Anconeus
This is a small triangular muscle on the back of the elbow. Its

attachments are shown in Figure 6.34. The muscle is a weak
extensor of the elbow. It is supplied by the radial nerve.
Fig. 6.35. Attachments of the supinator muscle.
Nerve Supply: Extensor Pollicis Longus (Fig. 6.36)
Deep branch of the radial nerve.
Action: Origin:
Supination of the forearm. a. Lateral part of posterior surface of the ulna (below the
origin of the abductor pollicis longus), and from
Note:
b. the adjoining part of the interosseous membrane.
The muscle has two layers, superficial and deep. The deep
branch of radial nerve runs downwards between these layers. Insertion:
Base of the distal phalanx of the thumb on its dorsal aspect.
Actions:
It extends the distal phalanx, the proximal phalanx and the
metacarpal of the thumb.
Nerve Supply:
Deep branch of radial nerve (C7, 8).
Abductor Pollicis Longus (Fig. 6.36)
Origin:
a. The lateral part of the posterior surface of the ulna.
b. Interosseous membrane.
c. The posterior surface of the radius.
Insertion:
Radial side of the base of the first metacarpal bone; and on
the trapezium.
Nerve Supply:
Deep branch of radial n. (C7, 8).
Actions:
Abduction and extension of the thumb.
Extensor Indicis (Fig. 6.37)
Origin :
Posterior surface of the ulna below the origin of the extensor
pollicis longus, and from interosseous membrane.
Insertion:
The tendon ends by joining the extensor digitorum tendon
for the index finger.
Nerve Supply:
Deep branch of radial nerve (C7, 8).
Actions:
The muscle extends the index finger.
Extensor Pollicis Brevis (Fig. 6.37)

Fig. 6.36. Attachments of the extensor pollicis longus,
and of the abductor pollicis longus. Origin:
Posterior surface of the radius below the origin of the
abductor pollicis longus, and from interosseous membrane.
63
64
Fig. 6.38. Attachments of the extensor retinaculum.

Fig. 6.39. Tendons passing under cover of the extensor

retinaculum.
Fig. 6.37. Attachments of the extensor indicis and the

extensor pollicis brevis.
Insertion:
Dorsal surface of the base of the proximal phalanx of the thumb.
Nerve Supply:
Deep branch of radial nerve (C7, 8). Fig. 6.40. Synovial sheaths on the dorsum of the
Action: wrist and hand
The muscle extends the thumb.
The space between the deep surface of the retinaculum and
Extensor Retinaculum (Figs 6.38 and 6.39) the underlying bones is divided into six compartments. Note
The extensor retinaculum is a thickened band of deep fascia the tendons passing through each compartment.
that runs across the back (and sides) of the wrist. It is about
2.5 cm in width. It holds the extensor tendons in place and Synovial Sheaths
facilitates their action by acting as a pulley. The tendons passing under the extensor retinaculum are
Laterally, the retinaculum is attached to the anterior border of surrounded by synovial sheaths. Normally, there are six
the radius. Medially it is attached to the triquetral and pisiform sheaths; one for the tendons passing through each
bones. compartment under the extensor retinaculum.
JOINTS OF THE UPPER LIMB
7 : Joints of the Upper Limb
JOINTS CONNECTING THE
SCAPULA AND CLAVICLE
The Acromioclavicular Joint

This is a plane synovial joint. It is formed by articulation of
small facets at the lateral end of the clavicle and the medial
margin of the acromion. Movements at this joint accompany
those at the sternoclavicular joint. These movements are
necessary for allowing various movements of the scapula
associated with movements of the arm at the shoulder joint.
Coracoclavicular ligament
The main bond of union between the scapula and clavicle is
through the coracoclavicular ligament. The ligament consists
of two parts-conoid and trapezoid. The trapezoid part is
Fig. 7.1. Upper part of scapula, lateral view, to show
attached, below, to the upper surface of the coracoid process of
attachments of coracoacromial ligament.
the scapula; and, above, to the trapezoid line on the inferior
surface of the clavicle. The conoid part is attached, below, to
the root of the coracoid process just lateral to the scapular notch.
It is attached, above, to the inferior surface of the clavicle on
the conoid tubercle.
Coracoacromial ligament
The coracoacromial ligament connects the coracoid and
acromial processes of the scapula, and along with them forms
the coracoacromial arch. It is triangular. Its apex is attached to
the medial aspect of the tip of the acromion. Its base is attached
to the lateral border of the coracoid process. The coracoacromial
arch protects the head of the humerus and prevents its upward
dislocation.
THE STERNOCLAVICULAR JOINT Fig. 7.2. Sternoclavicular joint as seen in

coronal section.
The sternoclavicular joint is synovial. There are three elements

taking part in it; namely the medial end of the clavicle, the
clavicular notch of the manubrium sterni, and the upper surface
of the first costal cartilage. Its cavity is subdivided into two junction. Anteriorly and posteriorly the disc fuses with the
parts by an intra-articular disc. The articular surfaces of the capsule.
clavicle and sternum are concavo-convex. There are two other ligaments associated with this joint.
The capsular ligament is attached laterally to the margins of The interclavicular ligament passes between the sternal ends
the clavicular articular surface; and medially to the margins of of the right and left clavicles (Fig. 7.2). The costoclavicular
the articular areas on the sternum and on the first costal cartilage. ligament is attached above to the rough area on the inferior
It is strong anteriorly and posteriorly where it constitutes the aspect of the medial end of the clavicle. Inferiorly, it is
anterior and posterior sternoclavicular ligaments. However, attached to the first costal cartilage and to the first rib.
the main bond of union at this joint is the articular disc. The The movements occurring at this joint are secondary to
disc is attached laterally to the clavicle on a rough area above movements of the scapula, that are in turn secondary to
and posterior to the area for the sternum. Inferiorly, the disc is movements of the arm. Simultaneous movements also occur
attached to the sternum and to the first costal cartilage at their at the acromioclavicular joint.
65
66
THE SHOULDER JOINT
The shoulder joint is a synovial joint of the ball and socket

variety. The joint is formed by articulation of the head of the
humerus and the glenoid cavity of the scapula.
The articular surface of the head of the humerus is rounded
like a hemisphere (Fig. 7.4). It is directed medially, backwards
and upwards. It is covered by a layer of hyaline articular
cartilage. The cartilage is thickest in the centre and thinnest at
the periphery thus increasing its convexity. The glenoid cavity
is directed laterally and forwards. It is much smaller than the
head of the humerus (Fig. 7.3). The cavity is shallow. The depth
of the cavity is increased somewhat by the articular cartilage
lining it; the cartilage is thinnest in the centre and thickest at
the periphery. The depth of the cavity is also increased by the
presence of a rim of fibrocartilage attached to the margin of
the glenoid cavity: this is the glenoidal labrum (Fig. 7.3). Fig. 7.3. Schematic coronal section through the
shoulder joint.
The capsular ligament is attached, medially, to the margins of
the glenoid cavity beyond the glenoidal labrum. Superiorly,
the line of attachment extends above the origin of the long the inferior part of the capsule is least supported and is the
weakest part.
head of the biceps from the supraglenoid tubercle. On the lateral

side the capsule is attached to the head of the humerus just The joint is surrounded by a number of bursae. They
beyond the articular surface, i.e. to the anatomical neck; facilitate movements between structures surrounding the
joint.
however, on the medial side the line of attachment extends
downwards on to the shaft so that part of it is within the
joint cavity. The capsule is strengthened by the following
ligaments.
a. The glenohumeral ligaments, superior, middle and

inferior, are attached medially to the upper part of the
anteromedial margin of the glenoid cavity. Laterally the
superior ligament reaches the upper part of the lesser
tubercle of the humerus. The middle ligament is attached
to the lower part of the lesser tubercle, and the inferior
ligament on the anatomical neck (Fig. 7.5).
b. The coraco-humeral ligament is attached, medially
to the root of the coracoid process (above the
supraglenoid tubercle), and laterally to the greater
tubercle of the humerus.
c. The transverse humeral ligament stretches between
the greater and lesser tubercles. It converts the
intertubercular sulcus into a canal through which the
tendon of the long head of the biceps leaves the joint
cavity.
The shoulder joint is surrounded by a number of muscles

that support it. These are the supraspinatus (superiorly),
the subscapularis (in front), the infraspinatus and teres
minor (behind) and the long head of the triceps (below).
With the exception of the long head of the triceps, the
tendons of these muscles blend with the capsule forming
what is called the rotator cuff. The long head of the Fig. 7.4. Upper end of humerus seen from: A. the front; B. from
triceps is some distance away from the capsule: as a result behind, to show the attachment of the capsular ligament.
The synovial membrane lines the inside of the capsular
ligament, both sides of the glenoidal labrum and the non-
articular parts of the humerus enclosed within the capsule. The
tendon of the long head of the biceps is enclosed in a tubular
sheath of synovial membrane: this sheath is prolonged, for
some distance, into the intertubercular sulcus.
The shoulder joint is supplied by the anterior and posterior
circumflex humeral, and the suprascapular arteries; and by the
suprascapular, axillary and lateral pectoral nerves.
Movements at the shoulder joint

Movements of the arm take place at the shoulder joint. These
are described with reference to the plane of the scapula. Note
that the scapula is placed obliquely (behind the thorax) and
that the glenoid cavity faces forwards and laterally.
1. The movements of abduction and adduction take place in
the plane of the scapula. In abduction the arm moves laterally
Fig. 7.5. Some ligaments of the shoulder joint.
and somewhat forwards. In adduction the arm returns to the
side of the body. Abduction and adduction take place partly at
the shoulder joint, and partly by rotation of the scapula.
2. Flexion and extension take place at right angles to the plane THE ELBOW JOINT
of the scapula. In flexion the arm moves forwards and somewhat
medially. Reversal of this movement is extension.
3. Medial and lateral rotation of the humerus takes place around This is a synovial joint of the hinge variety. Three bones
take part in forming it. These are the lower end of the humerus
an imaginary axis passing vertically through the bone. In medial
and the upper ends of the radius and ulna. The capitulum of
rotation the anterior aspect of the humerus rotates to face
the humerus articulates with the concave upper surface of
medially. The reverse takes place in lateral rotation.
the head of the radius (humero-radial joint); and the trochlea
Fig. 7.6. Scheme to show muscles producing movements at the shoulder joint.
67
68
of the humerus articulates with the trochlea notch at the upper
end of the ulna (humero-ulnar joint). The cavity of the joint is
continuous with that of the superior radio-ulnar joint.
The line of attachment of the articular capsule to the humerus
is shown in Figures 7.7A and B. Note that the coronoid fossa,
the radial fossa and the olecranon fossa lie within the joint
cavity. Inferiorly, the capsule is attached to the coronoid and
olecranon processes of the ulna around the margins of the
articular surface. On the lateral side it is not attached directly
Fig. 7.8. Attachments of ulnar collateral

ligament of the elbow joint.
Fig. 7.9. Attachments of the radial collateral

ligament of the elbow joint.
to the radius, but to the annular ligament of the superior

radioulnar joint, that encircles the head of the bone.
The capsular ligament is thickened on the medial and lateral
sides to form the ulnar and radial collateral ligaments.
The ulnar collateral ligament is triangular in form. Its apex

is attached to the medial epicondyle of the humerus, and its
base to the ulna. Some details are shown in Figure 7.8.
The radial collateral ligament is attached at its upper end
to the lateral epicondyle of the humerus and below to the
annular ligament of the superior radioulnar joint (Fig. 7.9).
The synovial membrane of the joint covers all non-articular
areas of bone enclosed within the capsule. These include
the radial, coronoid and olecranon fossae.
Fig. 7.7. Attachment of the capsular ligament of the The elbow joint receives its blood supply from the arterial
elbow joint to the humerus. A. Anterior aspect. anastomoses around it. It receives its nerve supply from
B. Posterior aspect. Epiphyseal lines are also shown. nerves that cross it: mainly the musculocutaneous and the
C. Lower articular surfaces of elbow joint, and capsular radial, but also from the ulnar, the median and the anterior
attachment. interosseous nerves.
The movements allowed at the elbow joint are flexion and
extension. When the joint is extended the supinated forearm
passes somewhat laterally (relative to the arm). The lateral angle
between the arm and forearm is about 160 degrees and is called
the carrying angle.
The muscles responsible for producing flexion at the elbow
joint are the brachialis, the biceps brachii and the
brachioradialis. Extension is caused by the triceps. The
anconeus plays a minor role in extension.
THE RADIOULNAR JOINTS
The upper and lower ends of the radius and ulna are joined to
each other at the superior and inferior radioulnar joints. The
shafts of the two bones are united by the interosseous membrane
(sometimes called the middle radioulnar joint). The superior Fig. 7.10. Schematic coronal section through the
and inferior joints are both synovial and of the pivot variety. wrist to show the formation of the articular surfaces
of the inferior radioulnar, wrist and midcarpal joints.
At the superior radioulnar joint the head of the radius rotates
within a ring formed by the radial notch of the ulna and the
annular ligament (Fig. 7.7C). The annular ligament surrounds
the circumference of the head of the radius and is attached
anteriorly and posteriorly to margins of the radial notch of the THE WRIST JOINT
ulna. We have seen that the annular ligament is continuous above
with the capsular ligament of the elbow joint. The cavity of the
The wrist joint is a synovial joint of the ellipsoid variety. It
superior radioulnar joint is continuous with that of the elbow
has a concave proximal articular surface formed by the distal
joint.
end of the radius, and by the inferior surface of the articular
disc of the inferior radioulnar joint (Fig. 2.10). The distal
The inferior radioulnar joint is formed by articulation of the
articular surface is convex. It is formed by the proximal
convex articular surface on the lateral side of the head of the
surfaces of the scaphoid, lunate and triquetral bones. The
ulna with the ulnar notch of the radius. The chief bond of union
articular capsule is attached to the margins of the proximal
between the two bones is through an articular disc. The disc is
and distal articular surfaces. Parts of it are thickened to form
triangular. Its apex (directed medially) is attached to the ulna
several ligaments. The anterior part of the capsule is
on a depression just lateral to the styloid process. Its base is
thickened in its lateral part to form the palmar radiocarpal
attached to the radius on the lower margin of the ulnar notch.
ligament; and in its medial part to form the palmar
Its upper surface forms part of the inferior radioulnar joint and
ulnocarpal ligament. The posterior part of the capsule is
articulates with the inferior surface of the head of the ulna. Its
thickened in its lateral part to form the dorsal radiocarpal
lower surface (Fig. 7.10) forms part of the proximal articular
ligament. The strongest bonds of union are, however, the
surface of the wrist joint. The cavities of these two joints are
ulnar and radial collateral ligaments.
completely separated by the disc.
The ulnar collateral ligament is attached proximally to the
Supination and Pronation of Forearm: styloid process of the ulna; and distally to the medial side of
These are rotary movements that take place at the superior and the triquetral and pisiform bones (Fig. 7.10). The radial
inferior radioulnar joints. When the forearm is held so that the collateral ligament is attached proximally to the styloid
palm faces forwards, the radius and ulna lie parallel to each process of the radius and distally to the lateral side of the
other: this is the position of supination. In pronation the forearm scaphoid bone.
rotates (along with the hand) so that the radius crosses in front The movements at the wrist joint are flexion, extension,
of the ulna and its lower end comes to lie medial to that of the adduction and abduction.. The muscles responsible for the
ulna. movements are shown in Figure 7.11.
The muscles responsible for supination are the supinator and
the biceps brachii. The latter can act only after the forearm has
been semi-flexed. Pronation is produced by the pronator
quadratus and the pronator teres.
The role of the brachioradialis in supination and pronation is
controversial.
69
70
OTHER JOINTS OF
THE UPPER LIMB
The midcarpal joint is present

between the proximal and distal
row of carpal bones. It allows
the same movements as the
wrist joint, extending their
range considerably.
The carpometacarpal joint of
the thumb is a synovial joint. It
is a typical example of a saddle
joint. The bones taking part are
the distal surface of the
trapezium, and the proximal
surface of the first metacarpal.
The surface of the metacarpal
is convex from side to side and
concave from front to back. The
surface on the trapezium shows
Fig. 7.11. Scheme to show the muscles responsible for movements at the wrist joint.
reciprocal curvatures.
Compared to other carpo
metacarpal joints this joint has
considerable mobility. The

movements of the thumb differ
from those of other digits as the
thumb is rotated through 90 on
its long axis, relative to the
other digits. As a result its
ventral surface faces medially
(not anteriorly) and its dorsal
surface faces laterally (not
posteriorly as in other digits).
Therefore, flexion and
extension of the thumb take
place in a plane parallel to that
of the palm while abduction and
adduction of the thumb take
place in a plane at right angles
to that for the other digits (i.e.,
at right angles to the plane of Fig. 7.12. Scheme to show the muscles responsible for movements at the
the palm). carpometacarpal joint of the thumb. Note that flexion is associated with a
certain amount of medial rotation, and extension with lateral rotation.
The muscles producing movements of the thumb are shown in The metacarpophalangeal joints are typical ellipsoid joints
Figure 7.12. allowing flexion, extension, abduction and adduction of the
The remaining intercarpal, carpo-metacarpal, and fingers. Rotation is not permitted.
intermetacarpal joints are all plane joints and permit slight The interphalangeal joints are typical hinge joints of the
gliding movements only. These movements confer considerable condylar variety. The thumb has only one such joint. Each
resilience to the region of the wrist. finger has two joints, proximal and distal. Movements at
these joints are important in gripping and other uses of the
fingers.
SURFACE MARKING AND CLINICAL CORRELATIONS
8 : Surface Marking of Some Structures and
Clinical Correlations of the Upper Limb
SURFACE MARKING
Axillary artery artery enters the palm where it becomes the superficial palmar
arch.
The axillary artery can be marked by drawing a line connecting
(a) the middle of the clavicle with (b) the point, at the level of Superficial palmar arch
the lower border of the posterior fold of the axilla, where the
pulsations of the artery can be felt. To mark the superficial palmar arch begin at a point just
lateral to the pisiform bone. From here the arch descends
Brachial artery vertically to reach the hook of the hamate. The rest of the
arch is marked as a curved line that passes laterally across
The brachial artery passes from the lower end of the axillary the palm with a marked convexity directed distally. The line
artery to the cubital fossa. Its upper end corresponds to the ends at a point on the distal border of the thenar eminence,
lower end of the axillary artery, and can be palpated as described in line with the cleft between the index and middle fingers.
for the axillary artery. The lower end lies at the level of the The most distal point on the arch lies at the level of the
neck of the radius. distal border of the fully extended thumb.
Deep palmar arch

Radial artery
The deep palmar arch lies about 1 cm proximal to the
The upper end of the radial artery corresponds to the lower end superficial palmar arch and has a slight distal convexity. It
of the brachial artery that can be found as described above. To begins at the proximal end of the first intermetacarpal space,
locate the artery at the lower end of the forearm place two fingers and ends just distal to the hook of the hamate.
in front of the lower end of the radius and feel the pulsations of
the radial artery. This is the situation at which doctors usually
examine the radial pulse of a patient. Just lateral to the artery Axillary nerve
you will feel the sharp anterior border of the radius. Just medial
to the artery you can feel the tendon of the flexor carpi radialis. The axillary nerve can be marked as a horizontal line about
The course of the radial artery in the hand can be marked by 2 cm above the midpoint between the tip of the acromion
joining the following points: (a) Point where radial pulse is felt process and the deltoid tuberosity of the humerus (insertion
at lower end of radius. (b) A point just below the styloid process. of deltoid).
(c) Point in the floor of the anatomical snuff box. (This is a
depression just below the wrist between two prominent tendons Musculocutaneous nerve
going to the thumb). (d) Proximal end of first intermetacarpal
space. First mark the axillary artery (as described above) and take
a point just lateral to the artery 3 cm above the lower border
Ulnar artery of the posterior fold of the axilla.
The lower end lies 2 cm above the bend of the elbow, just
The point indicating the upper end of the ulnar artery lateral to the biceps tendon.
corresponds to the lower end of the brachial artery, and may be
found as described for that artery. From here the ulnar artery Median nerve
passes downwards and medially to reach the medial border of
the forearm at the junction of its upper one-third with the lower In the arm the nerve is closely related to the brachial artery.
two-thirds. It then descends vertically to reach the wrist where First mark this artery. The median nerve can be marked as a
it lies just lateral to the pisiform bone. From here the ulnar line that lies lateral to the upper half of the artery, crosses
71
72
the artery near its middle, and then descends along the medial Ulnar nerve
side of the artery to reach the elbow.
In the forearm the nerve descends almost vertically In the arm:
approximately midway between the radial and ulnar borders, 1. First point corresponds to the upper end of the brachial
and reaches the front of the wrist at about its middle. artery (see above).
2. Second point corresponds to the middle of the brachial
artery: it lies at the middle of the medial border of the arm.
Radial nerve
3. The third point is the posterior aspect of the medial
epicondyle of the humerus.
In the arm:
The nerve can be marked by joining the following points:
In the forearm:
1. Point on lower border of posterior fold of axilla where
Connect a point behind the medial epicondyle with a point
pulsations of the axillary artery are felt.
in front of the wrist, just lateral to the pisiform bone.
2. Draw a line joining the lateral epicondyle of the humerus to
the deltoid tuberosity. Take a point on this line at junction of
its upper and middle thirds. Flexor retinaculum
3. Front of elbow (level of lateral epicondyle) 1 cm lateral to To draw its upper border join the pisiform bone to the
biceps tendon. tubercle of the scaphoid bone. The lower border corresponds
Join point 1 and point 2 on the back of the arm. Join point 2 to to a line joining the hook of the hamate to the tubercle of the
3 by a line passing over the lateral side of the arm to reach the trapezium.
front.
Extensor retinaculum
In the forearm:
The upper border is marked by a line starting from the
1. Take a point 1cm lateral to the biceps tendon.
anterior border of the radius 2 cm above its lower end, and

2. Second point over lateral border of arm at junction of upper
passing round the lateral side and back of the wrist to reach
2/3 and lower 1/3.
the styloid process of the ulna.
Join point 1 to point 2. Carry the line downwards and
The lower border starts from the lower end of the anterior
backwards round the lateral border of the forearm to reach the
border of the radius and runs parallel to the upper border to
interval between the first and second metacarpal bones.
reach the triquetral bone.
CLINICAL CORRELATIONS OF UPPER LIMB
Anomalies of Limbs 4. Early detection of cancer facilitates treatment. This can be

1. One or more limbs of the body may be partially, or done by periodic palpation of the breast, and by a procedure
completely, absent (phocomelia, amelia). called mammography.
2. Part of a limb may be deformed (e.g. club-foot, club-hand). 5. Cancer of the breast spreads through lymphatics to the
3. There may be abnormal fusion between different bones of a axillary lymph nodes. Some facts you should know are:
limb. Adjoining digits may be fused (syndactyly). a. The lymph nodes of the anterior group are in direct contact
4. The limbs may remain short in achondroplasia. with the axillary tail of the breast and cancer may spread to
them without having to pass through the lymph vessels.
b. Lymphatics of the skin over the breast cross the midline
CLINICAL CORRELATIONS OF THE BREAST and carcinoma of one breast can spread to the other breast
through them.
1. Inflammation of the breast is called mastitis. c. Some lymph vessels enter the thorax to reach the
2. Masses in the breast may be caused by neoplasms (tumours). parasternal and intercostal lymph nodes.
The breast is a common site of carcinoma. d. Some vessels from the breast communicate with
3. An operation for removal of the breast is called mastectomy. lymphatics within the abdominal cavity (subperitoneal
plexus). Cancer of the breast can spread to the peritoneum, to the liver and
to pelvic organs.
DAMAGE TO BONES, JOINTS, TENDONS
Common sites of fracture

The sites at which the long bones of the limb are commonly fractured are
shown in Figures 8.1 to 8.3. Some additional facts are as follows.
1. The humerus is related to several nerves and these may be damaged

because of fracture. Fracture through the surgical neck of the humerus can
damage the axillary nerve. Fracture through the middle of the shaft can
damage the radial nerve (that lies in the radial groove). In supracondylar
fracture the median nerve can be injured. The ulnar nerve can be damaged
in a fracture of the medial epicondyle.
2. Fracture of the lower end of the radius is called Colles fracture.
3. Bones of the hand can be fractured. The scaphoid is the most commonly
fractured carpal bone. Fig. 8.2. Fractures of humerus.
Dislocation of the shoulder joint

High degree of mobility at the shoulder joint is attained at the expense of
stability. Dislocations at the joint are therefore common. Typically the head
of the humerus is displaced forwards and comes to lie in the infraclavicular
fossa just below the coracoid process. This condition is called anterior or
subcoracoid dislocation.
Sometimes dislocation of the shoulder joint may occur repeatedly (recurrent
dislocation).
Other joints may also show dislocation.
Rupture of tendinous cuff of shoulder

Pain in the region of the shoulder can be caused by strain of the tendinous
cuff (rotator cuff) around the joint. The supraspinatus tendon may rupture,
and may cause inability to initiate abduction.
Fig. 8.3. Fractures of radius and ulna.
Tennis elbow
Repeated strain on the extensor muscles of the forearm can
cause injury to tissues near the lateral epicondyle. Pain occurs
over the epicondyle and along the radial border of the arm.
VASCULAR DISORDERS
Volkmanns ischaemic contracture

Spasm of the brachial artery can follow fractures in the region
of the elbow. This reduces blood supply to muscles of the
forearm, and ultimately leads to their fibrosis. Fibrosis shortens
Fig. 8.1. Fractures of clavicle and scapula.
muscles and leads to deformities of the wrist and digits.
73
74
Raynauds disease (or phenomenon)
In all persons, exposure to cold can cause vasoconstriction. In some persons
this response is abnormally high and vasoconstriction of arterioles in the distal
part of the limb may seriously impair blood supply to the hands. Basically the
condition is caused by an abnormally active sympathetic nerves.
APPLIED ANATOMY OF THE BRACHIAL PLEXUS

AND ITS BRANCHES
Erbs Point and Erbs Paralysis

The region where roots C5 and C6 of the brachial plexus meet to form the upper Fig. 8.4. Nerves meeting at Erbs point.
trunk is often referred to as Erbs point.
Six nerves meet here: these are roots C5 and C6, the anterior and posterior
divisions of the upper trunk, the suprascapular nerve and the nerve to the
subclavius (Fig. 8.4). Injury in this region produces a syndrome that is referred
to as Erbs paralysis. The arm cannot be abducted, and is medially rotated. The
forearm cannot be supinated and so it remains pronated, and the palm faces
backwards (waiters tip position, Fig. 8.5).
Klumpkes Paralysis
This is caused by injury to roots C8 and T1, or to the lower trunk, of the brachial
plexus. The flexors of the wrist and all the small muscles of the hand are
paralysed. It results in claw hand similar to that in paralysis of the ulnar nerve.
The wrist remains extended. The proximal phalanges are extended while the
middle and distal phalanges are flexed.
Cervico-axillary Canal and Scalenus Anticus Syndrome

In passing from the neck into the axilla the brachial plexus and the subclavian
artery pass through a triangular space called the cervico-axillary canal. The
canal is bounded medially by the first rib, in front by the clavicle, and behind by
the upper border of the scapula.
The structures passing through the canal can be compressed leading to various
symptoms. Pain radiating to the medial side of the arm is a conspicuous feature.
This is caused by pressure on the lower trunk of the brachial plexus by the first
rib.
Similar symptoms can also be produced by pressure of the scalenus anterior
muscle on the nerve trunk (Scalenus anticus syndrome or scalene syndrome).
Fig. 8.5. Waiters tip position of
upper limb in Erbs paralysis.
Cervical Rib
Occasionally a rudimentary rib may be present in relation to the seventh cervical
vertebra: this is called a cervical rib. When a cervical rib is present root T1 has
to curve over this rib (Fig. 8.6). This results in pressure on the root. Symptoms
similar to those of the scalene syndrome are observed.
Prefixed and Postfixed Brachial Plexus

We have seen that normally the brachial plexus is formed mainly by roots C5 to
T1 and that there are small contributions from C4 and T2 (Fig. 8.7A). Sometimes
the contribution from C4 is large; root T1 is small; and the contribution from T2
is absent. This is called a prefixed plexus.
Fig. 8.6. Relation of root T1 of

brachial plexus to a cervical rib.
The reverse condition is one in which
the plexus appears to be fixed one
segment too low: i.e., it is postfixed
(Fig. 8.7C). In this case the contribution
from C4 is missing; root C5 is small;
and the contribution from T2 is large.
The relationship of a postfixed brachial
plexus to a normal first rib is the same
as that of a normal plexus to a cervical
rib. Hence, the symptoms associated
with a cervical rib can be present in the
absence of such a rib if the brachial
plexus is postfixed.
EFFECTS OF INJURY TO
INDIVIDUAL NERVES OF
THE UPPER LIMB
Fig. 8.7. Some variations in the origin of the brachial plexus.
Injury to a nerve results in:
a. Paralysis of muscles supplied leading to inability to perform Carpal tunnel syndrome

movements depending on them. The carpal tunnel is a passage between the carpal bones
b. Deformity resulting from unopposed action of antagonists and the flexor retinaculum. The median nerve passes through
of the muscles paralysed. the tunnel. Any increase in the volume of contents of the
c. Abolition or dulling of sensations in the area of cutaneous tunnel can compress the median nerve. Pressure on the nerve
supply. gives rise to burning pain in the lateral three and a half
digits.
Long thoracic nerve
Injury to the long thoracic nerve leads to paralysis of the serratus Ulnar nerve
anterior. Overhead abduction of the arm is not possible. The The effects of paralysis of the ulnar nerve are as follows:
serratus anterior can be tested by asking the patient to place his 1. Flexion and adduction at the wrist are weak.
palms against a wall and push. When the muscle is paralysed 2. The terminal phalanges of the ring and little fingers cannot
the medial margin of the scapula projects backwards: this is be flexed.
called winging of the scapula.
Axillary Nerve
The axillary nerve can be injured in fractures of the upper end
of the humerus or by dislocation at the shoulder joint. Because
of paralysis of the deltoid, abduction of the arm is not possible.
Median Nerve
The effects of injury to the median nerve are as follows.
1. Flexion and abduction of the wrist are weak.
2. Power of pronation is lost.
3. Middle phalanges (of all digits) cannot be flexed.
4. The terminal phalanges of the index and middle fingers cannot
be flexed.
5. Movements of the thumb are affected. It remains in a position
of extension and adduction. This is referred to as an ape-like Fig. 8.8. Ape like hand in median
hand (Fig. 8.8). nerve palsy. Note the flattened thenar
There is sensory loss in the area supplied by the median nerve eminence and the adducted and
(Figs 5.3 A and B). extended thumb.
See carpal tunnel syndrome.
75
76
3. Movements of the little finger are affected. There is wasting of
the hypothenar eminence.
4. Abduction and adduction of the fingers is weak.
5. Flexion of the metacarpophalangeal joints and extension of
interphalangeal joints of the fingers is not possible: the
metacarpophalangeal joints remain extended and the
interphalangeal joints remain flexed resulting in a claw hand. Ulnar
nerve paralysis gives rise to a partial claw hand the medial two
digits being most affected. Complete claw hand is seen in combined
lesions of the ulnar and median nerves (Fig. 8.9).
Sensations are impaired in the area of supply (Figs 5.3 A and B).
Radial Nerve
The effects of injury to the radial nerve are as follows.
(1) The elbow cannot be extended. Fig. 8.9. Complete claw hand (anterolateral
view) produced as a result of injury to both
(2) The wrist and proximal phalanges cannot be extended. The
the median and ulnar nerves.
wrist remains flexed: this condition is called wrist drop (Fig. 8.10).
(3) Supination is not possible with the forearm extended.
Sensory loss: Sensations are lost in a small area of skin on the
lateral part of the dorsum of the hand.
INFECTIONS IN THE UPPER LIMB
Infections commonly take place in closed spaces such as bursae,

synovial sheaths, and some spaces in the hand. Fig. 8.10. Wrist drop seen in radial nerve
injury.
Bursitus
The subacromial bursa lies deep to the coracoacromial arch and corresponding palmar septa. It is subdivided into two
the adjoining part of the deltoid muscle. When the bursa is inflamed parts by the intermediate palmar septum, that connects
(subacromial bursitus) pressure over the deltoid, just below the the palmar aponeurosis to the third metacarpal bone.
acromion elicits pain. This compartment contains the midpalmar and thenar
Repeated pressure over the olecranon process can cause spaces described below.
inflammation of the olecranon bursa. The condition is called
students elbow or miners elbow.
Midpalmar and Thenar spaces
These are spaces of surgical importance that lie within
the intermediate compartment of the hand.
Compartments and Spaces of the Hand The thenar space lies between the lateral and
intermediate palmar septa.
The palm is divided into three compartments by two septa. The midpalmar space lies between the intermediate and
1. The lateral palmar septum passes from the lateral edge of the medial palmar septa.
palmar aponeurosis to the first metacarpal bone.
2. The medial palmar septum passes from the medial edge of the
palmar aponeurosis to the fifth metacarpal bone. Boundaries of thenar space
a. The lateral compartment lies lateral to the lateral septum. It MEDIALLY: Intermediate palmar septum.
contains the thenar muscles (except the greater part of the adductor LATERALLY: Lateral palmar septum
pollicis). ANTERIORLY: Lateral part of palmar aponeurosis, and flexor
b. The medial compartment lies medial to the medial septum. It tendons to index finger.
contains the hypothenar muscles. POSTERIORLY: Adductor pollicis, transverse head.
c. The intermediate compartment, lying deep to the palmar PROXIMALLY: Distal margin of the flexor retinaculum.
aponeurosis, is bounded medially and laterally by the DISTALLY: Proximal transverse crease of the palm.
Fig. 8.11. Transverse section across the hand to show its compartments, and the location of
some spaces of surgical importance.
Boundaries of midpalmar space synovial sheaths (over the digits), the ulnar bursa and the
MEDIALLY: Medial palmar septum radial bursa. Any of these can be the site of infection.
LATERALLY: Intermediate palmar septum
ANTERIORLY: Medial part of palmar aponeurosis, and flexor
Other spaces in the hand
tendons to medial three fingers.
POSTERIORLY: Fascia covering the medial three metacarpal bones Infection may occur in a web space, i.e. within the folds of
and intervening interosseous muscles. skin connecting bases of the digits.
PROXIMALLY: Distal margin of the flexor retinaculum. There are two spaces on the dorsum of the hand that are
DISTALLY: Distal transverse crease of palm. occasionally sites of infection. The subcutaneous space lies
just under the skin, while the subaponeurotic space lies
deep to the extensor tendons (Fig. 8.11).
Pulp Spaces of fingers
Infections in the region of the finger tips (known as whitlow or
felon) are common. Such infections cause much pain because Forearm space (of Parona)
the region of the tip of the finger is divided into a number of This space is located in the lower part of the anterior
small compartments, and distension of any compartment with compartment of the forearm, deep to the flexor tendons and
pus presses on nerve endings there. in front of the pronator quadratus. This space can be infected
by spread of pus through the ulnar bursa. This results in an
Digital synovial sheaths of the hand hour-glass shaped swelling, lying partly above the flexor
We have seen that flexor tendons to the digits are surrounded retinaculum and partly below it.
by synovial sheaths (see Fig. 6.8). These include the digital
77
78
PART 2:LOWER EXTREMITY
9 : Bones of the Lower Limb

Introduction
The skeleton of the lower limb consists of the bones of the

pelvic girdle, and those of the free limb (Fig. 9.1). The pelvic
girdle is made up of one hip bone on each side. Each hip bone
is made up of three parts that are fused together. The upper
expanded part of the bone is called the ilium. A small part in
front (shaded in the figure) is called the pubis. The lower part
of the bone is called the ischium. Anteriorly, the two pubic
bones meet in the midline to form a joint called the pubic
symphysis. Posteriorly, the sacrum is wedged in between the
ESSENTIALS OF ANATOMY : LOWER EXTREMITY
two hip bones. The hip bones and sacrum (along with the
coccyx) form the bony pelvis.
The bones of the free part of the limb are arranged in a pattern
similar to that in the upper limb. The bone of the thigh is called
the femur. There are two bones in the leg. The medial of the
two (lying towards the great toe) is called the tibia, while the
outer bone is called the fibula. The femur, tibia and fibula are
long bones having cylindrical shafts with expanded upper and
lower ends. In the region of the ankle, and the posterior part of
the foot, there are seven roughly cuboidal tarsal bones. The
largest of these is the calcaneus, that forms the heel. Next in
size we have the talus. In the anterior part of the foot there are
five metatarsal bones. Each digit (or toe) has three phalanges
proximal, middle and distal: however, the great toe has only
two phalanges proximal and distal. Fig. 9.1.Skeleton of the
pelvis and of right
The upper end of the femur fits into a deep socket in the hip lower limb.
bone (called the acetabulum) to form the hip joint. The lower
end of the femur meets the tibia to form the knee joint. A small
bone, the patella, is placed in front of the knee. The tibia and
fibula are joined to each other at their upper and lower ends to
form the superior and inferior tibiofibular joints. The lower
ends of the tibia and fibula join the talus to form the ankle
joint. Within the foot there are intertarsal, tarsometatarsal,
metatarsophalangeal and interphalangeal joints on a pattern
similar to those in the hand.
BONES OF THE LOWER LIMB
pelvis. Its upper border is in form of a broad ridge that is
convex upwards: this ridge is called the iliac crest.
THE HIP BONE
The posterior part of the ilium bears a large rough articular
area on its medial side for articulation with the sacrum. The
pubis lies in relation to the upper and medial part of the
Introductory Remarks
obturator foramen. It forms the most anterior part of the hip
bone. The two pubic bones meet in the middle line, in front,
Along with the sacrum and coccyx, the right and left hip bones
to form the pubic symphysis. The lowest part of the hip
form the bony pelvis. Each hip bone consists of three parts.
bone is formed by the ischium that lies below and behind
These are the ilium, the pubis, and the ischium. These three
the acetabulum and the obturator foramen. Using the
parts meet at the acetabulum that is a large deep cavity placed
information given above, a given hip bone can be correctly
on the lateral aspect of the bone. The acetabulum takes part in
orientated and its side determined.
forming the hip joint along with the head of the femur. Below
and medial to the acetabulum the hip bone shows a large oval The Ilium
or triangular aperture called the obturator foramen. The ilium
consists, in greater part, of a large plate of bone that lies above In addition to the features already mentioned note the
and behind the acetabulum, and forms the side wall of the greater following:
Fig. 9.2. Right hip bone, external aspect.
79
80
The anterior end of the iliac crest projects forwards as the centimetres below the posterior superior iliac spine the
anterior superior iliac spine. The posterior end of the crest posterior border presents another prominence called the
forms a projection called the posterior superior iliac spine. posterior inferior iliac spine. The lower part of the posterior
The iliac crest may be subdivided into a ventral segment, border forms the upper boundary of a deep notch called the
consisting of the anterior two-thirds of the crest, and a dorsal greater sciatic notch.
segment consisting of the posterior one-third. The ventral The lateral aspect of the ilium constitutes its gluteal surface.
segment shows a broad intermediate area that is bounded by This surface is marked by three ridges called the anterior,
inner and outer lips. The outer lip of the iliac crest is most posterior and inferior gluteal lines.
prominent about 5cm behind the anterior superior iliac spine. The posterior gluteal line is vertical. It extends from the
This prominence is called the tubercle of the iliac crest. The iliac crest, above, to the posterior inferior iliac spine below.
dorsal segment of the iliac crest has medial and lateral surfaces The anterior gluteal line is convex upwards and backwards.
separated by a ridge. Its anterior end meets the iliac crest in front of the tubercle;
The anterior border of the ilium extends from the anterior while its posterior end reaches the greater sciatic notch. The
superior iliac spine to the acetabulum. Its lowest part presents inferior gluteal line is horizontal. Its anterior end lies just
a prominence called the anterior inferior iliac spine. above the anterior inferior iliac spine; and its posterior end
The posterior border of the ilium extends from the posterior reaches the greater sciatic notch. The gluteal surface of the
superior iliac spine to the back of the acetabulum. A few ilium bears a prominent groove just above the acetabulum.
Fig. 9.3. Right hip bone, internal aspect.

The lower part of the gluteal surface
tuberosity we see a shallow lesser
extends behind the acetabulum where it
sciatic notch.
becomes continuous with the ischium.
The ramus of the ischium is attached
The lowest part of the ilium forms the
to the medial side of the lower end of
upper two fifths of the acetabulum.
the body. The ramus has an anterior
The medial surface of the ilium is
(external) surface and a posterior
divisible into the following parts. The
(internal) surface.
iliac fossa is smooth and concave and
forms the wall of the greater pelvis: it
occupies the anterior part of the medial The Pubis
surface. The sacropelvic surface lies
behind the iliac fossa. It can be The pubis consists of a body, a superior
subdivided into three parts. The upper ramus and an inferior ramus. The body
Fig. 9.4. Right ischial tuberosity,
part is rough and constitutes the iliac (Fig. 9.5) forms the anterior and most
seen from behind and below.
tuberosity. The middle part articulates medial part of the hip bone. It has an
with the lateral side of the sacrum. This anterior surface and a posterior surface.
part is called the auricular surface because of a resemblance The upper border of the body of the pubis is called the
to the pinna. The pelvic part of the medial surface lies below pubic crest. The crest ends laterally in a projection called
and in front of the auricular surface. It is smooth and takes part the pubic tubercle.
in forming the wall of the lesser pelvis. This surface is often The superior ramus of the pubis runs upwards backwards
marked (specially in the female) by a rough groove called the and laterally from the body. Its lateral extremity takes part
preauricular sulcus. The iliac fossa and the sacropelvic surface in forming the pubic part of the acetabulum. It meets the
are separated by the medial border of the ilium. Its lower part ilium at the iliopubic eminence. The superior ramus is
is rounded and forms the arcuate line. The lower end of the triangular in cross section (Fig. 9.6). It has three borders
arcuate line reaches the junction of the ilium and pubis. This and three surfaces.
junction shows an enlargement called the iliopubic eminence. The anterior border is called the obturator crest. The
posterior border is sharp and forms the pecten pubis or
pectineal line. The inferior border is also sharp and forms
the upper margin of the obturator foramen. The surface
The Ischium
between the obturator crest and the pecten pubis is the
The ischium consists of a main part
called the body, and a projection
called the ramus. The upper end
of the body forms the inferior and
posterior part of the acetabulum.
The lower part of the body has
three surfaces: dorsal, femoral and
pelvic. The lower part of the dorsal
surface has a large rough
impression called the ischial
tuberosity This tuberosity is
divided into upper and lower parts
by a transverse ridge (Fig. 9.4).
Each of these parts is again divided
into medial and lateral parts.
Superiorly the dorsal surface
becomes continuous with the
gluteal surface of the ilium. The
posterior border of the dorsal
surface of the ischium forms part
of the lower margin of the greater
sciatic notch. Just below this notch
the border projects backwards and
medially as the ischial spine.
Between the ischial spine and the Fig. 9.5. Medial part of right hip bone: anterosuperior aspect. The gray
upper border of the ischial lines demarcate the ilium, the ischium and the pubis
81
82
pectineal surface. The pelvic surface lies between the pecten
pubis and the inferior border. The surface between the obturator
crest and the inferior border is called the obturator surface. A
groove runs forwards and downwards across it and is called
the obturator groove.
The inferior ramus of the pubis passes downwards and laterally
to meet the ramus of the ischium. These two rami form the
medial boundary of the obturator foramen. In the intact pelvis
(Fig. 9.1) the conjoined rami of the pubis and ischium of the Fig. 9.6. Section at right angles to the long axis of
two sides form the boundaries of the pubic arch that lies below the superior ramus of the pubis.
the pubic symphysis.
The Acetabulum part: the gap in the margin is called the acetabular notch.
The acetabulum forms the hip joint with the head of the femur. The floor of the acetabulum is partly articular and partly
It is directed laterally and somewhat downwards and forwards. non-articular. The articular area for the head of the femur is
The margin of the acetabulum is deficient in the anteroinferior shaped like a horse-shoe and is called the lunate surface.
Fig. 9.7. Right hip bone showing attachments. External aspect.

The non-articular part of the floor of the acetabulum is called Some Important Attachments on the Hip Bone
the acetabular fossa. The contributions to the acetabulum by
the ilium, the ischium and the pubis are shown in Figure 9.5 in
A. The muscles attached to the iliac crest are as follows
which the lines of junction of the three parts are indicated by
(Figs 5.8 and 5.9).
gray lines.
1. The internal oblique muscle of the abdomen arises from
the intermediate area of the ventral segment of the iliac
The Obturator Foramen crest.
The obturator foramen is bounded above by the superior ramus 2. The external oblique muscle of the abdomen is inserted
of the pubis; medially by the body of the pubis, by its inferior into the anterior two-thirds of the outer lip of the ventral
ramus and by the ramus of the ischium; and laterally by the segment of the iliac crest.
body of the ischium. In the intact body the foramen is filled by 3. The lowest fibres of the latissimus dorsi take origin from
a fibrous sheet called the obturator membrane. The membrane the outer lip of the iliac crest just behind its highest point.
is deficient in the uppermost part of the foramen. 4. The tensor fasciae latae arises from the anterior part of
the outer lip of the iliac crest.
5. The transversus abdominis arises from the anterior two-
thirds of the inner lip of the ventral segment of the iliac
crest.
Fig. 9.8. Right hip bone

showing attachments.
Internal aspect.
83
84
6. The quadratus lumborum arises from the posterior one-third 11. The adductor brevis arises from the anterior surface of
of the inner lip of the ventral segment of the iliac crest. the body of the pubis and its inferior ramus.
7. The gluteus maximus arises from the lateral surface of the 12. The obturator externus arises from the superior and
dorsal segment of the iliac crest and from the gluteal surface inferior rami of the pubis, and from the ramus of the ischium,
of the ilium behind the posterior gluteal line. immediately around the obturator foramen.
13. The adductor magnus arises from the lower lateral part
of the ischial tuberosity, and from the ramus of the ischium.
B. The muscles attached to the external aspect of the hip
14. The semitendinosus and the biceps femoris (long head)
bone (excluding the iliac crest) are as follows (Fig. 5.8).
arise from the upper medial part of the ischial tuberosity.
1. The gluteus maximus arises from the lateral surface of the
15. The semimembranosus arises from the upper lateral part
dorsal segment of the iliac crest and from the gluteal surface of
of the ischial tuberosity.
the ilium behind the posterior gluteal line.
16. The quadratus femoris arises from the femoral surface
2. The gluteus medius arises from the gluteal surface of the
of the ischium just lateral to the ischial tuberosity.
ilium between the anterior and posterior gluteal lines.
3. The gluteus minimus arises from the gluteal surface of the
ilium between the anterior and inferior gluteal lines. C. The muscles arising from the internal aspect of the hip
4. The sartorius arises from the anterior superior iliac spine. bone are as follows (Fig. 5.9).
5. The straight head of the rectus femoris arises from the anterior 1. The iliacus arises from the upper two-thirds of the iliac
inferior iliac spine; and its reflected head from the groove above fossa.
the acetabulum. 2. The obturator internus arises from the pelvic surfaces of
7. The pectineus arises from the upper part of the pectineal the superior and inferior rami of the pubis, and the ramus of
surface of the superior ramus of the pubis. the ischium, immediately adjoining the obturator foramen;
8. The rectus abdominis (lateral head) arises from the pubic and from the pelvic surfaces of the ischium and of the ilium.
crest. 3. The psoas minor is inserted into the pecten pubis and into
9. The adductor longus arise from the anterior surface of the the iliopectineal eminence.
body of the pubis.
10. The gracilis arises from the anterior surface of the body, Greater and Lesser Sciatic Foramina
and the inferior ramus, of the pubis; and from the ramus of the The greater and lesser sciatic notches are converted into
ischium. foramina by the sacrotuberous and sacrospinous ligaments.
Fig. 9.9. Pelvis seen from the front.

The greater sciatic foramen transmits the following structures: prominent vertical ridge called the linea aspera. The
Piriformis; the superior and inferior gluteal nerves and vessels; information given above is sufficient to distinguish between
the internal pudendal vessels; the pudendal and sciatic nerves; a femur of the right or left side.
the posterior cutaneous nerve of the thigh; and the nerves to
the obturator internus and to the quadratus femoris.
The Upper End
Having emerged from the greater sciatic foramen the pudendal
nerve, the nerve to the obturator internus, and the internal
Apart from the head and the neck the upper end of the femur
pudendal vessels pass behind the ischial spine to enter the lesser
has two projections called the greater and lesser trochanters.
sciatic foramen. The tendon of the obturator internus emerges
The head is directed medially, upwards and somewhat
from the pelvis through this foramen.
forwards. It is slightly more than half a sphere. Near the
centre of the head there is a pit or fovea.
The neck connects the head to the shaft. It joins the shaft at
an angle of about 125 degrees. The greater and lesser
PELVIS AS A WHOLE
We have seen that the bony pelvis is made up of the two hip
bones, the sacrum and the coccyx (Fig. 9.9). It may be
subdivided into the greater (or false) pelvis and the lesser (or
true) pelvis. The walls of the greater pelvis are formed by the
broad upper parts of the two iliac bones (iliac fossae), and
posteriorly by the base of the sacrum. The communication
between the greater and lesser pelvis is called the superior pelvic
aperture or pelvic inlet. The margins of the aperture constitute
the pelvic brim. The pelvic brim is formed behind by the sacral
promontory, and the ridge separating the superior and anterior
surfaces of the sacrum; on either side by the arcuate line of the
ilium (also see figure 9.3); and anteriorly by the pecten pubis
and by the pubic crest. The arcuate line, the pecten pubis and
the pubic crest are collectively referred to as the linea
terminalis.
The cavity of the lesser pelvis is bounded in front by the body
and rami of the pubis; on either side by the pelvic surfaces of
the ilium and ischium; and behind by the anterior surfaces of
the sacrum and coccyx.
The inferior pelvic aperture is highly irregular. It is bounded
anteriorly by the pubic arch; laterally, in that order, by the ischial
tuberosity, the lesser sciatic notch, the ischial spine and the
greater sciatic notch. Posteriorly, it is formed by the lateral
margin of the sacrum and coccyx. When the ligaments are intact
the lateral margins are formed by the sacrotuberous ligaments
(that stretch from the side of the sacrum and coccyx to the ischial
tuberosity. The inferior aperture then appears to be rhomboidal.
THE FEMUR
The femur (Figs 9.10 to 9.16) is a long bone having a shaft, an

upper end and a lower end. The upper end is easily distinguished
from the lower end by the presence of a rounded head that is
joined to the shaft by an elongated neck. The head is directed
medially to articulate with the acetabulum of the hip bone. The
anterior and posterior aspects of the bone can be distinguished
by examining the shaft: it is convex forwards and the anterior
Fig. 9.10. Right femur, anterior aspect.
aspect is smooth, while the posterior aspect is marked by a
85
86
Fig. 9.11. Right femur: posteromedial view of

upper end.
Fig. 9.12. Right femur: lateral aspect of upper end.
trochanters are situated near the junction of the neck with the
shaft.
The greater trochanter forms a large quadrangular projection
on the lateral aspect of the upper end of the femur. Its upper
and posterior part projects upwards beyond the level of the
neck and thus comes to have a medial surface. On this surface
we see a depressed area called the trochanteric fossa (Fig.
9.11). The anterior aspect of the greater trochanter shows a
large rough area for muscle attachments. The lateral surface
of the greater trochanter is also marked by a ridge that runs
downwards and forwards across the lateral surface. Fig. 9.13. Right femur, posterior aspect.
The lesser trochanter is a conical projection attached to the
shaft where the lower border of the neck meets the shaft. The
posterior parts of the greater and lesser trochanters are joined
The Shaft
together by a prominent ridge called the intertrochanteric crest.
A little above its middle this crest bears a rounded elevation
The shaft of the femur has a forward convexity and is smooth
called the quadrate tubercle. Anteriorly, the junction of the
anteriorly. Its posterior aspect is marked by a rough vertical
neck and the shaft is marked by a much less prominent
ridge called the linea aspera. A section across the shaft is
intertrochanteric line. The upper end of this line reaches the
seen in Figure 9.14. We see that the shaft is triangular having
anterior and upper part of the greater trochanter; its lower end
three borders (lateral, medial and posterior) and three
lies a little in front of the lesser trochanter. Here it becomes
surfaces (anterior, lateral and medial). The lateral and medial
continuous with the spiral line that runs downwards and
borders are rounded. The posterior border corresponds to
backwards across the medial aspect of the shaft to reach its
the linea aspera. The linea aspera has distinct medial and
posterior aspect.
lateral lips. When traced upwards to the upper one-third of
Behind and below the epicondyle there is a prominent groove
that is divided into an anterior deeper part and a shallower
posterior part.
When seen from the medial aspect the medial condyle is
seen to be convex. The most prominent point on it is called
the medial epicondyle. The uppermost part of the medial
condyle is marked by a prominence called the adductor
tubercle (Fig. 9.13).
Important Attachments on the Femur

Fig. 9.14. T.S. across the shaft of the femur near its middle.
A. The muscles inserted into the femur are as follows
(Figs 9.15 and 9.16):
the shaft the lips diverge. The medial lip becomes continuous
1. The gluteus minimus is inserted on the anterior aspect of
with the spiral line. The lateral lip of the linea aspera becomes
the greater trochanter.
continuous with a broad rough area called the gluteal tuberosity.
2. The gluteus medius is inserted into the oblique strip
The upper end of the gluteal tuberosity reaches the greater
running downwards and forwards across the lateral surface
trochanter. The area between the gluteal tuberosity (laterally)
of the greater trochanter.
and the spiral line (medially) constitutes a fourth surface
3. The piriformis is inserted into the upper border of the
(posterior) over the upper one-third of the shaft. The two lips
greater trochanter.
of the linea aspera also diverge from each other over the lower
4. The obturator internus and gemelli are inserted into the
one-third of the shaft to become continuous with ridges called
anterior part of the medial surface of the greater trochanter.
the medial and lateral supracondylar lines. Here again, the shaft
5. The obturator externus is inserted into the trochanteric
has an additional surface directed posteriorly: this surface is
fossa on the medial surface of the greater trochanter.
triangular and is called the popliteal surface.
6. The psoas major is inserted into the medial part of the
anterior surface of the lesser trochanter.
7. The iliacus is inserted into the medial side of the base of
The Lower End the lesser trochanter, and into a small area below the latter.
8. The pectineus is inserted along a line descending from
The lower end of the femur consists of two large condyles, the root of the lesser trochanter to the upper end of the linea
medial and lateral. The two condyles are joined together aspera. The insertion lies between the gluteal tuberosity
anteriorly and, on this aspect, they lie in the same plane as the and the spiral line.
lower part of the shaft. Posteriorly, the two condyles project 9. The quadratus femoris is inserted on the quadrate tubercle,
much beyond the plane of the shaft, and here they are separated and into a small area below the latter.
by a deep intercondylar notch or fossa. 10. The deep fibres of the gluteus maximus are inserted into
the gluteal tuberosity.
When viewed from the side the lower margin of each condyle 11. The upper part of the adductor brevis is inserted between
is seen to form an arch that is convex downwards. When seen the insertions of the pectineus (medially) and the adductor
from below it is seen that the long axis of the lateral condyle is magnus (laterally) (see below). The lower part of the muscle
straight and is directed backwards and somewhat laterally. In is inserted into the linea aspera.
contrast the medial condyle is slightly curved having a medial 12. The adductor longus is inserted into the middle one-
convexity. third of the linea aspera.
The anterior aspect of the two condyles is marked by an articular 13. The adductor magnus is inserted into the medial margin
area for the patella. The area is concave from side to side to of the gluteal tuberosity, the linea aspera, and the medial
accommodate the convex posterior surface of the patella. It is supracondylar line. The hamstring part of the muscle ends
divided into medial and lateral parts. The lateral part is much in a tendon that is attached to the adductor tubercle.
larger (Fig. 9.10).
Inferiorly, the condyles articulate with the tibia to form the knee
joint. For this purpose each condyle bears a large convex B. The muscles taking origin from the femur are as
articular surface that is continuous anteriorly with the patellar follows:
surface. The articular surface covers the inferior and posterior 1. The vastus lateralis has a long linear origin. The line begins
aspects of each condyle. at the upper end of the intertrochanteric line, and passes
When seen from the lateral aspect the lateral condyle of the along the anterior and lower borders of the greater trochanter,
femur is seen to be more or less flat. A little behind the middle the lateral margin of the gluteal tuberosity, and the lateral
it is marked by a prominence called the lateral epicondyle. lip of the linea aspera.
87
88
Fig. 9.15. Attachments on the femur seen from the front. Fig. 9.16. Attachments on the femur seen from behind.
2. The vastus medialis also has a long linear origin from the 5. The short head of the biceps femoris arises from the linea
lower part of the intertrochanteric line, the spiral line, the aspera and from the upper part of the lateral supracondylar
medial lip of the linea aspera, and the medial supracondylar line.
line right up to the adductor tubercle. 6. The medial head of the gastrocnemius arises from the
3. The vastus intermedius arises from the upper three-fourths popliteal surface a little above the medial condyle. The lateral
of the anterior and lateral surfaces of the shaft. The medial head of the muscle arises from the lateral surface of the lateral
surface of the shaft does not give origin to the muscle, but is condyle.
covered by it. 7. The plantaris arises from the lower part of the lateral
4. The articularis genu arises from small areas on the anterior supracondylar line.
surface of the shaft below the origin of the vastus intermedius.
8. The popliteus arises (by a tendon) from the anterior part of non-articular. It is rough for attachment of the ligamentum
the groove on the lateral aspect of the lateral condyle. patellae.
C. Other attachments on the femur. Some Attachments on the Patella

1. The capsular ligament of the hip joint is attached to the neck
of the femur most of which is intracapsular. Anteriorly, the 1. The superior border gives attachment to the rectus femoris
capsule is attached to the intertrochanteric line, but posteriorly and to the vastus intermedius.
the capsule is attached about 1cm medial to the intertrochanteric 2. The apex gives attachment to the ligamentum patellae.
crest.
2. The ligament of the head is attached to the fovea on the head
of the femur.
3. The capsular ligament of the knee joint is attached to the
femoral condyles and to the posterior margin of the
intercondylar fossa.
THE PATELLA
The tendons of some muscles have, embedded in them, small

bones that help them to glide over bony surfaces. Such bones
are called sesamoid bones. The largest sesamoid bone in the
body is to be seen in the tendon of the quadriceps femoris as it
passes in front of the knee joint. It is called the patella.
The patella is shaped somewhat like a disc (Fig. 9.17). It roughly
triangular in outline. It has anterior and posterior surfaces that
are separated by three borders: superior, medial, and lateral.
The superior border is also called the base. The inferior part of
the bone shows a downward projection representing the apex
of the triangle.
The anterior surface is rough and can be felt through the

overlying skin. The upper part of the posterior surface is
articular. This part articulates with the patellar surface on the
anterior aspect of the condyles of the femur. It consists of a
larger lateral part and a smaller medial part, the two parts being
separated by a ridge. The lower part of the posterior surface is
Fig. 9. 18. Right tibia, anterior aspect

Fig. 9.17. Right patella, posterior aspect.
89
90
THE TIBIA
The tibia is the medial bone of the leg. It has a shaft, an upper end and
a lower end (Figs. 9.18 to 9.23). The upper end can be distinguished
from the lower end as it is much larger. The medial and lateral sides of
the bone can be distinguished by examining the lower end: this end has
a prominent downward projection, the medial malleolus, on its medial
side. The anterior and posterior aspects of the bone can be distinguished
by examining the shaft. The shaft is triangular in section (Fig. 9.19)
and has a sharp anterior border. The side to which a tibia belongs can
be determined from the information given above.
The Upper End
The upper end of the tibia consists of two parts called the medial and
lateral condyles that are separated by an intercondylar area. The anterior
aspect of the upper end of the tibia is marked by another projection
called the tibial tuberosity.
The upper surfaces of the medial and lateral condyles bear large, slightly
concave, articular surfaces that take part in forming the knee joint (Fig.
9.23). The medial articular surface is oval, and is larger than the lateral
surface that is rounded. The articular surfaces are separated by the

intercondylar area which is non-articular. The intercondylar area is
raised in its central part to form the intercondylar eminence. The medial
and lateral parts of the eminence are more prominent than its central
part and constitute the medial and lateral intercondylar tubercles. The
medial and lateral condylar articular surfaces extend on to the sides of
the intercondylar tubercles.
In addition to its upper surface the medial condyle has rough anterior,
medial and posterior surfaces that are distinctly marked off from the
shaft by a ridge (Fig. 9.20). The lateral condyle has similar anterior,
lateral and posterior surfaces. The posterior surface of the medial
condyle is marked by a groove. The posterolateral part of the lateral
condyle bears an oval articular facet for the upper end of the fibula
(Fig. 9.20). The anterior surfaces of the medial and lateral condyles
merge to form a large rough triangular area. The apex of the triangle is
placed inferiorly and is raised to form a large projection called the
tibial tuberosity. The tuberosity has an upper smooth part and a lower
rough part (Fig. 9.18). The lateral margin of the triangle mentioned
above has a prominent impression (that is also triangular).
Fig. 9.20. Right tibia. Posterioraspect.
The Shaft
If we cut a section across the shaft of the tibia (Fig. 9.19) we see that
the shaft is triangular. It has anterior, medial and lateral (or
interosseous) borders; and medial, lateral and posterior surfaces.
The anterior border runs downwards from the tibial tuberosity. Its
lower part turns medially and reaches the anterior margin of the
medial malleolus.
The interosseous or lateral border begins a little below and in front
of the articular facet for the fibula. It descends along the lateral
Fig, 9.19. Right tibia. Transverse section
through the shaft.
aspect of the shaft. Its lower end forms the anterior margin of a
rough triangular area seen on the lateral aspect of the lower end.
The upper end of the medial border lies below the most medial medially in its lower part, the lateral surface extends on to
part of the medial condyle. Its lower end becomes continuous the anterior aspect of the lower part of the shaft.
with the posterior margin of the medial malleolus. The posterior surface (Fig. 9.20) lies between the medial
The medial surface lies between the anterior and medial and interosseous borders. Over the upper one-third of the
borders. The upper end of the surface is rough just in front of shaft this surface is marked by a prominent ridge that runs
the medial border. The rest of the surface is smooth and can be downwards and medially across it. This ridge is called the
felt through the overlying skin. soleal line. The part of the posterior surface above the soleal
The lateral surface lies between the anterior and interosseous line is triangular. The part below the line is subdivided into
borders. Because of the fact that the anterior border turns medial and lateral parts by a faint vertical ridge.
The Lower End
The lower end of the tibia is much less expanded than the
upper end. Its medial part shows a downward projection
called the medial malleolus. The posterior aspect of the
malleolus is marked by a prominent groove. The lateral
aspect of the lower end shows a triangular fibular notch for
articulation with the fibula. It consists of an upper part that
is rough and a lower part that is smooth. The inferior surface
of the lower end bears an articular area that articulates with
the upper surface of the talus to form the ankle joint. The
area is continuous with another articular area on the lateral
aspect of the medial malleolus that articulates with the medial
side of the talus.
Some Attachments on the Tibia
A. The muscles inserted into the tibia are as follows

(Figs 9.21 and 9.22).
1. The pull of the quadriceps femoris is transmitted to the
tibia through the ligamentum patellae that is attached to the
smooth upper part of the tuberosity of the tibia.
2. The sartorius, the gracilis, and the semitendinosus are
inserted on the upper part of the medial surface. The area
for the sartorius is most anterior and that for the
semitendinosus is most posterior.
3. The semimembranosus is inserted into the posterior and
medial aspects of the medial condyle.
4. The popliteus is inserted into the posterior surface of the
shaft, on the triangular area above the soleal line.
B. The muscles taking origin from the tibia are as follows.

1. The tibialis anterior arises from the upper two-thirds of
the lateral surface of the shaft.
2. The soleus arises from the soleal line, and from the middle
one-third of the medial border of the shaft.
3. The tibialis posterior arises from the upper two-thirds of
the lateral part of the posterior surface of the shaft, below
the soleal line.
4. The flexor digitorum longus arises from the medial part
of the posterior surface of the shaft below the soleal line.
Fig. 9.21. Attachments on the tibia seen from the front
91
92
Fig. 9.23. Right tibia, showing attachments,

seen from above.
menisci and to the cruciate ligaments. For details see Figure

9.23.
3. The margins of the fibular facet give attachment to the

capsule of the superior tibiofibular joint.
4. The interosseous membrane is attached to the interosseous
border.
5. The articular capsule of the ankle joint is attached to the
margins of the articular surface on the lower end of the bone.
THE FIBULA
The fibula has a shaft, an upper end and a lower end (Figs
9.24 to 9.27). The upper end is irregularly expanded in all
directions. In contrast the lower end is flattened from side
to side and forms the lateral malleolus. The medial side of
the malleolus bears a triangular articular surface (for the
talus)(Figs 9.24 and 9.25). Just behind this articular surface
the malleolus shows a deep malleolar fossa (Fig. 9.25); and
this fact enables the anterior and posterior aspects of the
bone to be distinguished from one another. The side to which
a fibula belongs can be determined with the help of the
information given above.
Fig. 9.22. Attachments on the tibia seen from behind

The Upper End
C. Other attachments on the Tibia The upper end of the fibula is also called the head. Its
1. The capsular ligament of the knee joint is attached to the posterior and lateral part shows an upward projection called
condyles of the tibia a little below the margins of the articular the styloid process. In front of, and medial to, the styloid
sufaces. process the head shows a circular facet for articulation with
2. The intercondylar area, on the superior aspect of the upper the tibia (to form the superior tibiofibular joint). The part of
end of the tibia, gives attachment to the medial and lateral the bone immediately below the head is called the neck.
Fig. 9.24. Right fibula seen from Fig. 9.25. Right fibula, medial Fig. 9.26. Right fibula seen from
the front. aspect. behind.
The Lower End The Shaft
The lower end of the fibula is called the lateral malleolus. It The shaft has three borders: anterior, posterior and
has a lateral surface that can be felt through the overlying skin. interosseous (or medial).
The medial surface of the malleolus bears a triangular facet. The anterior border is sharp (Fig. 9.24). It begins just below
This facet articulates with the lateral surface of the talus and the anterior aspect of the head. Near its lower end it turns
forms part of the ankle joint. Behind the facet the medial surface laterally to join the apex of the triangular area of the shaft
of the malleolus shows a deep malleolar fossa. already identified above the lateral malleolus. The lowest
93
94
part of the anterior border forms the posterior margin of the b. The peroneus tertius arises from an area on the medial
triangle. surface below that for the extensor digitorum longus.
The upper end of the posterior border lies in line with the c. The extensor hallucis longus arises from the middle two-
styloid process (Fig. 9.26). Its lower end reaches the medial fourths of the medial surface, medial to the origin of the
part of the posterior surface of the lateral malleolus. extensor digitorum longus.
The interosseous border lies very near the anterior border 3. The lateral surface gives origin to the following.
(Figs 9.24 and 9.27) and may be indistinguishable from the a. The peroneus longus arises from the upper two-thirds of
latter in the upper part of the shaft. When traced downwards it the lateral surface. Part of the muscle also arises from the
passes medially and merges with the upper part of the rough lateral aspect of the head of the fibula. The common peroneal
area above the talar facet of the lateral malleolus. nerve lies between the two areas of origin.
The lateral surface of the fibula lies between the anterior and
posterior borders. The lower part of the lateral surface faces
backwards and becomes continuous with the posterior aspect
of the lateral malleolus.
The medial surface lies between the anterior and interosseous
borders. It is very narrow in the upper half of the shaft. Its
lower broader part faces forwards and medially. This surface
is, therefore, sometimes called the anterior surface.
The posterior surface lies between the interosseous and
posterior borders. Over its upper three fourths it is divided
into two distinct parts, medial and lateral, by a vertical ridge
called the medial crest (Fig. 9.25).
Attachments on the Fibula
A. The muscles attached to the fibula are as follows (Figs

9.28 to 9.30):
1. The biceps femoris is inserted into the head of the fibula.
2. The narrow medial surface gives origin to the following.
a. The extensor digitorum longus arises from the upper three-
fourths of this surface.
Fig. 9.27. Transverse sections across the shaft of the right

fibula to show its borders and surfaces. A. Through upper Figs. 9.28. Right fibula showing attachments.
part. B. Through lower part. Anterior aspect
b. The peroneus brevis arises from the lower two-thirds of the Some Relations of the Fibula
lateral surface. 1. The common peroneal nerve winds round the lateral aspect
4. The following muscles are attached to the posterior surface. of the neck of the fibula (Fig. 9.31).
a. The tibialis posterior arises from the upper two-thirds of the 2. The tendons of the peroneus longus and the peroneus
medial part of the posterior surface. brevis pass downwards just behind the lateral malleolus (Fig.
b. The soleus arises from the posterior aspect of the head and 9.30).
from the upper one-fourth of the lateral part of the posterior
surface.
c. The flexor hallucis longus arises from the lower two-thirds of
the lateral part of the posterior surface.
Figs. 9.29. Right fibula showing Figs. 9.30. Right fibula showing Figs. 9.31. Right fibula showing
attachments, seen from medial side. attachments. Posterior aspect attachments. Lateral aspect
95
96
THE SKELETON OF THE FOOT navicular bone there are three smaller bones. These are the
medial cuneiform, the intermediate cuneiform, and the
lateral cuneiform bones.
The skeleton of the foot is seen from above (dorsal aspect) in
Anterior to the tarsal bones we see five metatarsal bones.
Figure 9.32, and from below (plantar aspect) in Figure 9.33. The
Distal to the metatarsal bones there are the phalanges: three
posterior half (or so) of the foot is made up of seven tarsal
(proximal, middle, distal) for each digit except the great toe
bones. The largest tarsal bone is called the calcaneus: it is the
that has only two phalanges, proximal and distal.
bone that forms the heel. Placed above the calcaneus there is
another large bone called the talus. The talus articulates with
the lower ends of the tibia and fibula to form the ankle joint. The Calcaneus
Anterior (or distal) to the calcaneus and the talus there are two
bones of intermediate size. These are the navicular bone placed The calcaneus can be correctly orientated, and its side
medially, and the cuboid bone placed laterally. Distal to the determined using the following information (Figs 9.32, 9.33
to 9.35) .
1. The bone is elongated antero-
posteriorly. The anterior aspect is
Fig. 9.32. Skeleton of the foot easily distinguished from the
seen from above (dorsal aspect). posterior as it is covered by a large
articular facet, while the posterior
aspect is non-articular.
2. The superior aspect can be
distinguished from the inferior as it
bears three facets, while the inferior
aspect is nonarticular.
3. The medial aspect can be
distinguished from the lateral aspect
as it bears a prominent projection.
Having orientated the bone correctly
the following facts can now be
appreciated.
The calcaneus has anterior, posterior,
superior, inferior, medial and lateral
surfaces. The anterior surface is
fully covered by a large articular
facet for the cuboid bone. The
posterior surface is non-articular. It
is divisible into upper, middle and
inferior parts. The lateral surface is
more or less flat. Its anterior part
shows a small elevation called the
peroneal trochlea (or tubercle). The
medial surface is easily
distinguished as it bears a large
projection called the sustentaculum
tali that projects medially from its
anterior and upper part. The superior
or dorsal surface bears three facets:
anterior, middle and posterior that
articulate with corresponding facets
on the talus.
The plantar (or inferior) surface of
the calcaneus shows a prominence
in its posterior part called the
calcaneal tuberosity. The lateral and
medial parts of the tuberosity extend
further forwards than its central part
and are called the lateral and medial
processes, respectively, of the tuberosity. The anterior part of The Navicular Bone
the plantar surface shows another elevation called the anterior
tubercle. The navicular bone articulates proximally with the head of
the talus, distally with the three cuneiform bones, and
laterally with the cuboid (Figs 9.32 and 9.33). The medial
The Talus
part of the bone has a projection called the tuberosity.
The talus can be orientated correctly, and its side determined
using the following information (Figs 9.32, 9.33 and 9.36 to 9.39). The Cuboid Bone
1. The bone is elongated anteroposteriorly. The anterior end
(or head) can be distinguished from the posterior end as it is The cuboid bone articulates proximally with the calcaneus;
rounded and has a large convex articular surface. distally with the fourth and fifth metatarsal bones; and
2. The superior aspect of the bone bears a large pulley shaped medially with the navicular and lateral cuneiform bones
surface that is convex upwards. The inferior aspect bears three (Figs 9.32 and 9.33). The lateral and plantar aspects of the
facets.
3. The lateral surface bears a large

triangular facet, while the medial side
shows a comma shaped facet.
The talus has a head, a neck and a
body. The distal surface of the head
has a large convex surface that
articulates with the navicular bone.
The upper surface of the body of the Fig. 9.33. Skeleton of the
talus is covered by a large trochlear foot seen from below
articular surface that articulates with (plantar aspect)
the lower end of the tibia.
The lateral and medial sides of the
bone are shown in Figures. 9.37 and
9.38 respectively. The lateral
surface bears a large triangular facet
for articulation with the lateral
malleolus of the fibula, while the
medial surface bears a comma
shaped facet that is broad anteriorly
and tapers off posteriorly. This facet
articulates with the medial malleolus
of the tibia.
The lower and posterior part of the
body of the talus projects backwards.
This projection is called the posterior
process. A groove divides this
process into medial and lateral
tubercles.
When the talus is viewed from below
(Fig. 9.39) we see that the articular
area on the head, for the navicular
bone, extends on to the inferior
aspect of the head.
Behind this there are three facets,
anterior middle and posterior, that
articulate with corresponding facets
on the upper surface of the calcaneus.
The middle and posterior facets are
separated by a deep groove called the
sulcus tali.
97
98
Fig. 9.34. Right calcaneus seen from above.

Fig. 9.36. Right talus, seen from above.
Fig. 9.35. Right calcaneus seen from below. Fig. 9.37. Right talus, seen from the lateral side.
Fig. 9.38. Right talus seen from the medial side. Fig. 9.39. Right talus seen from below.
bone show a groove that is limited posteriorly by a ridge. The The Metatarsal Bones
lateral end of this ridge forms a projection called the tuberosity.
The metatarsal bones are five in number (Figs 9.32 and 9.33).
They are numbered from medial to lateral side (in contrast
The Medial Cuneiform Bone
to the metacarpal bones that are numbered from lateral to
medial side). The metatarsal bones are similar in structure
The medial cuneiform bone is the largest of the cuneiform bones
to the metacarpal bones. Each bone has a distal end or head;
(Figs 9.32 and 9.33).
a proximal end or base and an intervening shaft. The head is
It can be distinguished by the fact that it bears a large kidney-
rounded. The base is enlarged and has proximal, dorsal,
shaped facet on one side. It articulates proximally with the
plantar, medial and lateral surfaces. The shaft is slightly
navicular bone; distally with the first metatarsal bone; and
convex on its dorsal side and concave on the plantar side.
laterally with the intermediate cuneiform and second metatarsal
The articulations of the metatarsal bones are shown in Figure
bones.
9.32.
The Intermediate Cuneiform Bone

The Phalanges of the Foot
The intermediate cuneiform bone is the smallest of the
The phalanges of the foot are arranged on a pattern similar
cuneiform bones. It is shaped like a typical wedge (Figs 9.32
to that in the hand (Figs 9.32 and 9.33). There are three
and 9.33). It articulates proximally with the navicular bone,
phalanges in each toe except the great toe: proximal, middle
distally with the second metatarsal bone, medially with the medial
and distal. The great toe has only two phalanges, proximal
cuneiform bone, and laterally with the lateral cuneiform bone.
and distal. The phalanges of the foot are similar in shape to
those of the hand, but are much shorter and thinner than the
The Lateral Cuneiform Bone latter.
The skeleton of the foot gives attachment to numerous
The lateral cuneiform bone articulates proximally with the muscles and ligaments. These will be considered in the
navicular bone; distally with the third metatarsal bone; medially sections on muscles and joints.
with the intermediate cuneiform and second metatarsal bones;
and laterally with the cuboid and fourth metatarsal bones (Figs
9.32 and 9.33).
99
100
10 : Front and Medial Side of Thigh

Before considering deeper structures in the thigh it is convenient to study the cutaneous innervation,
the superficial veins and the lymphatic drainage of the entire lower limb.
CUTANEOUS INNERVATION OF LOWER LIMB
Front of thigh
The cutaneous nerves that supply the front of thigh are shown cutaneous branches of the obturator nerve. Three areas
in Figure 10.1. Note that four longitudinal strips of skin are just below the inguinal ligament are supplied (from lateral
supplied (from lateral to medial side) by the lateral cutaneous to medial side) by the subcostal and iliohypogastric nerves,
nerve of the thigh, the intermediate cutaneous nerve of the the femoral branch of the genitofemoral nerve, and the
thigh, the medial cutaneous nerve of the thigh, and by ilioinguinal nerve.
Fig. 10.1. Cutaneous nerves supplying the

Fig. 10.2. Cutaneous nerves on front of leg and
front of the thigh.
dorsum of foot.
FRONT AND MEDIAL SIDE OF THIGH
Back of thigh
The cutaneous nerve supply of the back of the thigh is
shown in Figure 10.4. Most of this aspect of the thigh is
innervated by the posterior cutaneous nerve of the
thigh. Note that this nerve also supplies the upper part
of the back of the leg. Laterally and medially we can
see some areas supplied by the same nerves that have
already been seen from the front. These are the obturator
nerve and the medial cutaneous nerve of the thigh, on
the medial side, and the lateral cutaneous nerve of the
thigh on the lateral side.
Back of leg
The cutaneous nerve supply of the back of the leg is
shown in Figure 10.5. On the medial and lateral sides we
see the same nerves as seen from the front viz., the
saphenous nerve medially, and the lateral cutaneous
Fig. 10.3. Cutaneous nerves in gluteal region.
Front of leg and dorsum of foot

The cutaneous nerve supply of the front of the leg is shown in
Figure 10.2. The medial side of the front of the leg is supplied
by the saphenous nerve. The lateral side of the leg is supplied,
in its upper part, by the lateral cutaneous nerve of the calf
and, lower down, by the superficial peroneal nerve.
The greater part of the dorsum of the foot, including most of
the toes, is supplied by the superficial peroneal nerve. A
triangular area of skin covering the adjoining sides of the big
toe and the second toe is supplied by the deep peroneal nerve.
A strip along the medial side of the foot is supplied by the
saphenous nerve, but the area supplied does not reach the big
toe. A strip along the lateral side of the foot is supplied by the
sural nerve: the area reaches the little toe.
Gluteal region
The cutaneous nerves supplying the gluteal region are shown
in Figure 10.3. The first point to note is that whereas the
predominant nerve supply of the entire lower limb is through
ventral rami of spinal nerves, some areas of skin over the gluteal
region are supplied by dorsal rami. An area over the sacrum is
innervated by dorsal rami of spinal nerves S1, 2, 3. More
laterally a wide area is innervated by dorsal rami of nerves L1,
2, 3. (All other areas are innervated by nerves derived from
ventral rami).
The upper and lateral part of the gluteal region is supplied by
lateral cutaneous branches of the subcostal nerve, and of the
iliohypogastric nerve. The lower lateral part of the gluteal
region receives a branch from the lateral cutaneous nerve of
the thigh. Areas just above the fold of the buttock are supplied
by the perforating cutaneous nerve, near the midline, and by
the gluteal branch of the posterior cutaneous nerve of the thigh, Fig. 10.4. Cutaneous nerves on back of thigh.
more laterally.
101
102
nerve of the calf, laterally. A strip along the middle of the
back of the leg is innervated, in its upper part, by the
posterior cutaneous nerve of the thigh, and in its lower part
by the sural nerve. The skin over the heel is supplied by
medial calcaneal branches of the tibial nerve.
Sole
The cutaneous innervation of the skin of the sole is shown
in Figure 10.6. The anterior part of the sole, including the
medial 3 digits, is supplied by the medial plantar nerve.
The lateral part (including the lateral 1 digits) is supplied
through the lateral plantar nerve. Branches from these
nerves also supply the dorsal aspect of the terminal parts of
the toes including the nail beds. A strip of skin along the
lateral margin of the sole (reaching up to the lateral surface
of the little toe) is supplied by the sural nerve. On the medial
side a strip is supplied by the saphenous nerve: this strip
does not reach the big toe. Skin over the heel is supplied by
medial calcaneal branches of the tibial nerve.
VEINS OF THE LOWER LIMBS

The veins of the lower limbs can be divided into deep and
superficial veins (like those of the upper limbs). The deep
veins are placed subjacent to the deep fascia, and run along
arteries. The superficial veins lie in the superficial fascia
and many of them can be seen through the skin. The
superficial veins drain into deep veins at their termination.
They are also connected to deep veins through perforating
veins that pass through deep fascia.
Fig. 10.5. Cutaneous nerves on back of leg.
Fig. 10.7. Veins on the dorsum of

Fig. 10.6. Cutaneous nerve supply of the sole.
the foot.
Superficial veins of the lower limbs:
The dorsal and plantar surfaces of the foot are covered by subcutaneous
venous plexuses. On the dorsum of the foot a dorsal venous arch can
be recognised (Fig. 10.7). Dorsal digital and dorsal metatarsal veins
drain into this arch. Along the sides of the foot there are medial and
lateral marginal veins) that communicate with both the plantar and
dorsal venous networks. These veins are continued into two large
superficial veins, the great (or long) saphenous vein, and the small (or
short) saphenous vein respectively.
The great saphenous vein is a continuation of the medial marginal
vein of the foot. It ascends into the leg a little in front of the medial
malleolus. Ascending on the medial side of the leg it crosses the medial
side of the knee joint, and ascends on the medial side of the thigh. In
the upper part of the thigh it passes somewhat laterally and passes
through an aperture in the deep fascia (saphenous opening) to end in
the femoral vein (Fig. 10.8).
The great saphenous vein receives numerous tributaries. Just before it
pierces the deep fascia it receives the superficial epigastric, superficial
circumflex iliac and external pudendal veins: these veins accompany
the corresponding arteries. It also receives the anterior cutaneous vein
of the thigh that drains the lower part of the front of the thigh. Just
below the knee it receives the anterior vein of the leg, and the posterior
arch vein. Over the dorsum of the foot the great saphenous vein receives
the medial marginal vein of the foot. The great saphenous vein is
connected to the deep veins of the leg and thigh through a number of
perforating veins that are mentioned below.
The small (or short) saphenous vein is a continuation of the lateral
marginal vein of the foot. It ascends behind the lateral malleolus, and
Fig. 10.8. Superficial veins of lower

limb. Numbered arrows indicate the
position of perforating veins.
Deep veins of lower limbs:
The deep veins are the femoral; the popliteal; the anterior and
posterior tibial; medial and lateral plantar; the plantar venous arch;
and metatarsal and digital veins. These veins accompany the
corresponding arteries and (by and large) have tributaries
corresponding to the branches of the arteries.
The femoral and popliteal veins are large. They will be described in
appropriate sections. The veins accompanying the other arteries
of the lower limb are venae comitantes. Fig. 10.9. Superficial and deep inguinal lymph nodes.
103
104
runs upwards along the middle of the back of the leg. Over the LYMPH NODES AND LYMPHATIC
lower part of the popliteal fossa it perforates the deep fascia DRAINAGE OF THE LOWER LIMB
and ends in the popliteal vein a few centimeters above the
knee joint (Fig. 10.8).
Lymph Nodes of the Lower Limb
Perforating veins
With the exception of a few small nodes in the popliteal
The perforating veins (or perforators) are so called as they
fossa, all the lymph nodes of the lower limb lie in the inguinal
perforate through the deep fascia to connect the superficial
region. These inguinal lymph nodes are present in two
veins to deep veins. Valves in them allow blood flow from
groups, superficial and deep, that are separated by the deep
superficial to deep veins, but not in the reverse direction.
fascia. The superficial nodes are further divided into upper
Similar communications with deep veins exist where the great
and lower groups (Fig. 10.9).
and small saphenous veins end in deep veins.
The upper superficial inguinal lymph nodes lie along the
inguinal ligament, immediately below the latter: they are
divisible into medial and lateral subgroups. The lower
superficial inguinal lymph nodes lie along the great
saphenous vein.
Fig. 10.10. Scheme to show the areas drained by the inguinal lymph nodes.
The deep group of inguinal nodes lies along the medial side of pudendal artery (on the medial side). Veins accompanying
the femoral vein. these three arteries end in the terminal part of the saphenous
The areas of the body drained by the inguinal nodes are shown vein.
in Figure 10.10. Note that in addition to the lower limb these The superficial fascia in the upper part of the front of the
nodes drain structures in the perineum, and the abdominal wall thigh consists of two layers. There is a superficial fatty layer,
below the level of the umbilicus. and a deep membranous layer. The membranous layer of
superficial fascia is loosely attached to the deep fascia of
the thigh. However, the two fasciae are firmly adherent to
each other along a horizontal line starting at the pubic
Lymphatic Drainage of the Lower Limb
tubercle and passing laterally for about 8 cm. This horizontal
line is referred to as Holdens line. Any fluid leaking into
Most of the vessels draining the superficial tissues of the limb
the space deep to the membranous layer of fascia does not
travel along the great saphenous vein and end in the lower group
descend below Holdens line.
of the superficial inguinal nodes. The skin of the lateral side
and back of the leg is drained by vessels that run along the
short saphenous vein and end in the popliteal lymph nodes, Fasciae latae
from where the lymph passes through deeply placed lymph The deep fascia of the thigh is called the fasciae latae. When
vessels to the deep inguinal nodes. The deep lymph vessels of traced superiorly its gains attachment to the inguinal
the limb run along the main blood vessels. They end in the ligament. Along the lateral margin of the thigh the fasciae
deep inguinal nodes. Some deep vessels of the gluteal region latae is thickened and forms a strong band passing from the
run along the superior and inferior gluteal vessels to end in anterior part of the iliac crest to the upper end of the tibia
nodes along the internal iliac vessels. (front of lateral condyle). This band is called the iliotibial
tract. Two muscles, the tensor fasciae latae and the gluteus
maximus are inserted into this tract.
Intermuscular septa (lateral, medial and posterior) passing
from deep fascia to the femur help to divide the thigh into
anterior, medial and posterior compartments.
SOME SUPERFICIAL STRUCTURES
IN THE THIGH
Muscles seen on the front and
The inguinal ligament medial side of the thigh
The inguinal ligament lies at the upper end of the front of the
thigh, i.e. at its junction with the anterior abdominal wall. The The muscles to be seen on the front and medial side of the
ligament is attached at its lateral end to the anterior superior thigh will be studied in detail later. At this stage the names
iliac spine; and at its medial end to the pubic tubercle. The and positions of some of them should be noted (See Figure
ligament is really the folded lower edge of the aponeurosis of a 10.11). Running diagonally across the thigh there is a long
muscle of the abdominal wall called the external oblique muscle. thin muscle called the sartorius. Running downwards along
the lateral margin of the upper part of the thigh we see the
tensor fasciae latae and the iliotibial tract (already
Superficial inguinal ring
mentioned above). Between the sartorius and the tensor
This is an aperture in the abdominal wall located just above the
fasciae latae we see parts of a large muscle, the quadriceps
medial end of the inguinal ligament. The spermatic cord passes
femoris. This is the main muscle of the front of the thigh. It
through the ring.
is so called as it consists of four parts (Fig. 10.15). Running
vertically down the centre of the thigh there is the rectus
Saphenous opening femoris. Its lower end is attached to the upper border of the
A little below the medial end of the inguinal ligament we see patella. To the lateral side of the rectus femoris we see the
the saphenous opening. This is an oval aperture in the deep vastus lateralis, and to its medial side we see the vastus
fascia of the thigh. The lateral and inferior margins of the medialis. The fourth part of the quadriceps femoris is the
opening are sharp: this is the falciform margin. The saphenous vastus intermedius. All the four parts of the quadriceps
opening is closed by a sheet of fascia that has many small holes femoris are inserted into the patella. Their pull is transmitted
in it: this is the cribriform fascia. The cribriform fascia is to the tibia through the ligamentum patellae that passes from
penetrated by: the lower end of the patella to the tibia.
1. The great saphenous vein. Medial to the upper part of the sartorius we see two muscles:
2. Three small branches of the femoral artery. These are the the iliacus laterally, and the psoas major medially: the two
superficial circumflex iliac artery (laterally), the superficial muscles are often referred to collectively as the iliopsoas.
epigastric artery (in the middle) and the superficial external Both these muscles have their origin within the abdominal
105
106
The boundaries of the triangle are as follows (Figs 10.11
and 10.12). The upper boundary or base of the triangle
is formed by the inguinal ligament. The triangle is
bounded laterally, by the medial margin of the sartorius;
and medially, by the medial margin of the adductor
longus. The apex of the triangle, directed inferiorly, lies
where the medial and lateral borders meet.
The floor of the triangle is formed (from lateral to medial
side) by the iliacus, the psoas major, the pectineus and
the adductor longus. The roof of the triangle is formed
by the fasciae over the region, and superficial structures
within them. These include the saphenous opening, the
cribriform fascia, the terminal part of the saphenous vein,
and the superficial inguinal lymph nodes.
The main contents of the femoral triangle are as follows:
1. Running down the middle of the femoral triangle we
see the femoral artery.
2. Medial to the artery we see the femoral vein.
3. A short distance lateral to the artery we see the trunk
of the femoral nerve.
Other contents of the triangle are:
4. Branches of the femoral artery:
(a) Superficial circumflex iliac artery.
(b) Superficial epigastric artery.

(c) Superficial external pudendal artery.
(d) Deep external pudendal artery.
(e) Profunda femoris artery. It gives off the medial
and lateral circumflex femoral arteries.
5. Branches of femoral nerve:
After a short course the femoral nerve divides into
anterior and posterior divisions, each of which divides
into a number of branches.
Fig. 10.11. Muscles seen on front and medial side of thigh.
cavity. They enter the thigh by passing deep to the inguinal

ligament and are inserted into the upper part of the femur.
The area medial to the sartorius, and below the level of the psoas
major is occupied by a number of muscle belonging to the medial
compartment of the thigh. These are the pectineus, the adductor
longus, the adductor magnus and the gracilis. Deep to the
adductor longus there is adductor brevis.
Femoral triangle
The region on the front of thigh medial to the upper part of the
sartorius is called the femoral triangle. The region is of importance
as it contains several vessels and nerves. Fig. 10.12. Boundaries of the femoral triangle.
(a) Branches of posterior division MUSCLES OF FRONT OF THIGH
Branches to the rectus femoris, to vastus
lateralis, to vastus intermedius, and to vastus
medialis. Psoas Major
Saphenous nerve.
(b) Branches of anterior division The greater part of this muscle lies in the abdomen and pelvis.
Branch that supplies the sartorius muscle and Its lower end enters the thigh.
then continues as the intermediate cutaneous
nerve of the thigh.
Origin:
Medial cutaneous nerve of the thigh.
a. Through 5 slips attached to transverse processes and
(c) The nerve to the pectineus arises from the femoral
bodies of lumbar vertebrae; and to intervertebral discs.
nerve within the pelvis and enters the thigh by passing
b. Through tendinous arches that run vertically along the
deep to the inguinal ligament.
sides of upper four lumbar vertebrae.
6. The femoral branch of the genitofemoral nerve runs
downwards anterior to the femoral artery.
7. The lateral cutaneous nerve of the thigh is seen near the Insertion:
lateral angle of the femoral triangle. Into lesser trochanter of femur.
Adductor canal Nerve Supply:

By branches from ventral rami of spinal nerves L1, L2 and
The adductor canal is a space deep to the sartorius, over the L3.
middle one-third of the thigh. For obvious reasons it is also
called the subsartorial canal. The boundaries of the canal can
Actions:
be visualised by examining a transverse section (Fig. 10.13).
1. Flexion of the thigh at the hip joint.
The canal is bounded anteriorly by the vastus medialis;
2. Flexion of the lumbar part of the vertebral column (as in
posteriorly, by the adductor longus (above) and the adductor
sitting up from supine position).
magnus (below); and medially, by a strong fibrous membrane
lying deep to the sartorius.
The contents of the canal are:
1. Femoral artery. Psoas Minor
2. Femoral vein.
3. The saphenous nerve The muscle is not always present. When present it runs
4. Branch of the femoral nerve to the vastus medialis. downwards in front of the psoas major. The muscle lies
5. Some branches of the obturator nerve. within the abdomen. It is considered here because of its close
6. The subsartorial plexus of nerves lies over the fascia association with the psoas major.
forming the roof of the adductor canal.
The adductor canal is a region of surgical importance. The
Origin:
femoral artery can be easily approached here.
From intervertebral disc between T12 and L1, and from
adjoining parts of the bodies of these vertebrae (Fig. 10.14).
Insertion:
Into iliopectineal eminence and pecten pubis.
Nerve Supply:
A branch from L1.
Action:
It is a weak flexor of the lumbar vertebral column.
Fig. 10.13. Boundaries and contents of the adductor canal.
107
108
Fig. 10.14. Scheme to show attachments of psoas major, psoas minor and iliacus.
Iliacus Nerve Supply:

By the femoral nerve.
Origin: Actions:
The iliacus arises from (Fig. 10.14): 1. Flexion of thigh.
1. Iliac fossa 2. Flexion of lumbar part of vertebral column.
2. Inner lip of the iliac crest.
3. Iliolumbar ligament.
4. Anterior sacro-iliac ligament.
5. Lateral part of upper surface of sacrum. Tensor Fasciae Latae (Fig. 10.13)
Insertion: Origin:
The iliacus is inserted into: 1. Anterior part of the outer lip of the iliac crest, and
1. The tendon of psoas major. 2. Outer aspect of the anterior superior iliac spine.
2. Lesser trochanter of the femur.
Insertion:
Into the upper end of the iliotibial tract. The pull of the muscle
is transmitted through this tract to the lateral condyle of the
tibia. The attachment to the tibia is on a triangular area on the
front of the lateral condyle.
Nerve Supply:
Branch from the superior gluteal nerve.
Actions:
1. It helps to maintain the erect posture (a) by stabilizing the
pelvis on the head of the femur, and (b) by stabilizing the femur
on the tibia.
2. It helps to extend the leg.
3. It helps in medial rotation of the thigh.
Sartorius
Origin:
The sartorius arises from the anterior superior iliac spine (Fig.
10.3).
Insertion:
It is inserted on the tibia along a vertical line on the upper part
of the medial surface. The insertion is anterior to that of the
gracilis and of the semitendinosus.
Note
1. The medial border of the upper part of the sartorius forms
the lateral boundary of the femoral triangle (Fig. 10.12). Fig. 10.15. Scheme to show the arrangement of the
2. In the middle one-third of the thigh the muscle forms the parts of the quadriceps femoris.
roof of the adductor canal (Fig. 10.13).
Nerve Supply: Femoral nerve.
2. The spiral line
Actions: 3. The medial lip of the linea aspera.
The sartorius helps in: 4. The medial supracondylar line.
1. Flexion of the leg (at knee joint).
2. Flexion of thigh (at hip joint). The vastus intermedius arises from a large area extending
3. Abduction of thigh. onto the following:
4. Lateral rotation of thigh. 1. Anterior surface of shaft.
2. Lateral surface of shaft.
Quadriceps Femoris The vastus lateralis has a long linear origin from the
following:
This muscle consists of four parts (Figs 10.13 and 10.15). These 1. The upper end of the intertrochanteric line.
are the rectus femoris, the vastus lateralis, the vastus medialis, 2. The anterior border of the greater trochanter.
and the vastus intermedius. 3. The lower border of the greater trochanter.
4. The lateral margin of the gluteal tuberosity.
5. The lateral lip of the linea aspera.
Origin (Figs 9.15 and 9.16):
The rectus femoris has a tendinous origin from the hip bone. It
arises by two heads. The straight head arises from the anterior Insertion:
inferior iliac spine. The reflected head arises from the ilium The vastus lateralis is inserted into (Fig. 10.15):
just above the acetabulum. 1. the lateral border of the patella, and
The vastus medialis has a long linear origin from the following: 2. through the lateral patellar retinaculum into the lateral
1. The lower part of intertrochanteric line. condyle of the tibia
109
110
The vastus medialis is inserted into the medial border of the
patella, and through the medial patellar retinaculum into the
medial condyle of the tibia.
The rectus femoris is inserted into the upper border of the
patella.
The vastus intermedius is also inserted into the upper border
of the patella, but deep to the rectus femoris.
The pull of the quadriceps femoris is transmitted to the tibia
through the ligamentum patellae.
Nerve Supply:
Femoral nerve.
Actions:
The muscle straightens the lower extremity at the knee (as in
standing up from a sitting position). This involves extension
of both the leg and the thigh (at the knee and hip joints).
The rectus femoris can produce flexion of the thigh (at the
hip). With the thigh fixed (as in standing) it can rotate the pelvis
forwards on the head of the femur.
The vastus medialis prevents lateral displacement of the patella
during extension of the knee.
Note: The muscle is not active while standing upright because
the knee is locked when the knee is fully extended.
Articularis Genu (Fig. 10.16)

The articularis genu consists of a few fascicles of muscle fibres
arising from the anterior surface of the shaft of the femur. The
fibres are inserted into the synovial membrane of the knee
joint.
MUSCLES OF MEDIAL SIDE OF THIGH
Gracilis (Fig. 10.16)
Origin:
Medial margin of pubic arch. The area of origin includes parts
of:
1. Body of the pubis.
2. Inferior ramus of pubis.
3. Ramus of ischium.
Insertion:
The gracilis is inserted into the upper part of the medial surface
of the tibia (behind the insertion of the sartorius: Fig. 5.36).
Nerve Supply:
Obturator nerve.
Actions: Fig. 10.16. Scheme to show the attachments of the
The gracilis helps in: gracilis and articularis genu.
1. Flexion of the leg (at the knee joint).
2. Medial rotation of thigh (at the hip joint)
3. Adduction of the thigh.
Nerve Supply:
This is through the anterior division of the obturator nerve.
Actions:
The adductor longus helps in adduction and flexion of the
thigh.
Adductor Brevis
Origin:
From the pubis: the area of origin includes the lower part of
the body and the inferior ramus. The origin is lateral to that
of the gracilis and below that of the adductor longus.
Insertion:
Posterior aspect of the femur (i) along a line passing from
the lesser trochanter to the linea aspera, and (ii) the upper
part of the linea aspera itself.
Fig. 10.17. Scheme to show the attachments of the

pectineus.
Pectineus (Figs 10.13 and 10.17)
Origin:
The pectineus takes origin from the superior ramus of the pubis
(pecten pubis and part of the pectineal surface).
Insertion:
The pectineus is inserted on the posterior aspect of the femur
on a line passing from the lesser trochanter to the linea aspera.
Nerve Supply:
The muscle has a double nerve supply by branches from:
1. The femoral nerve.
2. The accessory obturator or the (main) obturator nerve.
Actions:
The muscle is an adductor and flexor of the thigh.
Adductor Longus (Fig. 10.18)
Origin:
Front of the body of the pubis.
Insertion:
Posterior aspect of the middle one-third of the shaft of the femur.
The insertion is into the linea aspera between that of the vastus
medialis (medially), and of the adductor brevis and adductor Fig. 10.18. Scheme to show the attachments of the
magnus (laterally). adductor longus.
111
112
Fig. 10. 19. Scheme to show the attachments of the

adductor brevis.
Nerve Supply:
Obturator nerve.
Actions:
Adduction and flexion of the thigh.
Adductor Magnus
This muscle has an adductor part and a hamstring part

(Fig. 19.20). Each part has its own origin, insertion and
nerve supply. (The hamstring part belongs to the back of
the thigh, but is considered here for completeness).
Origin:
a. The adductor part arises from the ramus of the ischium.
b. The hamstring part arises from the inferior and lateral Fig. 10.20. Attachments of the adductor magnus.
part of the ischial tuberosity.
Insertion: Actions:
a. The adductor part is inserted along the medial margin Adduction of the thigh. The hamstring part of the muscle may
of the gluteal tuberosity; into the linea aspera; and into produce extension of the thigh..
the medial supracondylar line.
b. The hamstring part is inserted (through a tendon) into Note:
the adductor tubercle (on medial condyle of the femur). Near the insertion of the muscle there are a series of apertures
for passage of blood vessels. The largest (and lowest) of these
is for the femoral vessels. The others are for the profunda femoris and perforating
arteries.
Nerve Supply:
The adductor part is supplied by the obturator nerve, and the hamstring part
by the sciatic nerve (tibial part).
THE FEMORAL ARTERY
The femoral artery is the continuation of the external iliac artery into the thigh.
It begins at the midinguinal point (i.e. midway between the pubic symphysis
and the anterior superior iliac spine). It descends first on the front of the thigh
(upper-third), and then on its medial side (middle-third). It ends at the junction
of the middle and lower-thirds of the thigh. Here it passes through an aperture
in the adductor magnus muscle to reach the back of the thigh where it becomes
the popliteal artery.
The upper part of the femoral artery lies in the femoral triangle (Fig. 10.11).
Within the triangle the femoral artery lies successively over the psoas major,
the pectineus and the adductor longus. At the apex of the femoral triangle the
artery passes into the adductor canal. Within the canal the artery lies first on the
adductor longus and then on the adductor magnus.
Fig. 10.21. Relationship of
Other relations of femoral artery: femoral artery to femoral vein.
1. The femoral artery is accompanied by the femoral vein. Just below the
inguinal ligament the vein is medial to the artery (Fig. 10.21). However, the vein
gradually crosses to the lateral side posterior to the artery: it is directly behind
the artery at the apex of the femoral triangle, and lateral to the lower end of the
artery.
2. The femoral nerve is lateral to the upper part of the artery (Fig. 10.22). Lower
down the artery is related to the branches of the nerve, some of which cross it.
The branch to the pectineus crosses behind the upper part of the artery. The
medial cutaneous nerve of the thigh crosses the artery from lateral to medial
side near the apex of the femoral triangle. The saphenous branch crosses the
artery within the adductor canal. The nerve to the vastus medialis is lateral to
the artery in the adductor canal.
3. The femoral branch of the genitofemoral nerve is also lateral to the upper part
of the femoral artery (within the femoral sheath), but lower down it passes to the
front of the artery (Fig. 10.22).
4. The profunda femoris artery (a branch of the femoral artery itself) and its
companion vein, lie behind the upper part of the femoral artery (where it lies on
the pectineus). Lower down, however, the femoral and profunda femoris arteries
are separated by the adductor longus.
In the upper part of the femoral triangle the femoral artery and vein are enclosed
in a funnel-like covering of fascia that is called the femoral sheath. The cavity
within the femoral sheath is divisible into three parts. The lateral part contains
the femoral artery. The middle part contains the femoral vein. The medial part
is occupied only by some lymph nodes and some areolar tissue: this part is
called the femoral canal.
Fig. 10.22. Some nerves related to the
femoral artery.
Branches of the Femoral Artery
These are shown in Figure 10.23. The first three branches are superficial and the
remaining are deep. The superficial branches arise from the femoral artery just
113
114
Profunda Femoris Artery
The profunda femoris artery is the largest branch of the femoral

artery (Fig. 10.24). It is the main artery of supply for the muscles
of the thigh. It arises from the lateral side of the femoral artery,
3 to 4 cm below the inguinal ligament. It descends first lateral
to the femoral vessels and then behind them. In the lower part
of its course it is separated from the femoral artery by the
adductor longus. It gives off several branches that are shown
in Figure 10.24. These are the medial and lateral circumflex
femoral arteries, and three perforating arteries. The terminal
part of the profunda femoris artery itself is called the fourth
perforating artery.
The perforating branches pass through several muscles attached
to the femur, at or near the linea aspera.
Lateral circumflex artery (Fig. 10.24):

Its ascending branch passes laterally to the lateral side of the
hip joint.
The transverse branch winds round the lateral side of the femur
(passing through muscles) and takes part in forming the cruciate
anastomosis (Fig. 11.9).
The descending branch runs downwards behind the rectus

femoris and along the vastus lateralis. Some of its branches reach
the knee.
Medial circumflex artery (Fig. 10.24)

This artery winds round the medial side of the femur passing
through muscles. It emerges on the back of the thigh between
the upper border of the adductor magnus and the quadratus
femoris. It then divides into transverse and ascending branches.
The transverse branch takes part in forming the cruciate
Fig. 10.23. Branches of femoral artery
below the inguinal ligament; and piercing the femoral sheath

and the cribriform fascia they become subcutaneous. Their
further course is given below.
The superficial epigastric artery ascends across the inguinal
ligament and then runs upwards and medially towards the
umbilicus.
The superficial external pudendal artery runs medially to
supply the skin over the external genitalia and on the lower
part of the abdomen.
The deep external pudendal artery runs medially deep to the
fascia lata. It becomes superficial after crossing the adductor
longus and supplies the external genitalia.
The descending genicular artery arises from the femoral near
its lower end. It gives numerous muscular branches, articular
branches to the knee joint and a saphenous branch that
accompanies the saphenous nerve (through the adductor canal)
and supplies the skin over the upper and medial part of the
leg.
Fig. 10.24. Branches of profunda femoris artery.
anastomosis. The ascending branch ascends to reach the
trochanteric fossa. The medial circumflex artery also gives an
acetabular branch to the hip joint.
FEMORAL VEIN
The course and relations of the femoral vein correspond to

those of the femoral artery: these have been considered above.
The relationship of the femoral vein to the femoral artery is
shown in Figure 10.21 and has been described above.
The chief tributaries of the femoral vein are the great saphenous
vein, the profunda femoris vein; the medial and lateral
circumflex femoral veins; and a number of muscular branches.
Note that the medial and lateral circumflex veins generally open
directly into the femoral vein and not through the profunda
femoris vein. The veins accompanying the superficial branches
of the femoral artery (viz. the superficial circumflex iliac, the
superficial epigastric and the superficial external pudendal) end
in the great saphenous vein and not directly into the femoral
vein.
THE FEMORAL NERVE Fig. 10.25. Branches of the femoral nerve.
The femoral nerve arises, in the abdomen, from the lumbar the apex of the femoral triangle (Fig. 10.22). It divides into
plexus. The nerve is derived from the ventral rami of spinal branches that supply the skin of the medial side of the thigh:
nerves L2, L3 and L4. It passes behind the inguinal ligament to the area of skin supplied is shown in Figure 10.1. The nerve
enter the thigh. Here it lies lateral to the femoral artery. After a takes part in forming the subsartorial plexus (along with
short course it ends by dividing into anterior and posterior branches of the saphenous and obturator nerves).
divisions. The distribution of the femoral nerve is as follows: 3. The saphenous nerve arises from the posterior division of
the femoral nerve. It descends along the lateral side of the
A. Muscular branches (Fig. 10.25): femoral artery. In the adductor canal the nerve crosses the
1. While still in the abdomen the femoral nerve gives branches artery from lateral to medial side (Fig. 10.22). It leaves the
to the iliacus. adductor canal at its lower end and runs down along the
2. A little above the inguinal ligament the femoral nerve gives medial side of the knee. Here it pierces the deep fascia and
off the nerve to the pectineus. The nerve passes downwards becomes subcutaneous. It then runs down the medial side
and medially behind the femoral vessels to reach the pectineus. of the leg (along side the long saphenous vein). A branch
3. The sartorius receives a branch from the anterior division of extends along the medial side of the foot (but ends short of
the femoral nerve. This branch arises in common with the the great toe). The area of skin supplied by the nerve is shown
intermediate cutaneous nerve of the thigh (see below). in figure 10.1. The saphenous nerve takes part in forming
4. The rectus femoris, the vastus lateralis, the vastus medialis the subsartorial plexus and the patellar plexus.
and the vastus intermedius receive branches from the posterior
division of the femoral nerve. C. Articular branches:
1. The posterior division of the femoral nerve sends fibres
B. Cutaneous branches (Fig. 10.25):
to the knee joint through the nerve to the vastus medialis.
1. The intermediate cutaneous nerve of the thigh arises from 2. Some fibres reach the hip joint through the nerve to the
rectus femoris.
the anterior division of the femoral nerve. The area of skin
supplied by the nerve is shown in Figure 10.1.
2. The medial cutaneous nerve of the thigh is a branch of the D. Vascular branches
anterior division of the femoral nerve. It runs part of its course The femoral nerve gives some branches to the femoral artery
along the lateral side of the femoral artery which it crosses near and its branches.
115
116
THE OBTURATOR NERVE
This nerve arises from the lumbar plexus. It is formed by union

of roots arising from L2, L3, and L4 (Fig. 10.26). For convenience
of description its course can be considered in three parts. The
first part runs downwards in the substance of the psoas major.
The second part of the nerve lies in the lateral wall of the true
pelvis (Fig. 23.7). It leaves the lateral wall of the pelvis by
passing through the upper part of the obturator foramen to
enter the thigh. The third part of the nerve lies in the thigh. As
it passes through the obturator foramen it divides into anterior
and posterior divisions. The anterior division lies in front of
the obturator externus (above) and the adductor brevis (below):
it lies behind the pectineus (above) and the adductor longus
(below). The posterior division lies in front of the obturator
externus (above) and the adductor magnus (below). It is behind
the pectineus (above) and the adductor brevis (below).
The obturator nerve is distributed as follows (Fig. 10.26):
A. Muscular branches:
a. Branches arising from the anterior division supply the
obturator externus, the adductor longus and the gracilis; and
occasionally the pectineus and the adductor brevis.

b. Branches of the posterior division supply the obturator
externus, the adductor brevis and the adductor magnus.
B. Cutaneous branches:
After supplying the muscles named above the anterior division
supplies the skin of the lower medial part of the thigh (Fig.
10.1).
These are given off to the hip joint and to the knee joint.
D. Vascular branches:
The anterior division ends by supplying the femoral artery.
Accessory obturator nerve:

Occasionally some fibres of the obturator nerve arising from
L2 and L3 follow a separate course and are termed the
accessory obturator nerve.
Femoral Branch of Genitofemoral Nerve
The femoral branch of the genitofemoral nerve descends on Fig. 10.26. Scheme to show the course and
the lateral side of the external iliac artery. It passes deep to the distribution of the obturator nerve.
inguinal ligament and comes to lie lateral to the femoral artery:
here it lies within the femoral sheath. It becomes superficial
by piercing the anterior wall of the sheath, and the deep fascia,
initial part lies within the psoas major. Emerging from the
and supplies an area of skin over the upper part of the femoral
lateral border of the muscle the nerve runs downwards,
triangle (Fig. 10.1).
laterally and forwards over the iliacus muscle to reach the
anterior superior iliac spine. It enters the thigh by passing
Lateral cutaneous nerve of thigh behind the lateral end of the inguinal ligament. It divides
into anterior and posterior branches through which it supplies
The lateral cutaneous nerve of the thigh arises from the lumbar the skin on the anterolateral part of the thigh right up to the
plexus. It is derived from the dorsal divisions of L2 and L3. Its knee (Fig. 10.1).
GLUTEAL REGION : BACK OF THIGH : POPLITEAL FOSSA
11 : Gluteal Region, Back of Thigh
Popliteal Fossa
GLUTEAL REGION
MUSCLES OF GLUTEAL REGION (b) maintain the upright position of the trunk by preventing
the pelvis from rotating forwards on the head of the femur
under the influence of gravity.
Gluteus Maximus C. Through the ilio-tibial tract it steadies the femur on the
tibia in standing.
Through a combination of all the actions described above it
Origin: helps to maintain the upright position.
The gluteus maximus arises from one large area that extends
onto the following (Fig. 11.1):
1. External surface of the ilium including the posterior gluteal Structures Deep to the Gluteus Maximus
line and the area behind it. Several bones, ligaments, muscles, nerves and vessels lie
2. The sacrotuberous ligament. under cover of the gluteus maximus. These are shown in
3. The aponeurosis covering the erector spinae. Figure 11.2.
4. The lower lateral part of the posterior surface of the sacrum.
5. The lateral part of the posterior surface of the coccyx.
Insertion:
1. Most fibres of the muscle are
inserted into the iliotibial tract (Fig.
11.2).
2. Some deeper fibres are inserted
into the gluteal tuberosity of the
femur.
Nerve Supply:
Inferior gluteal nerve (L5, S1, S2)
(Fig. 11.10).
Actions:
A. Acting from its origin the gluteus
maximus produces extension of the
thigh (as in standing up from a
sitting position, climbing, or
jumping). It also causes lateral
rotation of the thigh.
B. Acting from its insertion (when
the femur and tibia are fixed as in
standing) the muscle can:
(a) straighten the trunk, after
stooping, by rotating the pelvis
backwards on the head of the femur;
and
Fig. 11.1. Scheme to show the attachments of the gluteus maximus.
117
118
Fig. 11.2. Gluteal region seen after removal of the greater part of the
gluteus maximus.
Gluteus Medius
Origin:
The gluteus medius arises from the outer surface of the ilium
(Fig. 11.3). The area of origin is bounded above by the iliac
crest, behind by the posterior gluteal line (pgl), and in front by
the anterior gluteal line (agl). Fig. 11.3.
Scheme to show
Insertion:
attachments of the
It is inserted into the lateral surface of the greater trochanter gluteus medius.
of the femur. The insertion is on a ridge that runs downwards
and forwards.
Nerve Supply of Gluteus Medius and Minimus
The gluteus medius and minimus are both supplied by the
superior gluteal nerve (L5, S1).
Actions of Gluteus Medius and Minimus:
Both the gluteus medius and minimus are abductors of the thigh.
The minimus and the anterior fibres of the medius can act as
flexors and medial rotators, whereas the posterior fibres of the
medius can act as extensors and lateral rotators of the thigh.
With the femur fixed (as in standing) the medius and minimus
pull the corresponding side of the pelvis downwards by rotating
it over the head of the femur. As a result the opposite side of
the pelvis is raised. In this way the muscles of one side prevent
the opposite side of the pelvis from sinking downwards when
the limb of that side is off the ground. In fact the pelvis on the
unsupported side is somewhat higher than on the supported
side. In paralysis of the medius and minimus the unsupported
side becomes lower than the supported side. This is referred to
as the Trendelenberg sign.
Gluteus Minimus
Origin:
The gluteus minimus arises from the outer surface of the ilium
between the anterior and inferior gluteal lines (igl) (Fig. 11.4).
Insertion:
It is inserted on a ridge on the anterior aspect of the greater
trochanter of the femur.
Nerve supply and action:
See under gluteus medius.
Piriformis
The muscle arises within the pelvis. It leaves the pelvis through
the greater sciatic foramen to reach the gluteal region (Fig. 11.5). Fig. 11.5. A. Sacrum seen from the front to show the
origin of the piriformis. B. Scheme to show the
attachments of the piriformis. The pelvis and femur are
viewed from behind.
Origin:
The piriformis arises from the lateral part of the anterior (or
pelvic) aspect of the sacrum.
Insertion:
The muscle is inserted into the upper border of the greater
trochanter of the femur.
Nerve supply:
The muscle is innervated by direct branches from L5, S1,
S2.
Action:
The piriformis is a lateral rotator of the femur.
Obturator Internus
Origin:
This muscle arises from:
(1) Inner (pelvic) surface of the hip bone. The areas of the
Fig. 11.4. Scheme to show the attachments of the hip bone include the body, the superior ramus, and the
gluteus minimus. The hip bone and femur are viewed inferior ramus of the pubis; ramus and body of the ischium;
from the lateral side. and part of the pelvic surface of the ilium .
(2) The pelvic surface of the obturator membrane.
119
120
Fig. 11.6. Scheme to show the arrangement of the

obturator internus. The upper part of the pelvis has been
removed by cutting transversely across the ischium and
pubis. The femur is seen from above.
Fig. 11.7. Scheme to show attachments of the

The fibres of the muscle converge towards a tendon that leaves quadratus femoris.
the pelvis through the lesser sciatic foramen to enter the gluteal
region. The tendon turns through 90 degrees and runs laterally
behind the hip joint to reach its insertion (Fig. 11.6). Nerve supply:
Insertion: The superior gemellus is supplied by the nerve to the
The tendon is inserted into the anterior part of the medial obturator internus (L5, S1). The inferior gemellus is supplied
surface of the greater trochanter of the femur. The insertion is by a branch from the nerve to the quadratus femoris (L5, S1)
above and in front of the trochanteric fossa. (Fig. 11.10).
Nerve supply: Action: The gemelli help in lateral rotation of the femur.
The muscle is supplied by the nerve to obturator internus (L5,
S1) (Fig. 11.10). Quadratus Femoris (Fig. 11.2)
Actions:
The muscle is a lateral rotator of the femur. Origin:
The quadratus femoris takes origin from the lateral border
Gemelli (Fig. 11.2) of the ischial tuberosity (Fig. 11.7).
Insertion:
These are two small muscles situated in the gluteal region, It is inserted into the quadrate tubercle. This is a bony
above and below the tendon of the obturator internus. elevation present on the upper part of the trochanteric crest
of the femur.
Origin: Nerve supply:
The superior gemellus arises from the posterior aspect of the The nerve to the quadratus femoris is a branch from the sacral
ischial spine. plexus (L4, L5, S1) (Fig. 11.10).
The inferior gemellus takes origin from the uppermost part of
the ischial tuberosity. Action:
The quadratus femoris is a lateral rotator of the femur.
Insertion:
The gemelli are inserted into the tendon of the obturator
internus (and exert their pull through it on the greater trochanter Obturator Externus
of the femur).
Origin:
The obturator externus takes origin from the external surface
of the anterior part of the pelvis. The area of origin covers
parts of the following (Fig. 11.8):
Fig. 11.8. A. Attachments of the obturator
externus. The pelvis is viewed from the
anteroinferior aspect.
(a) Ramus of ischium.

(b) Ramus of pubis. ARTERIES OF GLUTEAL REGION
(c) Obturator membrane (medial two-thirds).
The muscle ends in a tendon that runs upwards and laterally
behind the neck of the femur to reach the gluteal region. Inferior Gluteal Artery
Insertion: The inferior gluteal artery is a branch of the anterior division

The tendon is inserted into the trochanteric fossa (situated on of the internal iliac artery. It begins within the pelvis. It passes
the medial aspect of the greater trochanter) of the femur. through the greater sciatic foramen, below the piriformis to
Nerve supply: enter the gluteal region (See Figures, 11.2 and 11.9). It then
The muscle is supplied by a branch from the obturator nerve descends deep to the gluteus maximus muscle, over the
(L3, L4). obturator internus (and gemelli) and the quadratus femoris
and extends into the upper part of the thigh. Branches from
Actions: the artery are meant mainly for supply of the muscles
It is a lateral rotator of the femur. mentioned above. Other branches are as follows:
(a) A fine branch, the artery of the sciatic nerve, descends
Note on actions of small muscles around the hip joint along this nerve into the thigh.
Although the various small muscles related to the hip joint are (b) An anastomotic branch takes part in forming the cruciate
described as medial or lateral rotators, their main action is to anastomosis (Fig. 11.9).
stabilise the joint. (c) A coccygeal branch runs towards the coccyx.
121
122
Fig. 11.9. Dissection of the gluteal region showing the arteries of the region. Note the arteries
taking part in the cruciate anastomosis.
Superior Gluteal Artery Internal Pudendal Artery
The superior gluteal artery is the main continuation of the This artery is a branch of the anterior trunk of the internal
posterior trunk of the internal iliac artery. It leaves the pelvic iliac artery. It follows a complicated course that can be fully
cavity by passing through the greater sciatic foramen, above appreciated only after the pelvis and perineum have been
the piriformis muscle (Figs 11.2 and 11.9). The artery divides studied. The artery passes out of the pelvic cavity through
into superficial and deep branches. The superficial branch the greater sciatic foramen to enter the gluteal region (Fig.
ramifies deep to the gluteus maximus and supplies it. The deep 11.2). Here it lies inferior to the piriformis muscle. It
branch passes upwards over the gluteal surface of the ilium: it descends across the back of the ischial spine and leaves the
divides into superior and inferior divisions both of which lie gluteal region through the lesser sciatic foramen. It further
deep to the gluteus medius. The superior division runs along course will be considered when we study the perineum.
the upper border of the gluteus minimus, while the inferior
division crosses the lower part of the same muscle. These
Cruciate anastomosis
branches supply the gluteus medius and gluteus minimus, and
This anastomosis (shaped like a cross) is seen in the lower
also send twigs to the hip joint. The inferior division also sends
part of the gluteal region (Fig. 11.9). The arteries taking part
a branch to the trochanteric anastomosis described below.
are the anastomotic branch of the inferior gluteal artery (from
above), the first perforating artery (from below), and
transverse branches of the medial and
lateral circumflex femoral arteries (on the
medial and lateral sides respectively).
Trochanteric anastomosis
This anastomosis is seen in relation to the
greater trochanter of the femur. The
arteries taking part are the descending
branch of the superior gluteal artery, and
ascending branches of the medial and
lateral circumflex femoral arteries.
Sometimes a branch from the inferior
gluteal artery also joins the anastomosis.
THE SCIATIC NERVE
The sciatic nerve lies partly in the gluteal

region and partly in the back of the thigh.
A complete description is given here for
sake of convenience. Fig. 11.10. Scheme to show nerves supplying muscles in the gluteal region.
The sciatic nerve is the main continuation
of the sacral plexus (Fig. 11.10). It is the
thickest nerve of the body. It receives
fibres from spinal nerves L4 to S3. It
passes from the pelvis to the gluteal
region through the greater sciatic
foramen, below the piriformis (Figs.
11.2 and 11.11). It descends through
the gluteal region into the back of
the thigh. At the junction of the
middle and lower-thirds of the thigh
the sciatic nerve ends by dividing
into the tibial and common peroneal
nerves.
In its course through the gluteal
region the nerve lies deep (or
anterior) to the gluteus maximus. It
lies successively on the posterior
surface of the ischium, the superior
gemellus, the obturator internus
(tendon), the inferior gemellus and
the quadratus femoris. In the thigh
the nerve lies upon the adductor
magnus, and is crossed superficially
(i.e. posteriorly) by the long head of
the biceps femoris.
Apart from its terminal branches the
sciatic nerve gives the following
branches.
a. Branches arising from the tibial
part of the nerve supply the
hamstrings viz., the long head of the
biceps femoris, the semitendinosus,
Fig. 11.11. Nerves in the gluteal region.
the semimembranosus and the
123
124
adductor magnus (part arising from the ischial tuberosity). ends by supplying the obturator internus. Before passing
b. The common peroneal part of the sciatic nerve gives a branch through the lesser sciatic foramen it gives a branch to the
to the short head of the biceps femoris muscle. superior gemellus.
c. Articular branches are given off to the hip joint.
Nerve to Piriformis
Superior Gluteal Nerve (Fig. 11.11)
The nerve to the piriformis arises from S1 and S2. It is
The superior gluteal nerve is derived from spinal nerves L4, confined to the pelvis and ends by entering the anterior
L5 and S1. It passes from the pelvis to the gluteal region through surface of the piriformis.
the greater sciatic foramen, above the piriformis. It divides
into superior and inferior branches. Both these branches run
forwards deep to the gluteus medius. The superior branch Posterior Cutaneous Nerve of Thigh
supplies the gluteus medius, and (occasionally) the gluteus
minimus. The inferior branch also supplies these two muscles: The posterior cutaneous nerve of the thigh is derived from
it ends by supplying the tensor fasciae latae. S1, and S2 and S3. It passes from the pelvis to the gluteal
region through the greater sciatic foramen, below the
piriformis. It passes downward through the gluteal region
Inferior Gluteal Nerve (Fig. 11.11)
(deep to the gluteus maximus) to enter the back of the thigh.
The inferior gluteal nerve is derived from spinal nerves L5, Its lowest part extends into the upper part of the leg. It
S1 and S2. It passes from the pelvis to the gluteal region through supplies an extensive area of skin including that over the
the greater sciatic foramen, below the piriformis. It supplies lower part of the gluteal region, the perineum, the back of
the gluteus maximus. the thigh, and the back of the upper part of the leg.
Nerve to Quadratus Femoris (Fig. 11.11) Perforating Cutaneous Nerve (Fig. 11.11)
The nerve to the quadratus femoris is derived from spinal The perforating cutaneous nerve is derived from S2 and S3.
nerves L4, L5 and S1. It passes from the pelvis to the gluteal It enters the gluteal region by piercing through the
region through the greater sciatic foramen, below the piriformis. sacrotuberous ligament. It supplies the skin over the
It runs downwards deep to the superior gemellus, the tendon inferomedial part of the gluteus maximus (Fig. 10.3).
of the obturator internus, and the inferior gemellus. After giving
a branch to the inferior gemellus it reaches the anterior
(or deep) surface of the quadratus femoris and enters it to Pudendal Nerve (Fig. 11.11)
supply the muscle.
The pudendal nerve arises from the sacral plexus and derives
its fibres from nerves S2, S3 and S4. The nerve passes from
Nerve to Obturator Internus (Fig. 11.11) the pelvis to the gluteal region through the greater sciatic
foramen. The nerve has a short course through the gluteal
The nerve to the obturator internus is derived from L5, S1 and region. Emerging at the lower border of the piriformis it
S2. It passes from the pelvis to the gluteal region through the crosses the sacrospinous ligament and disappears into the
greater sciatic foramen passing below the piriformis. lesser sciatic foramen. The further course of the nerve will
It runs down posterior to the ischial spine and again enters the
be studied in the pelvis and perineum.
pelvis by passing through the lesser sciatic foramen. The nerve
BACK OF THIGH AND POPLITEAL FOSSA
GENERAL REVIEW OF BACK OF MUSCLES OF BACK OF THIGH

THIGH AND POPLITEAL FOSSA
Semitendinosus (See Fig. 11.4)
Running down the back of the thigh we see three long
muscles as follows. The muscle is so called because its lower half is tendinous. It
1. To the medial side of the midline of the thigh we see belongs to the hamstring group of muscles.
the semitendinosus muscle.
2. Deep to the lower part of the semitendinosus we see
the semimembranosus muscle.
3. Just lateral to the midline of the thigh we see the biceps
femoris. Note that this muscle has a, superficial long
head, and a deep short head. The semitendinosus, the
semimembranosus, and the biceps femoris are
collectively referred to as the hamstrings.
Over the lowest part of the back of the femur we see the
origin of the gastrocnemius. It has two heads, medial
and lateral. Running along the lateral head of the
gastrocnemius we see a small muscle the plantaris.
Deep to these muscles we see some muscles already
studied in the front and medial side of the thigh. Identify
the adductor magnus, the gracilis and the vastus lateralis.
Popliteal Fossa
In the lower one-third of the thigh (and the upper part of

the back of the leg) we see a quadrilateral depression
within which some vessels and nerves can be seen. This
depression is called the popliteal fossa.
Boundaries of Popliteal Fossa
1. Above and laterally: biceps femoris.
2. Above and medially: semitendinosus, and
semimembranosus.
3. Below and laterally: lateral head of gastrocnemius,
and plantaris.
4. Below and medially: medial head of gastrocnemius.
5. Roof: fascia over the fossa.
6. Floor: popliteal surface of femur, capsule of knee joint,
and fascia over the popliteus muscle.
Main contents of Popliteal Fossa
1. Popliteal artery
2. Popliteal vein.
3. Tibial nerve.
4. Common peroneal nerve.
Fig. 11.12. Dissection of the gluteal region, back of thigh
and popliteal fossa.
125
126
Semimembranosus (Fig. 11.15)
This is a muscle of the hamstring group. The muscle is so

called because its upper part is membranous.
Origin:
From upper lateral part of ischial tuberosity.
Fig. 11.13. Deep dissection of the gluteal region, back

of thigh and popliteal fossa.
Origin:
The semitendinosus arises from the upper and medial part
of the ischial tuberosity, in common with the biceps femoris
(Fig.11.14).
Insertion:
Into upper part of medial surface of shaft of tibia. The area
of insertion is behind that of the sartorius, and below and
behind that for the gracilis.
Nerve supply:
Tibial part of sciatic nerve.
Actions (common to all hamstring muscles):
1. Acting from their origin (i.e. when the pelvis is fixed) the
hamstring muscles flex the leg at the knee joint.
2. Acting from their insertion (i.e. when the knee is fixed,
as in standing upright) they exert a downward pull on the
ischial tuberosity. This is useful (a) in preventing the pelvis
Fig. 11.14. Attachments of the semitendinosus.
from rolling forwards on the head of the femur, and (b) in
straightening the trunk after bending forwards.
Actions:
See under semitendinosus.
Biceps Femoris (Fig. 11.16)
Origin:
The muscle has two heads.
(a) The long head arises from the upper medial part of
the ischial tuberosity.
(b) The short head arises from the linea aspera of the
femur (between the insertion of the adductor magnus,
medially; and the origin of the vastus lateralis laterally.
Insertion:
The two heads end in a common tendon that is inserted
into the head of the fibula.
Nerve supply:
By branches from the sciatic nerve (L5, S1, S2). The long
head is supplied by the tibial part of the nerve and the
short head by the peroneal part.
Actions:
See under semitendinosus.
POPLITEAL VESSELS
The Popliteal Artery
The popliteal artery begins at the junction of the middle

and lower-thirds of the thigh. It is continuous with the
lower end of the femoral artery through the opening in the
adductor magnus. The artery runs downwards and laterally
over the floor of the popliteal fossa (popliteal surface of
femur, capsule of knee joint and popliteus). It ends at the
lower border of the popliteus by dividing into the anterior
and posterior tibial arteries. Superficially the artery is
partly overlapped by muscles forming the medial margin
of the popliteal fossa. It is also covered by skin and fascia.
The artery is accompanied by the popliteal vein. The vein
is posterior (i.e. superficial) to the artery. At the upper
end of the artery the vein is on its lateral side. The vein
gradually crosses the artery so that it comes to lie medial
to the lower end of the artery. The artery is also related to
the tibial nerve that is separated from it by the popliteal
vein. Like the vein the nerve crosses the artery from lateral
to medial side.
Fig.11.15. Attachments of semimembranosus muscle.
Branches of the Popliteal Artery

Insertion: The popliteal artery terminates by dividing into the
The muscle end in a tendon that is inserted into the medial anterior and the posterior tibial arteries. Other branches
condyle of the tibia. are shown in Figure 11.17.
Nerve supply:
Branch from tibial part of sciatic nerve.
127
128
Fig. 11.17. Branches of popliteal artery.
Fig. 11.16. Attachments of biceps femoris muscle.

Fig. 11.18. Anastomoses around the knee joint.
Anastomoses around the knee joint

The knee is surrounded by complex arterial anastomoses as
shown in Figure 11.18.
tributaries of the popliteal vein are the anterior and posterior
tibial veins, and the short saphenous vein. Smaller tributaries
correspond to branches of the popliteal artery.
NERVES ON BACK OF THIGH
The nerves on the back of the thigh are the sciatic nerve, the
tibial nerve and the common peroneal nerve. The sciatic
nerve has already been described. The tibial nerve is
distributed mainly in the leg and will be considered in
Chapter 13. The common peroneal nerve is described below.
The Common Peroneal Nerve
This is also called the lateral popliteal nerve. It is derived

from the sacral plexus through roots L4, L5, S1 and S2.
Starting at the bifurcation of the sciatic nerve it runs
downwards and laterally along the lower part of the biceps
femoris muscle to reach the head of the fibula (Fig. 11.13).
It winds round the lateral side of the neck of the fibula and
ends by dividing into its superficial and deep peroneal
branches. Apart from these terminal branches the common
Fig. 11.19. Scheme to show the course and branches of the
common peroneal nerve. peroneal nerve gives off the following branches (Fig. 11.19).
The lateral cutaneous nerve of the calf supplies the skin

The Popliteal Vein over the upper two-thirds of the lateral side of the leg (Fig.
10.2).
The course and relations of the popliteal vein are similar to The sural communicating branch arises near the upper end
those of the popliteal artery described above. The relationship of the fibula. It joins the sural nerve and is distributed with
of the vein to the artery has been described above. The chief it.
129
130
12 : Front and Lateral Side of Leg:

Dorsum of Foot
Compartments of the leg
The leg is divided into anterior, lateral and posterior compartments by

intermuscular septa (Fig. 12.1). These septa may be regarded as extensions
of deep fascia.
The anterior intermuscular septum passes from deep fascia to the anterior
border of the fibula. It separates the anterior and lateral compartments. The
posterior intermuscular septum passes from deep fascia to the posterior
border of the fibula. It separates the lateral and posterior compartments. The
anterior and posterior compartments are separated from each other by the
interosseous membrane (that stretches between the interosseous borders of
the tibia and fibula). The posterior compartment of the leg is divided into
superficial, middle and deep parts by superficial and deep transverse septa.
MUSCLES OF ANTERIOR
COMPARTMENT OF LEG
Tibialis Anterior
Origin:
The muscle takes origin as follows (Fig. 12.3):
a. The main origin is from the lateral surface of the shaft of the tibia (upper half
to two thirds). The upper end of this area extends on to the lateral condyle.
Fig. 12.2. Front and lateral side of leg.
b. The muscle also arises from the adjoining part of the

The muscle ends in a tendon that runs across the front of the
ankle.
Insertion:
Fig. 12.1. Intermuscular septa and compartments The muscle is inserted into; (a) the medial cuneiform bone
of the leg. (medial and plantar aspect), and (b) the first metatarsal bone
(medial side of base).
FRONT AND LATERAL SIDE OF LEG :DORSUM OF FOOT
Nerve supply:
Deep peroneal nerve (L4, L5).
Actions:
The tibialis anterior takes part in:
a. Dorsiflexion of the foot.
b. Inversion of the foot.
c. Helping to maintain the arches of the foot.
Extensor Hallucis Longus
Origin:
This muscle arises from the middle two-fourths of the
medial surface of the fibula, and from the adjoining
part of the interosseous membrane (Fig. 12.4).
The muscle ends in a tendon that runs downwards
across the ankle.
Insertion:
Dorsal aspect of the base of the distal phalanx of the
great toe.
Nerve supply :
The muscle is supplied by a branch from the deep
peroneal nerve (L5, S1).
Actions:
a. It extends the phalanges of the great toe.
b. Continued action helps to dorsiflex the foot.
Extensor Digitorum Longus
Origin:
1. From the upper three-fourths of medial surface of
the fibula (Fig. 12.5).
2. Interosseous membrane.
3. The uppermost part of the origin extends on to the
lateral condyle of the tibia.
At the ankle the tendon passes deep to the extensor
retinacula (Fig. 12.9) and then divides into four slips,
one each for the 2nd, 3rd, 4th and 5th digits. The
tendons for the 2nd, 3rd and 4th digits are joined (on
their lateral sides) by a tendon of the extensor
digitorum brevis (Figs 12.5 and 12.7).
Insertion:
The insertion is like that of the extensor digitorum in
the hand. Over the proximal phalanx. the tendon (for
that digit) divides into three slips: one intermediate,
and two collateral (Fig. 12.6). The intermediate slip is
Fig. 12.3. Scheme to show attachments of inserted into the base of the middle phalanx. The two
the tibialis anterior. collateral slips reunite over the middle phalanx and
are inserted into the base of the distal phalanx.
Over the proximal phalanx the tendon is expanded into
a triangular dorsal digital expansion, that receives the
insertions of interosseous and lumbrical muscles.
131
132
Fig. 12.4. Attachments of the extensor

hallucis longus.
extensor digitorum longus.
Fig. 12.6. Insertion of extensor digitorum longus.
Nerve supply: Deep peroneal nerve (L5, S1).

Actions: The muscle helps in extension of the toes, and in Fig. 12.7. Scheme to show attachments of
dorsiflexion of the foot. extensor digitorum brevis.
Extensor Digitorum Brevis (Fig. 12.7)

Peroneus Tertius
Origin:
From anterior part of calcaneus. This muscle may be regarded as the lower separated part of
the extensor digitorum longus
Insertion:
The muscle ends in four tendons that pass to the first, second, Origin:
third and fourth digits. The peroneus tertius arises from the medial (or anterior)
The tendons for the second, third and fourth digits end by surface of the shaft of the fibula, and from the adjoining
joining the corresponding tendons of the extensor digitorum part of the interosseous membrane below the level of the
longus (Figs 12.5 and 12.7). The part of the muscle that gives origin of the extensor digitorum longus.
origin to the tendon for the first digit is called the extensor
Insertion:
hallucis brevis. Its tendon is inserted into the dorsal surface of
The tendon is inserted into the fifth metatarsal bone, on the
the base of the proximal phalanx of the great toe.
dorsal surface of its base.
Nerve supply:
Nerve supply: Deep peroneal nerve (L5, S1).
Deep peroneal nerve (S1, 52).
Actions: Dorsiflexion and eversion of the foot.
Action:
The muscle helps the extensor digitorum longus to extend the
phalanges of the foot. The extensor hallucis brevis extends the
proximal phalanx of the great toe.
133
134
EXTENSOR AND PERONEAL RETINACULA
Extensor retinacula
The superior extensor retinaculum is attached (a) medially

to the anterior border of the tibia, and (b) laterally to the anterior
aspect of the fibula (Fig. 12.8).
The inferior extensor retinaculum is shaped like the letter
Y placed on its side; the stem of the Y is directed laterally
and the two limbs pass medially.
The stem of the Y is attached to the upper surface of the
calcaneus. The upper limb of the Y is attached to the medial
malleolus.
The lower limb of the Y winds round the medial side of the
foot to become continuous with the plantar aponeurosis,
Tendons passing under cover of extensor retinacula
The tendons passing under cover of the extensor retinacula
are (from medial to lateral side (Fig. 12.9) those of the tibialis
anterior, the extensor hallucis longus, the extensor digitorum
longus, and the peroneus tertius, Fig. 12.8. Attachments of superior and inferior
As they pass under the retinacula the extensor tendons are extensor retinacula.
surrounded by synovial sheaths. There is one sheath each for

the tibialis anterior and for the extensor hallucis. The extensor
digitorum and the peroneus tertius have a common sheath.
Peroneal retinacula
The peroneal retinacula (Fig. 12.10) are present on the lateral

aspect of the ankle. They keep the peroneal tendons (see below)
in place.
The superior peroneal retinaculum is attached above to the
lateral malleolus and below to the lateral surface of the
calcaneus.
The inferior peroneal retinaculum is attached below to the
lateral surface of the calcaneus. Above it becomes continuous
with the inferior extensor retinaculum.
MUSCLES OF LATERAL
COMPARTMENT OF LEG
Fig. 12.9. Synovial sheaths of tendons on the front of
the ankle and their relationship to the extensor
Peroneus Longus (Fig. 12.10) retinacula.
Origin:
retinaculum. The tendon then runs along the lateral aspect
a. Head of fibula, and
of the calcaneus and then winds round the lateral side of the
b. Upper two-thirds of lateral surface of fibula. There is a gap
cuboid bone.
between these two areas of origin: the common peroneal nerve
passes through this gap. Insertion:
The muscle ends in a tendon that passes behind the lateral Finally, the tendon runs medially across the sole to reach its
malleolus; here it is covered by the superior peroneal insertion into (a) the lateral side of the base of the first
Fig. 12.11. Attachments of peroneus brevis FRONT AND LATERAL SIDE OF LEG :DORSUM OF FOOT
(lateral view).
a. Eversion of the foot.

b. Steadying the leg on the foot in standing.
c. Maintaining the arches of the foot (both longitudinal
Fig. 12.10. Attachments of peroneus longus as seen from the and transverse).
lateral side (a), and from below (b).
Peroneus Brevis
metatarsal bone, and (b) the lateral side of the medial cuneiform
bone.
Origin:
Nerve supply: The muscle arises from the lower two thirds of the lateral
Superficial peroneal nerve (L5, S1, 52). surface of the shaft of the fibula (Fig. 12.11). At the ankle
Actions: the tendon passes behind the lateral malleolus and then
The muscle helps in: runs forwards on the lateral surface of the calcaneus.
135
136
Insertion:
ARTERIES AND NERVES OF THE REGION
Lateral side of the base of the fifth metatarsal bone.
Nerve supply:
Superficial peroneal nerve (L5, S1, S2). The Anterior Tibial Artery
Actions:
The anterior tibial artery begins as a terminal branch of the
I. Eversion of the foot.
popliteal artery near the lower border of the popliteus muscle.
2. It helps to steady the foot on the leg.
Its origin is, therefore, situated in the upper part of the back of
Synovial sheath of peroneal tendons the leg. Almost immediately the artery turns forwards through
As the tendons of the peroneus longus and brevis run the upper part of the interosseous membrane to enter the
downwards and forwards lateral to the ankle, they are held in anterior compartment of the leg. It now descends over the
place by the superior and inferior peroneal retinacula. They anterior surface of the interosseous membrane and in front of
are enclosed in a synovial sheath that is common to the two the tibia. It terminates in front of the ankle joint, by becoming
tendons. continuous with the dorsalis pedis artery.
Fig. 12.12. Course and some relations of the anterior

tibial artery. m = muscular branch.
Fig. 12.13. Branches of the anterior tibial artery.
The branches of the anterior tibial artery are shown in Figure
12.13. They are as follows.
The anterior tibial recurrent artery ascends to take part in the
anastomoses around the knee.
The posterior tibial recurrent artery arises from the uppermost
part of the anterior tibial artery in the back of the leg. It supplies
the superior tibiofibular joint.
Numerous muscular branches (m) supply muscles of the anterior
compartment of the leg.
The anterior lateral malleolar artery arises near the ankle and
runs to the lateral malleolus.
The anterior medial malleolar artery arises near the ankle and
runs to the medial malleolus.
The Dorsalis Pedis Artery
This artery is also called the dorsal artery of the foot. It is the
continuation of the anterior tibial artery. Beginning in front of
the ankle it runs forwards, downwards and medially on the
dorsum of the foot to reach the space between the first and
second metatarsal bones. Here it turns downwards through the
space (between the two heads of the first dorsal interosseous
muscle) to enter the sole of the foot.
The branches of the dorsalis pedis artery are shown in Figure
12.14.
The Deep Peroneal Nerve
This is also called the anterior tibial nerve. It begins on the

lateral side of the neck of the fibula, deep to the peroneus longus.
It passes downwards and medially, enters the anterior
compartment of the leg and descends in front of the interosseous
membrane, and lower down on the anterior aspect of the shaft
Fig. 12.15. Distribution of the deep

peroneal nerve.
Fig. 12.14. Branches of dorsalis
pedis artery.
137
138
of the tibia. Accompanied by the anterior tibial artery it
reaches the front of the ankle joint. It ends here by dividing
into lateral and medial terminal branches.
The distribution of the deep peroneal nerve is as follows
(Fig. 12.15):
1. In the leg the nerve gives branches to muscles of the
anterior compartment: these are the tibialis anterior, the
extensor hallucis longus, the extensor digitorum longus, and
the peroneus tertius.
2. The lateral terminal branch supplies the extensor digitorum
brevis.
The skin of part of the dorsum of the foot is supplied by the
deep peroneal nerve through its medial terminal branch. This
branch runs forwards on the dorsum of the foot along with
the dorsalis pedis artery. It divides into two dorsal digital
nerves that supply the adjacent sides of the great toe and the
second toe (Fig. 10.2).
These supply the ankle joint and some joints of the foot.
The Superficial Peroneal Nerve
This nerve is also called the musculocutaneous nerve. It

begins at the neck of the fibula deep to the peroneus longus
(Fig. 12.16).
It is the nerve to muscles of the lateral compartment of the
leg: these are the peroneus longus and the peroneus brevis.
Reaching the lower part of the leg the nerve becomes
superficial and supplies the skin on its lateral side (Fig. 10.2).
It then divides into medial and lateral terminal branches that
descend across the ankle to reach the dorsum of the foot.
Each terminal branch divides into two dorsal digital nerves.
The medial branch gives one dorsal digital nerve to the
medial side of the great toe; and another to the adjacent sides
of the second and third toes. The lateral branch gives one
dorsal digital nerve to the contiguous sides of the third and
fourth toes and another to the adjacent sides of the fourth
and fifth toes. The lateral terminal branch also supplies the
skin on the lateral side of the ankle.
Fig. 12.16. Distribution of the superficial

peroneal nerve.
BACK OF LEG AND SOLE
13 : Back of Leg and Sole
MUSCLES OF THE BACK OF THE LEG
Gastrocnemius
Origin:
The gastrocnemius arises from the femur by two heads (Fig.
13.1).
The medial head arises from the posterior aspect of the
medial condyle, and from the adjoining part of the posterior
surface. The lateral head arises from the lateral surface of
the lateral condyle.
Insertion:
The tendocalcaneus is the common tendon of insertion of
both the gastrocnemius and the soleus. It is the strongest
tendon in the body. It is attached below to the middle of the
posterior surface of the calcaneus.
Nerve supply: Tibial nerve (S1, S2).
Actions of gastrocnemius and of soleus:
1. These muscles are strong plantar flexors of the foot. This
movement provides the propelling force in walking, running
or jumping.
2. As the upper part of the muscle crosses the knee joint, it
helps in flexion of that joint.
Notes:
1. The gastrocnemius and the soleus are together called
the triceps surae.
2. The uppermost parts of the medial and lateral heads of
the gastrocnemius form the boundaries of the lower part of
the popliteal fossa.
Plantaris
This is a small muscle lying deep to the gastrocnemius

(Fig. 13.2).
Origin:
From lower part of lateral supracondylar line of femur.
Insertion:
Into the tendocalcaneus.
Actions:
Because of its small size it is of little functional importance.
Fig. 13.1. Scheme to show the attachments of the
gastrocnemius
139
140
Soleus
This muscle lies deep to the gastrocnemius.

Origin:
It arises from the following (Fig. 13.2):
1. The posterior aspect of the head of the
fibula.
2. The upper one-fourth of the posterior
surface of the fibula.
3. A fibrous band stretching from the head
of the fibula to the tibia.
4. The soleal line of the tibia.
5. The middle one-third of the medial border
of the tibia.
Insertion:
Into tendocalcaneus and through it into the
posterior surface of the calcaneus.
Actions:
Described above with gastrocnemius.
Popliteus
This is a triangular muscle in the floor of

the popliteal fossa.
Origin:
The muscle arises, by a tendon, from the
lateral aspect of the lateral condyle of the
femur. In this situation there is a prominent
groove: the popliteus takes origin from the
anterior part of the groove. The posterior
part of the groove is occupied by the
popliteus tendon in full flexion at the knee.
The origin lies within the capsule of the knee
joint. The muscle emerges from the knee
joint through an aperture in the capsule.
Insertion:
Into a triangular area on the posterior surface
of the shaft of the tibia (Fig. 13.3).
Nerve supply :
Tibial nerve (L4, L5, S1).
Actions:
When the leg is off the ground, the popliteus
rotates the tibia medially on the femur. When
the leg is placed on the ground (thus fixing
the tibia) the muscle rotates the femur
laterally on the tibia. Because of this action
the muscle can unlock the knee joint at the Fig. 13.2. Scheme showing attachments of the
beginning of flexion. soleus and of the plantaris.
Fig. 13.3. Posterior aspect of the popliteal region to
show the popliteus.
Flexor Hallucis Longus
Origin:
The muscle takes origin from the lower two-thirds of the
posterior surface of the fibula (Fig. 13.4) and from the
The muscle ends in a tendon which runs across the lower part
of the tibia (1) and the posterior aspect of the talus (2) to reach
the calcaneus.
Here it turns forwards below the sustentaculum tali which serves
as a pulley for it.
Insertion:
The tendon then runs forward in the sole to be inserted into the
plantar aspect of the base of the distal phalanx (Fig. 13.6. Also
see figure 13.2).
Nerve supply: Tibial nerve (S2, S3). Fig. 13.4. Flexor hallucis longus muscle.
Actions.
a. Flexion of the distal phalanx of the great toe.
b. Plantar flexion of the foot. The muscle ends in a tendon which passes behind the medial
c. The muscle helps to maintain the longitudinal arch of the malleolus. It then turns laterally to enter the sole of the foot.
foot. In the sole the tendon divides into four slips, one each for
the 2nd, 3rd, 4th and 5th digits. (Also see Figures 13.6 and
13.16).
Flexor Digitorum Longus Insertion:

Each slip is inserted into the distal phalanx (plantar surface
of the base) of the digit concerned.
Origin:
From posterior surface of shaft of tibia (Fig. 13.7). Nerve supply: Tibial nerve (S2, S3).
141
142
Fig. 13.5. Medial side of foot showing the tendons

passing deep to the flexor retinaculum. Note the
insertion of the flexor hallucis longus and of the
tibialis posterior.
Fig. 13.7. Flexor digitorum longus muscle.

Also see Figure 13.6.
Tibialis Posterior
Fig. 13.6. Course and attachments of flexor

hallucis longus and flexor digitorum longus in the foot. Origin:
This muscle arises from (Fig. 13.8A):
a. Posterior surface of the shaft of the tibia below the soleal
Actions: line.
The muscle causes plantar flexion of the distal phalanges. Its b. Posterior surface of the fibula.
continued action helps in flexion of the middle and proximal c. Interosseous membrane.
phalanges, and in plantar flexion of the foot. It also helps to The tendon passes behind the medial malleolus to reach the
maintain the longitudinal arches of the foot. sole of the foot.
Fig. 13.9. Flexor retinaculum and structures passing
deep to it. Note the extent of the tendon sheaths.
Nerve supply: Tibial nerve (L4, L5).

Actions:
1. Inversion of the foot.
2. Maintains the longitudinal arches of the foot.
Flexor Retinaculum
The flexor retinaculum is a thickened band of deep

fascia present on the medial side of the ankle (Fig.
13.9). It is attached above to the medial malleolus, and
below to the medial surface of the calcaneus. The
structures passing under cover of it are as follows (from
above downwards, and also from medial to lateral
side): (1) tendon of the tibialis posterior, (2) tendon of
the flexor digitorum longus, (3) the posterior tibial
vessels, (4) the tibial nerve, and (5) the tendon of the
flexor hallucis longus.
Synovial Sheaths
The three tendons passing deep to the flexor
retinaculum are surrounded by synovial sheaths which
begin proximal to the retinaculum. The sheath for the
tibialis posterior extends to the insertion of the muscle.
The sheath for the flexor hallucis longus may end near
the base of the first metatarsal, or may extend right up
Fig. 13.8. A. Scheme to show the tibialis posterior muscle
to the insertion into the terminal phalanx.
and its origin. B. Skeleton of foot seen from below to show
The sheath for the flexor digitorum longus expands to
insertion of tibialis posterior.
enclose the proximal parts of the tendons for the digits.
The distal parts of the tendons for the 2nd, 3rd and 4th
Insertion:
digits have independent synovial sheaths. The 5th digit
The main insertions inserted into the tuberosity of the navicular bone, has a similar sheath which is continuous proximally
and the medial cuneiform bone. Some slips reach other bones of the with the sheath for the tendon of the flexor digitorum
foot. longus.
143
144
tubercle of the calcaneus by dividing into the medial and
ARTERIES OF THE BACK OF THE LEG
lateral plantar arteries.
The upper part of the artery lies deep to (or anterior to) the
gastrocnemius and soleus muscles, but its lower part is
The Posterior Tibial Artery
covered only by skin and fascia. The artery is accompanied
by the tibial nerve.
The posterior tibial artery is a terminal branch of the popliteal
artery (Fig. 13.10). It, therefore, begins in the upper part of
the back of the leg, at the lower border of the popliteus muscle. Branches of Posterior Tibial Artery
It terminates on the posteromedial side of the ankle, midway The branches of the posterior tibial artery are shown in
between the medial malleolus (of the tibia) and the medial Figure 13.11.
Fig. 13.10. Posterior tibial and peroneal arteries. Fig. 13.11. Branches of posterior tibial and
peroneal arteries.
Peroneal Artery lateral margins of the phalanges. The fascia constitutes the
fibrous flexor sheath. The tendons are thus enclosed in an
The peroneal artery is the largest branch of the posterior tibial. osseo-aponeurotic canal. This canal is lined by a synovial
It runs downwards up to the ankle. Its branches are shown in sheath to permit smooth movement of the tendons.
Figure 13.11.
Flexor Digitorum Brevis

MUSCLES AND RELATED STRUCTURES
IN THE SOLE Origin:
From tuberosity of the calcaneus (medial process) (Fig.
13.13).
Plantar Aponeurosis
The muscle ends in four tendons, one each for the 2nd, 3rd,
4th and 5th digits.
Underlying the skin of the sole there is a thick layer of deep
fascia which is given the name plantar aponeurosis. It consists Insertion:
of central, medial and lateral parts. The central part is the The tendon for each digit divides into two slips that are
thickest and strongest (Fig. 13.12). It overlies the flexor inserted into the sides of the middle phalanx (Fig. 13.14).
digitorum brevis. Traced distally the aponeurosis broadens and
Nerve supply: Medial plantar nerve (S2, S3).
divides into five processes, one for each digit.
Actions:
a. Flexion of the middle and proximal phalanges.
Fibrous Flexor Sheaths
b. It helps to maintain the arches of the foot.
Over each toe the deep fascia (which is thick) winds round the
sides of the flexor tendons of the digit to get attached to the
Fig. 13.12. Scheme to show arrangement of the

plantar aponeurosis. Fig. 13.13. Attachments of the flexor digitorum brevis.
145
146
surface, and the lateral head from the lateral process of the
tuberosity.
Insertion:
Into tendon of flexor digitorum longus.
Nerve supply: Lateral plantar nerve (S2, S3).
Actions:
This muscle straightens the oblique pull of the flexor
digitorum longus.
Lumbrical Muscles of the Foot

Fig.. 13.14. Arrangement of tendons of flexor
These are four slender muscles numbered from the medial
digitorum longus and brevis over a digit.
to the lateral side (Fig. 13.16).
Origin:
Abductor Hallucis They take origin from the digital tendons of the flexor
digitorum longus.
Origin:
The abductor hallucis arises from (Fig. 13.15):
a. the medial process of the calcaneal

tuberosity,
b. and the flexor retinaculum.
Insertion:
Proximal phalanx of the great toe (medial side
of base).
Action:
The abductor hallucis abducts and flexes the
great toe.
Abductor Digiti Minimi
Origin:
Tuberosity of the calcaneus (lateral and medial
processes)(Fig. 13.15).
Insertion: .
Proximal phalanx of the fifth toe.
Actions:
The abductor digiti minimi abducts the fifth toe.
Flexor Digitorum Accessorius
Origin:
From the calcaneus by two heads (Fig. 13.16).
The medial head arises from the medial Fig. 13.15. Scheme to show attachments of the abductor hallucis
and the abductor digiti minimi.
Action:
Flexion of great toe.
Flexor Digiti Minimi Brevis
Origin:
From the base of the fifth metatarsal bone (plantar surface)
(Fig. 13.17).
Insertion:
Into proximal phalanx of little toe (on the lateral side of its
base).
Action:
Flexion of little toe.
Fig. 13.17. Attachments

of flexor hallucis brevis
Fig. 13.16. Scheme to show the attachments of the flexor
and flexor digiti minimi
digitorum accessorius and the lumbrical muscles.
brevis.
Insertion:
Each muscle ends in a tendon which
curves round the medial side of the
corresponding metatarsophalangeal joint.
It is inserted partly into the base of the
proximal phalanx, and partly into the
extensor expansion.
Flexor Hallucis Brevis
Origin:
Mainly from the plantar surface of the
cuboid bone (Fig. 13.17).
Insertion:
The muscle divides into two parts each
of which ends in a tendon. The two
tendons are inserted into the proximal
phalanx of the great toe (corresponding
side of the base).
147
148
Adductor Hallucis
The adductor hallucis has two

heads oblique and transverse.
Origin:
The oblique head arises from
the bases of the 2nd, 3rd and
4th metatarsal bones.
The transverse head arises
from the plantar aspect of the
metatarsophalangeal joints of
the 3rd, 4th and 5th toes.
Nerve supply: Lateral plantar
nerve (S2, S3).
Insertion:
The two heads end in a
common tendon which is
inserted into the proximal
Fig. 13.18. Attachments of adductor hallucis.
phalanx of the great toe (lateral
side of base).
Actions:
The muscle adducts the great Each plantar interosseous muscle arises from one metatarsal
toe. bone (from the plantar aspect of the shaft) (Fig. 13.19). It is
inserted into the base of the proximal phalanx, and into the
dorsal digital expansion of the corresponding digit.
Interosseous Muscles of the Foot
Each dorsal interosseous muscle arises from the shafts of
two adjoining metatarsal bone (Fig. 13.20). The dorsal
Introductory remarks interossei are inserted into the bases of the proximal
These are small muscles placed between the metatarsal bones. phalanges, and into the dorsal digital expansions.
There are three plantar, and four dorsal, interossei. They are
numbered from medial to lateral side.
Fig. 13.19. Scheme to show attachments of plantar Fig. 13.20. Scheme to show attachments of dorsal
interossei. interossei of foot.
Details of the attachments of individual interosseous muscles
ARTERIES OF THE SOLE
are shown in Figures 13.19 and 13.20.
Actions of interossei
The interossei adduct or abduct the toes with reference to an Medial Plantar Artery
axis passing through the second digit. The plantar interossei
are adductors. They pull the 3rd, 4th and 5th toes towards the The medial plantar artery is a terminal branch of the posterior
second toe. The dorsal interossei are abductors of the 2nd, 3rd tibial artery. It begins behind the medial malleolus, deep to
and 4th toes. the flexor retinaculum, and runs distally along the medial
In addition to abduction and adduction, the interossei flex the border of the sole of the foot. The branches of the artery are
metatarsophalangeal joints and extend the interphalangeal joints shown in Figure 13.21.
by virtue of their insertion into the dorsal digital expansions.
Nerve supply: Lateral Plantar Artery
All the interossei are supplied by the lateral plantar nerve (S2,
S3). This is the other terminal branch of the posterior tibial artery.
It begins behind the medial malleolus deep to the flexor
retinaculum. From here it runs obliquely across the sole to
reach the base of the fifth metatarsal bone. The artery now
turns medially and runs deep in the sole across the bases of
the metatarsal bones. This part of the artery is called the
Fig. 13.21. Scheme to branches of medial and lateral plantar arteries.
149
150
plantar arch. It ends by joining the termination of the dorsalis tendocalcaneus by dividing into the medial and lateral plantar
pedis artery (in the interval between the bases of the first and nerves.
second metatarsal bones).
Important relations of the tibial nerve are as follows.
The branches of the lateral plantar artery (including those of
In the upper part of the popliteal fossa the nerve lies lateral to
the plantar arch) are shown in Figure 13.21.
the popliteal artery and vein (Fig.11.13). It crosses superficial
(i.e., posterior) to these vessels at the level of the knee joint
NERVES OF THE BACK OF LEG and, thereafter, lies medial to them. In the leg the nerve is at
AND OF THE SOLE first medial to the posterior tibial vessels, but crosses behind
these vessels to reach their lateral side. (Fig. 18.17).
The distribution of the tibial nerve (excluding that of its
The Tibial Nerve
terminal branches) is as follows (Fig. 23.14):
This is also called the medial popliteal nerve. It is a terminal A. Muscular branches:
branch of the sciatic nerve. It descends through the popliteal 1. Branches given off in the lower part of the popliteal fossa
fossa, and the back of the leg. In the lower part of the leg it supply the two heads of the gastrocnemius, the plantaris,
ends midway between the medial malleolus and the the soleus and the popliteus. The nerve to the popliteus has
an interesting course. After running down superficial
(posterior) to this muscle the nerve turns round its lower
border to reach its anterior surface which it enters.
2. Branches arising in the leg supply the soleus, the tibialis
posterior, the flexor digitorum longus and the flexor hallucis
longus.
1. The sural nerve is the main cutaneous branch. It arises in
the popliteal fossa and runs down the back of the leg. The
terminal part of the nerve runs forwards along the lateral
margin of the foot reaching right up to the lateral side of the
little toe. The nerve supplies skin on the posterolateral part
of the leg and along the lateral margin of the foot (See Fig.
10.5).
2. The medial calcaneal branches supply the skin over the
heel (See Figs 10.5 and 10.6).
The tibial nerve gives branches to the knee joint and to the
ankle joint.
Medial Plantar Nerve
The medial plantar nerve is a terminal branch of the tibial

nerve. It begins on the posteromedial aspect of the ankle
midway between the tendocalcaneus and the medial
malleolus: here it lies under cover of the flexor retinaculum
(See Fig. 18.18C). The nerve passes forwards in the medial
part of the sole. It is accompanied by the medial plantar
artery. The nerve ends by dividing into one proper digital
branch for the great toe, and three common plantar digital
branches. The nerve is distributed as follows (Fig. 13.23):
A. Cutaneous branches:
a. Branches arising from the trunk of the nerve supply the
skin of the medial part of the sole (Fig. 23.15).
b. The skin on the medial side of the great toe is supplied by
Fig. 13.22. Branches of tibial nerve.
the proper digital branch to this digit.
The Lateral Plantar Nerve
The lateral plantar nerve is a terminal branch of the tibial

nerve. It begins on the posteromedial aspect of the ankle
midway between the tendocalcaneus and the medial
malleolus. It passes forwards and laterally across the
sole (Fig. 13.24). The nerve ends (near the tubercle of
the fifth metatarsal bone) by dividing into superficial
and deep branches.
The trunk of the lateral plantar nerve is accompanied by
the lateral plantar artery (Fig. 18.21).
The superficial branch runs distally and ends by
dividing into two plantar digital nerves. The lateral of
these runs along the lateral side of the fifth digit. The
medial one divides into two branches that supply the
adjacent sides of the fourth and fifth digits (Fig. 13.24).
The deep branch begins near the tubercle of the fifth
metatarsal bone. From here it runs medially deep to the
flexor tendons and the adductor hallucis.
The distribution of the lateral plantar nerve and its
terminal branches is as follows (Fig. 13.24).
1. Branches arising from the trunk supply the flexor
digitorum accessorius and the abductor digiti minimi.
Fig. 13.23. Distribution of medial plantar nerve.
c. Each common plantar digital nerve divides into

two proper digital nerves. The first (most medial)
common plantar digital nerve divides into the proper
digital nerves that supply the skin on the adjacent
sides of the great toe and second toe; the second
into those that supply the second and third toes; and
the third into those that supply the third and fourth
toes.
B. Muscular branches:
a. Branches arising from the trunk of the nerve supply
the abductor hallucis, and the flexor digitorum brevis.
b. The flexor hallucis brevis receives a branch from
the digital nerve to the great toe.
c. The first lumbrical muscle is supplied by a branch
from the first plantar digital nerve.
These supply the tarsal, tarsometatarsal joints,
metatarsophalangeal and interphalangeal joints.
Fig. 13.24. Distribution of lateral plantar nerve.
151
152
2. The flexor digiti minimi brevis is supplied by the digital branch B. Cutaneous branches:
for the lateral side of the fifth toe. This nerve also supplies the 1. Some branches arising from the trunk of the nerve supply
interosseous muscles that lie between the fourth and fifth the skin of the lateral part of the sole (See Fig. 10.6).
metatarsal bones (i.e. the 3rd plantar and the fourth dorsal 2. The skin on the lateral side of the little toe and the
interosseous muscles). contiguous sides of the fourth and fifth toes is supplied by
3. The deep branch supplies all interossei except those lying the corresponding digital branches.
between the fourth and fifth metatarsals. It also supplies the
2nd, 3rd and 4th lumbrical muscles, and the adductor hallucis.
14 : Joints of the Lower Limb
THE HIP JOINT
This is a synovial joint of the ball and socket variety. The line. The lateral band is attached to the upper part of the
rounded head of the femur fits into the deep cavity provided same line. Because of its shape it is also called the Y-shaped
by the acetabulum of the hip bone. The depth of the acetabulum ligament.
is increased by the presence of a rim of fibrocartilage called The pubofemoral ligament (Fig. 14.2A) is attached above
the acetabular labrum. and medially to the ilio-pectineal eminence and the superior
The cavity of the acetabulum is partly articular and partly ramus of the pubis. It passes downwards and laterally to
non-articular. The articular surface is shaped like a horse shoe. blend with the medial band of the iliofemoral ligament and
The inferior part of the acetabulum is non-articular and is called with the capsular ligament.
the acetabular fossa. Here the rim of the acetabulum is also The ischiofemoral ligament (Fig. 14.2B) is attached
deficient the gap being called the acetabular notch. A part of medially to the ischium just beyond the acetabulum and
the acetabular labrum bridges across the notch as the transverse laterally to the greater trochanter.
ligament of the acetabulum. The synovial membrane of the hip joint is extensive. It lines
The head of the femur is somewhat more than half a sphere. It the inside of the capsular ligament, the intracapsular part of
faces upwards, medially and slightly forwards. Near its centre
it is marked by a pit called the fovea.
The proximal and distal articular surfaces are joined together
by a capsular ligament, and directly by a ligament passing from
the head of the femur to the acetabulum. This ligament is called
the ligament of the head of the femur. It is attached, laterally,
to the fovea on the head of the femur, and medially to the two
ends of the acetabular notch, and between them to the transverse
ligament.
The capsular ligament of the hip joint is strong. Medially it is
attached to the hip bone around the margins of the acetabulum.
Laterally, it covers the greater part of the neck of the femur.
Anteriorly it is attached to the trochanteric line; posteriorly to
the neck of the femur a short distance medial to the trochanteric
crest; above to the base of the greater trochanter; and infe-
riorly to the neck near the lesser trochanter (Fig. 14.2).
The capsule is strengthened by the presence of three ligaments:
iliofemoral, pubofemoral and ischio-femoral. The iliofemo-
ral ligament is the strongest. It is attached above to the anterior
inferior iliac spine (Fig. 14.2A). Inferiorly, its fibres diverge
to form two bands, medial and lateral. The medial band runs
vertically to be attached to the lower part of the trochanteric Fig. 14.1. Schematic section across the hip joint.
JOINTS OF THE LOWER LIMB
Fig. 14.2. Hip joint. A. Anterior aspect. B. Posterior aspect.
Fig. 14.3. Scheme to show the

muscles responsible for
movements at the hip joint.
the neck of the femur, both surfaces of the

acetabular labrum, the acetabular fossa, and
the ligament of the head of the femur (Fig.
14.1).
The hip joint is supplied by branches from the
obturator, medial circumflex femoral, superior
gluteal and inferior gluteal arteries; by the
femoral, obturator and superior gluteal nerves,
and by the nerve to the quadratus femoris.
The movements at the hip joint are flexion,
extension, abduction, medial rotation and
lateral rotation. The muscles responsible for
them are shown in Figure 14.3.
153
154
joint is also complex because its cavity is partially divided
THE KNEE JOINT
into upper and lower parts by plates of cartilage called the
medial and lateral menisci.
The knee joint is a synovial joint of the condylar variety. It is The proximal articular surface covers the anterior, inferior
a compound joint having two distinct articular surfaces on the and posterior aspects of the medial and lateral condyles of
medial and lateral condyles of the femur, for articulation with the femur (Fig. 14.4). Anteriorly, the medial and lateral
corresponding surfaces on the medial and lateral condyles of articular surfaces are continuous with each other, but
the tibia. The anterior aspect of the lower end of the femur posteriorly they are separated by the intercondylar notch.
articulates with the posterior aspect of the patella. The knee The part of the femoral articular surface situated on the
anterior aspect of its lower end articulates with the patella.
It is concave from side to side and is subdivided by a vertical
groove into a larger lateral part and a smaller medial part. A
small part of the inferior surface of the medial condyle,
adjacent to the anterior part of the intercondylar notch comes
in contact with the patella in extreme flexion of the joint.
The tibial articular surface of each femoral condyle is convex
anteroposteriorly, the curvature being much more marked
in the posterior part. The condyles are also convex from
side to side. The long axis of the lateral condylar articular
surface (4) is straight and is placed anteroposteriorly. The
axis of the medial condylar surface (5) shows an
anteroposterior curve, the convexity of the curve being
directed medially.
The distal articular surfaces of the knee joint are present

on the upper surfaces of the medial and lateral condyles of
the tibia (See Fig. 14.5). These surfaces are slightly concave
centrally, and flat at the periphery, where they are covered
by the corresponding menisci. The articular surface of the
medial condyle is oval. The articular surface of the lateral
condyle is almost circular.
The posterior surface of the patella bears a large articular
area for the femur (See Fig. 9.17). It is convex and is divided
by a ridge into a larger lateral part and a smaller medial part.
The attachment of the capsule of the knee joint is
complicated because of the presence of the patella anteriorly,
and because of the fact that anteriorly the capsule blends
indistinguishably with the lower tendinous part of the
quadriceps femoris muscle. To understand the attachments
on the femur we may begin on the medial side. Here the
capsule is attached to the medial and posterior aspects of
the condyle just beyond the articular surface (Fig. 14.4A).
Traced laterally the line of attachment passes along the
posterior margin of the intercondylar notch to the posterior
surface of the lateral condyle (Fig. 14.4B), and then to the
lateral side of the condyle where it is attached above the
origin of the popliteus muscle (Fig. 14.4D). Anteriorly, the
capsule merges with expansions from two muscles: the vastus
medialis (medially) and the vastus lateralis (laterally). These
expansions are attached to the upper, lateral and medial
borders of the patella; and below the patella to the medial
and lateral sides of the ligamentum patellae.
The inferior attachment of the capsule may also be traced
beginning from the medial side (Fig. 14.5). It is attached to
the medial margin of the medial condyle of the tibia. Traced
Fig. 14.4. Lower end of femur showing attachments of the posteriorly the line of attachment passes (in that order) on
capsule of the knee joint. A. Anterior aspect. B. Posterior to the posterior aspect of the medial condyle (Fig. 14.5), the
aspect. C. Inferior aspect. D. Lateral aspect. posterior margin of the intercondylar area, the posterior and
The capsule is strengthened in several situations by
ligaments and expansions as follows.
a. Anteriorly, below the patella the capsule is replaced by
the ligamentum patellae. This ligament is attached above
to the non-articular lower part of the posterior surface of
the patella and below to the upper smooth part of the tibial
tuberosity.
b. On the medial and lateral sides of the joint there are strong
collateral ligaments. The tibial collateral ligament is
attached above to the medial surface of the medial condyle
of the femur just below the adductor tubercle (Fig. 14.6).
Inferiorly, the deeper fibres of the ligament are attached to
the medial condyle of the tibia: they are adherent to the
medial meniscus and blend with the capsule. The more
superficial fibres of the ligament gain attachment to the upper
part of the medial surface of the shaft of the tibia (Figs 14.6
and 14.7). The fibular collateral ligament is attached above
to the lateral epicondyle of the femur (Fig. 14.4) above the
groove for the popliteus. Below it is attached to the head of
the fibula. The ligament is separated from the lateral meniscus
by the tendon of the popliteus and is, therefore, not adherent
to the meniscus.
The posterior aspect of the capsule is strengthened by the
oblique popliteal ligament. This ligament is an expansion
from the tendon of the semimembranosus (Fig. 14.6). It
passes upwards and laterally from the posterior aspect of
the medial condyle of the tibia to be attached to the femur
on the lateral part of the intercondylar line and to the lateral
condyle.
Apart from the capsular ligament and its associated
ligaments, the femur and tibia are united by two strong
ligaments that lie within the joint. These are the anterior
and posterior cruciate ligaments (so called because they cross
each other). The anterior cruciate ligament is attached
below to the anterior part of the intercondylar area of the
Fig. 14.5. Upper end of right tibia to show attachments of

the capsule of the knee joint (green). A. Superior aspect.
B. Anterior aspect. C. Posterior aspect.
then the lateral margin of the lateral condyle. There is a gap in

the capsular attachment behind the lateral condyle. The
popliteus, that arises from within the knee joint, leaves it through
this gap. Here the lower margin of the capsule is attached to a
band of fibres called the arcuate popliteal ligament. This
ligament passes from the head of the fibula to the posterior
margin of the intercondylar area of the tibia (Fig. 14.16).
Anteriorly, the expansions from the vastus medialis and the
vastus lateralis gain attachment to the anterior aspect of the
medial and lateral condyles of the tibia: here these expansions Fig. 14.6. Schematic diagram showing some structures on
the posterior aspect of the knee joint.
are called the medial and lateral patellar retinacula (Fig. 14.5).
155
156
full extension. Locking is produced by continued action of
the same muscles that produce extension, namely the
quadriceps femoris. When the knee is locked the position of
extension can be maintained without much muscular activity.
The locked knee can be flexed only after it is unlocked by
a reversal of the rotation. Unlocking is brought about by the
action of the popliteus muscle.
The muscles responsible for movements of the knee joint
are as follows. Flexion is produced mainly by the hamstring
muscles. It is assisted by the gastrocnemius, popliteus,
sartorius, gracilis and plantaris muscles. Extension is
produced by the quadriceps femoris and by the tensor fasciae
latae. Muscles producing locking and unlocking of the joint
have been mentioned in the preceding paragraph.
Fig. 14.7. Menisci of the knee joint seen from above after The knee joint is supplied by branches of the descending
removing the femur. genicular, popliteal, anterior tibial and lateral circumflex
arteries; and by branches from the obturator, femoral, tibial
and common peroneal nerves.
tibia (Figs 14.5 and 14.7). Its upper end is attached to the medial
The knee joint is surrounded by several muscles. The
aspect of the lateral condyle of the femur (i.e. on the lateral wall
posterior aspect of the joint is related to the popliteal vessels
of the intercondylar notch). The posterior cruciate ligament
and to the tibial nerve, and more laterally to the common
is attached below to the posterior part of the intercondylar
peroneal nerve.
area of the tibia. Its upper end is attached above to the lateral
surface of the medial condyle of the femur.

The medial and lateral menisci of the knee joint are intra-
articular discs made of fibrocartilage. They have a thick
peripheral border and a thin inner border. They intervene THE ANKLE JOINT
between the femoral and tibial condyles (Fig. 14.6). In
accordance with the shape of the tibial condyles the lateral
The ankle joint is a synovial joint of the hinge variety. The
meniscus is smaller and its outline more nearly circular than
bones taking part are the lower end of the tibia, the lower
that of the medial meniscus (Fig. 14.7). The anterior and
end of the fibula, and the upper part of the talus.
posterior ends of the lateral meniscus are attached to the
Three distinct surfaces on the talus take part in the formation
intercondylar area of the tibia just in front of and behind the
of the joint. The superior or trochlear surface (a in Figure
intercondylar eminence (Fig. 14.5A). The anterior end of the 14.8) is convex from front to back. It is slightly concave
medial meniscus is attached to the most anterior part of the from side to side, so that it is like a pulley and hence the
intercondylar area of the tibia in front of the anterior cruciate name trochlear surface. It comes in contact with a
ligament. Its posterior end is attached to the posterior part of reciprocally shaped surface on the lower end of the tibia
the intercondylar area in front of the attachment of the posterior (e in Figure 14.9). The medial side of the talus bears a comma-
cruciate ligament. The anterior margins of the two menisci are shaped articular surface (c). The medial surface articulates
connected by a band of fibres called the transverse ligament with the lateral surface of the medial malleolus of the tibia
(Fig. 14.7). The menisci provide for better adaptation of the (f in Figure 14.9). The lateral surface of the talus has a large
articular surfaces of the joint. They participate in gliding triangular surface (b), the apex of the triangle being directed
movements (see below) and assist in lubrication of the joint. downwards. It articulates with the medial surface of the
The synovial membrane of the knee joint covers all structures lateral malleolus of the fibula (d in Figure 14.9).
within the joint excepting the articular surfaces and the surfaces The capsular ligament of the ankle joint is attached just
of the menisci. It lines the inner side of the tendinous expansion beyond the margins of the articular surfaces. A small part of
of the quadriceps femoris (that replaces the capsule anteriorly) the neck of the talus is included within the joint cavity. The
and some parts of the tibia and femur enclosed within the capsule is strengthened on the medial and lateral side by
capsule. strong ligaments.
The main movements at the knee joint are those of flexion and On the lateral side of the ankle there are three distinct bundles
extension. The tibia and menisci glide forwards relative to the that constitute the lateral ligament of the joint (Fig. 14.10).
femoral condyles in extension; and backwards in flexion. a. The anterior talofibular ligament extends from the lateral
Further, flexion is associated with lateral rotation of the femur malleolus to the anterior part of the talus.
(or medial rotation of the tibia if the foot is off the ground); and b. The posterior talofibular ligament passes from the lateral
extension is associated with medial rotation. The medial malleolus to the posterior process of the talus.
rotation of the femur is most marked during the last stages of c. The calcaneofibular ligament passes from the lateral
extension. This rotation locks the knee joint in the position of malleolus. to the lateral surface of the calcaneus.
more anteriorly on the talus form the anterior tibio-talar
ligament.
The ankle joint is supplied by branches from the anterior tibial
and peroneal arteries and from the deep peroneal and tibial
nerves.
The movements that take place at the ankle joint are those of
plantar flexion and dorsiflexion. The muscles producing these
movements are as follows. Dorsiflexion is produced by muscles
of the anterior compartment of the leg viz., tibialis anterior,
extensor digitorum longus, extensor hallucis longus and
peroneus tertius. Plantar flexion is produced mainly by the
gastrocnemius and soleus muscles. It is assisted by the plantaris,
the tibialis posterior, the flexor hallucis longus and flexor
digitorum longus. Note that plantar flexion provides the
propulsive force for walking, running and jumping.
Fig. 14.8. Right talus showing attachments of

capsular ligament of ankle joint. A. Superior aspect.
B. Lateral aspect. C. Medial aspect.
Fig. 14.10. Ligaments on the lateral aspect of the ankle joint.
Fig. 14.9. Superior articular surface of ankle joint

seen from the anteroinferior aspect.
The medial or deltoid ligament is triangular (Fig. 14.11).

Above it is attached to the medial malleolus. Its anterior
fibres pass to the navicular bone and form the tibio-
navicular ligament. The middle fibres are attached,
below, to the sustentaculum tali of the calcaneus and form
the tibiocalcanean ligament. The posterior fibres are
attached to the posterior part of the talus. They form the
posterior tibio-talar ligament. Deeper fibres attached
Fig. 14.11. Ligaments on the medial aspect of the ankle joint.
157
158
INTERTARSAL JOINTS
These will not be considered in detail. The three most important

joints between the tarsal bones are:
1. The subtalar joint (Fig. 14.12) between the posterior facet
on the inferior surface of the talus and on the superior surface
of the calcaneus .
2. The talocalcaneonavicular joint in which the surfaces
taking part are the head of the talus, that fits into a concavity
on the posterior aspect of the navicular bone; and the anterior
and middle facets on the inferior aspect of the talus and on the
superior aspect of the calcaneus (Fig. 14.12).
3. The calcaneocuboid joint in which reciprocally concavo-
convex surfaces on the anterior surface of the calcaneus and
the posterior aspect of the cuboid fit each other (Fig. 14.12).
The talocalcaneonavicular and the calcaneocuboid joints lie
Fig. 14.12. Schematic vertical section along the long
along the same transverse plane and are collectively referred axis of the talus, to show the various joints formed by it.
to as the transverse tarsal joint.
Some important ligaments connecting the tarsal bones are as
follows:
a. The long plantar ligament (Fig. 14.13) is attached posteriorly
to the plantar surface of the calcaneus, and anteriorly to the
plantar surface of the cuboid bone distal to the groove for the
peroneus longus. It converts this groove into a tunnel. Some
fibres of the ligament are prolonged into the bases of the 2nd,
3rd and 4th metatarsal bones.
b. The short plantar ligament (or plantar calcaneo-cuboid
ligament) passes from the anterior tubercle of the calcaneus
to the cuboid proximal to the groove for the peroneus longus.
c. The plantar calcaneonavicular or spring ligament passes
from the anterior margin of the sustentaculum tali of the
calcaneus to the plantar surface of the navicular bone. This
ligament is in contact above with the head of the talus and its
upper surface forms part of the articular surface of the
talocalcaneonavicular joint.
d. The bifurcate ligament (Fig. 14.10) is Y-shaped. The stem of Fig. 14.13. Posterior part of right foot (plantar aspect)
the Y is attached posteriorly to the anterior part of the upper to show attachments of some ligaments.
surface of the calcaneus. Anteriorly it splits into two bands:
one passing to the dorsal aspect of the cuboid bone and another
to the dorsal aspect of the navicular bone.
e. The interosseous talocalcaneal ligament lies deep between
the talus and the calcaneus. It passes from the sulcus tali to the ARCHES OF THE FOOT
sulcus calcanei joining the talus and calcaneus in the interval
between the subtalar and talocalcaneo-navicular joints The bones of the foot are so arranged that they form a series
(Fig.14.12). of arches. There are two longitudinal arches, medial and
lateral; and a number of transverse arches.
The medial longitudinal arch is formed (from posterior to
Tibiofibular Joints anterior side) by the calcaneus; the talus; the navicular; the
medial, intermediate and lateral cuneiform bones; and the
The tibia and fibula are joined to each other at the superior medial three metatarsal bones. The arch rests posteriorly on
and inferior tibiofibular joints. The superior joint is a synovial the tubercles of the calcaneus, and anteriorly on the heads
joint of the plane variety. At the inferior tibio-fibular joint the of the metatarsals. The summit of the arch is formed by the
tibia and fibula are united by fibrous tissue(syndesmosis). talus (Fig. 14.14).
The lateral longitudinal arch is formed by the calcaneus,
the cuboid, and the lateral two metatarsal bones (Fig. 14.15).
The calcaneus is thus common to both arches.
The transverse arches are best marked in the middle of the foot.
As a result of the transverse arches the medial border of the
foot remains off the ground in its middle part. Each foot has
only half an arch the complete transverse arch being formed
when the feet are placed together.
As a result of the presence of the arches body weight is
transmitted to the ground only through the tuberosity of the
calcaneus and the heads of the first and fifth metatarsal bones.
The presence of the arches confers considerable resilience to
the foot and makes it a more efficient lever for propulsion
forwards of the body.
The factors that help to maintain the arches of the foot are:
(a) The configuration of the articular surfaces. The talus plays Fig. 14.14. Scheme to show constitution of the
an important role in maintaining the medial longitudinal arch medial longitudinal arch of the foot.
by acting as its key stone.
(b) Flattening of the arches is prevented by ligaments, specially
those that run longitudinally on the plantar aspect of the foot.
These include the long and short plantar ligaments and the
plantar calcaneonavicular ligament.
(c) The plantar aponeurosis plays an important role by
connecting the anterior and posterior ends of the longitudinal
arches like a tie-beam.
(d) The muscles and tendons running longitudinally on the
plantar aspect of the foot have a similar action. The tendons of
the tibialis posterior and the peroneus longus together form a
sling that holds the longitudinal arches up.
Flattening of the arches is seen in some individuals. It is called Fig. 14.15 . Scheme to show constitution of the lateral
flat foot, or pes planus. The reverse condition in which the longitudinal arch of the foot.
arches are too marked is also known: it is termed pes cavus.
159
160
15 : Surface Marking and Clinical

Correlations of Lower Limb
SURFACE MARKING
Femoral artery Lateral plantar artery

Draw a line joining the midinguinal point to the adductor Its beginning is at the same point as that for the medial
tubercle. The femoral artery corresponds to the upper two- plantar artery. The lateral plantar artery is marked by drawing
thirds of this line. The upper half of the artery lies in the femoral a line starting at this point and running obliquely (laterally
triangle and the lower half in the adductor canal. and distally) across the sole to reach a point about 2.5 cm
medial to the tuberosity of the fifth metatarsal bone.
Profunda femoris artery
Draw the same line as for the femoral artery as described above. Plantar arch
The upper and lower ends of the profunda femoris both lie on The plantar arch can be marked by a line drawn across the
this line: the upper end is 3.5 cm below the midinguinal point, sole joining the termination of the lateral plantar artery to
and the lower end is 10 cm below the midinguinal point. the point of termination of the dorsalis pedis artery (see note
above).
Popliteal artery
This artery is marked on the posterior aspect (i.e. over the Femoral vein
popliteal fossa). The upper end of the artery (first point) lies at First mark the femoral artery. Now mark the vein alongside
the junction of the middle and lower-thirds of the back of the the artery so that its upper end is medial to the artery, and its
thigh, 2.5 cm medial to the midline. The second point should lower end is just lateral to the artery.
be taken at the level of the knee joint, in the midline. The third Popliteal vein
point (lower end) lies over the middle of the back of the leg at First mark the popliteal artery. Draw the vein so that its upper
the level of the tibial tuberosity. The artery is marked by joining end is lateral to the artery and lower end medial to the artery.
these three points. The vein gradually crosses behind the artery.
Posterior tibial artery Great saphenous vein
This artery is marked on the back of the leg. Its upper end lies It begins over the medial part of the dorsum of the foot and
over the middle of the back of the leg at the level of the tibial passes upwards in front of the medial malleolus. It then
tuberosity. Its lower end lies on the posteromedial side of the ascends over the leg passing across the medial surface of
ankle midway between the medial malleolus and the the tibia, and higher up along its medial border, to reach the
tendocalcaneus. posteromedial aspect of the knee. It then runs upwards across
Anterior tibial artery the medial side of the thigh to reach the saphenous opening.
This artery is marked on the front of the leg. Its upper end lies (Remember that the centre of the saphenous opening is 4 cm
about 2.5 cm medial to the head of the fibula. The lower end below and lateral to the pubic tubercle).
lies in front of the ankle midway between the medial and lateral Short saphenous vein
malleoli. The vein begins over the lateral part of the dorsum of the
Dorsalis pedis artery foot. From here the vein ascends behind the lateral malleolus,
Its upper end lies in front of the ankle midway between the and up the back of the leg, to reach the centre of the popliteal
fossa.
malleoli. It terminates at the proximal end of the space between
the first and second metatarsal bones. Femoral nerve
The nerve is marked as a short vertical line (2.5 cm or 1"
Medial plantar artery
long) beginning 1.2 cm (half inch) lateral to the midinguinal
It begins on the posteromedial side of ankle midway between
point.
the medial malleolus and the tendo-calcaneus. From here draw
a line over the sole to the cleft between the great toe and Sciatic nerve
second toe. The proximal half of this line represents the Draw a line connecting the posterior superior iliac spine and
position of the artery. the ischial tuberosity. Take a point (x) 2.5 cm lateral to the
middle of this line. This point lies over the upper end of the reach the neck of the fibula. Here the nerve turns forwards
nerve. Next take a point (y) midway between the ischial and downwards to reach the lateral side of the neck of the
tuberosity and the greater trochanter. Join points x and y with a fibula. It ends here by dividing into the deep and superficial
slight convexity to the lateral side. From point y carry the line peroneal nerves.
downwards to the upper end of the popliteal fossa (at the level
Deep peroneal nerve
of the junction of the middle and lower-thirds of the thigh,
Its upper end corresponds to the lower end of the common
midway between its medial and lateral margins). The nerve ends
peroneal nerve (lying lateral to the neck of the fibula). The
here by dividing into the tibial and common peroneal nerves.
lower end of the nerve lies in front of the ankle midway
Tibial nerve between the medial and lateral malleoli.
The upper end of this nerve corresponds to the lower end of the
Superficial peroneal nerve
sciatic nerve. The nerve runs vertically to the lower angle of
Its upper end lies at the same point as that of the deep
the popliteal fosssa (that corresponds to a point on the back of
peroneal nerve (lateral to the neck of the fibula). The lower
the leg, at the level of the tibial tuberosity, midway between the
end lies on the lateral side of the leg at the junction of its
medial and lateral margins). From here the nerve runs
middle and lower-thirds.
downwards and medially to reach the interval between the
medial malleolus and the tendocalcaneus. Medial and lateral plantar nerves
These nerves accompany the corresponding arteries and can
Common peroneal nerve
be marked as described for the arteries.
The upper end of this nerve corresponds to the lower end of
the sciatic nerve. The nerve runs downwards and laterally to
CLINICAL CORRELATIONS
Some congenital anomalies of the lower limb Fracture of the neck of the femur is common in old persons..
It can occur as a result of slight injury. Fracture of the neck
1. Congenital deformities are frequently seen in the region of compromises blood supply to the head of the femur. Lack of
the ankle and foot, and are of various types. The general term adequate blood supply can be responsible for delayed union,
talipes is applied to them. In the most common variety of or non-union. However, if blood supply of the head is
deformity the foot shows marked plantar flexion (= equinus: insufficient to maintain its viability there is avascular
like the foot of a horse), and inversion (= varus: inward bend). necrosis of the head. Such patients can have much relief by
Hence, this condition is called talipes equino varus. In lay mans complete hip replacement using metallic implants.
parlance it is called club foot. The condition may be unilateral Fractures can also occur through the shaft, or through the
or bilateral. femoral condyles.
2. The medial longitudinal arch of the foot may be poorly
developed (pes planus or flat foot). A flat footed person may Fractures of the patella
have difficulty in walking long distances, or in running. The patella can be fractured by direct injury. The patella can
3. The hip joint is a common site of congenital dislocation also be fractured by sudden violent contraction of the
occurring as a result of imperfectly formed bone ends. quadriceps femoris.
Fractures of the tibia and fibula
The tibia may be fractured through a condyle (usually
Fractures lateral), through the shaft, through the medial malleolus. The
Fractures of the femur fibula may be fractured through the shaft or through the
The femur may be fractured (1) through the neck; (2) through lateral malleolus.
the trochanteric region; (3) through the shaft (at any level); (4) Injuries to the tibia and fibula in the region of the ankle are
just above the condyles (supracondylar fracture); or (5) through referred to as Potts fracture.
a condyle. Blood supply to the tibia is poor at the junction of the upper
two-thirds and lower one-third of the shaft. Fractures here
may therefore show delayed union or non-union.
161
162
Fractures of the bones of the foot the injection displays the branches of the artery into which
These are not common. Occasionally the calcaneus and, less the dye is injected. The procedure is called angiography.
commonly, the talus may be fractured. Points of narrowing of the artery can be detected.
Metatarsal bones and phalanges of the foot can be fractured
Venous return from the lower limbs
by dropping of a heavy object on the foot. The fifth metatarsal
Venous blood from the lower limbs has to ascend to the heart
bone can be fractured through its base as a result of a twisting against gravity. This ascent depends on the following
injury of the foot. Metacarpal bones can also be fractured by factors.
the stress of prolonged walking or running (fatigue fracture, a. The atmospheric pressure within the thoracic cavity is
stress fracture, or March fracture). negative and this tends to suck blood in the venous system
towards the heart.
Dislocations b. The veins of the lower limb are provided with numerous
valves along their course. The valves, when competent, allow
Dislocation may take place at the hip joint, the knee joint or the blood flow only towards the heart.
ankle joint. The patella can be dislocated laterally. c. The leg and thigh are enclosed in a tight sleeve of deep
fascia. The deep veins lie within the sleeve, along with
arteries and muscles. The superficial veins lie outside the
Injuries to Ligaments sleeve. Perforators penetrate the sleeve. When muscles
contract they increase in thickness raising the pressure within
Ligaments around the knee or ankle joint can be injured. The the sleeve. This pressure compresses the deep veins and,
menisci of the knee joint can be torn. because of the presence of valves, blood is pushed towards
the heart. In this way muscular contraction acts as a pump
Some infections that helps venous return from the lower limbs. The muscles
of the calf are specially important in this regard. Venous

1. Synovial sheaths around the ankle can undergo infection return through deep veins is also aided by pulsations of
and inflammation. adjoining arteries.
2. Bursae (e.g., over ischial tuberosity, or around knee joint) Varicose veins
can be inflamed because of repeated friction. In some persons veins over the calf (or sometimes over other
3. Ingrowing toe nail regions) become dilated and tortuous. These are called
In this condition, seen in the big toe, one end of the distal edge varicose veins. The basic cause of the development of
of the nail grows into soft tissue causing pain and setting up varicose veins is incompetence of valves at the termination
inflammation. of superficial veins and in perforators. Blood then leaks from
4. Paronychia deep veins (with high pressure) to superficial veins.
This is infection of soft tissue in relation to a nail bed. The site of the leak can be determined using the
5. Deep plantar abscess Trendelenburg test as follows: The patient is asked to lie
The space deep to the plantar aponeurosis may be infected. down on his back and raise the leg. This empties the
superficial veins. The sphenofemoral junction is closed by
pressure of the thumb. The patient is now made to stand up.
Some Disorders of Arteries and Veins
If the veins are normal the veins should not refill until the
pressure is released. Immediate filling of the veins from
Severe narrowing of arteries of the lower limb, with an
above indicates that the valve at the sphenofemoral junction
inadequate collateral circulation, can lead to pain in muscles.
is not competent. Slow filling from below indicates the
The pain is brought on by walking and disappears with rest. presence of an incompetent perforator below the level of
As the pain appears every time the person takes a few steps it the pressure.
is called intermittent claudication (Claudication = limping).
Some additional facts about the long saphenous vein
Thromboangiitis obliterans (Buergers disease) Segments taken from the long saphenous vein are used as
In this condition arteries of the leg and foot are narrowed, and grafts in coronary bypass surgery (i.e. for replacing a blocked
there is thrombophlebitis of veins. The condition is seen only segment of a coronary artery).
in male smokers. Symptoms of arterial insufficiency are present.
Gangrene of toes can occur.
Some conditions involving Nerves
Use of femoral artery for arteriography
The femoral artery is used for inserting a catheter that is passed Pressure on the lumbosacral nerve roots is often produced
through the external iliac and common iliac arteries into the by prolapse of an intervertebral disc. Typically, the condition
aorta. It can then be passed into one of the branches of the causes severe pain that begins in the gluteal region and
aorta. The catheter can be used for injecting a suitable contrast radiates down the back of the thigh and leg to reach the foot
medium into the artery. A radiograph taken immediately after (sciatica).
Femoral nerve
Injury to the femoral nerve can take place through stab or
gunshot wounds. The quadriceps femoris is paralysed. There is
loss of sensation in the area supplied by the saphenous nerve.
Sciatic nerve
The sciatic nerve can be injured by carelessly given
intramuscular injections in the gluteal region. (This can be
avoided by giving injections only in the upper and lateral part
of the gluteal region). The nerve can also be injured in fractures
of the pelvis and dislocations of the hip joint.
Injury to the nerve paralyses muscles of the back of the thigh
(hamstrings), and all muscles of the leg and foot. The foot hangs
downwards (by its own weight): the condition is called foot
drop. Fig. 15.1. Scheme to show formation of
Common peroneal nerve the femoral sheath.
This nerve is commonly injured as it is superficially placed. It
can be involved in fractures of the upper end of the fibula.
Muscles of the anterior and lateral compartments of the leg are
paralysed. There is foot drop. Because of paralysis of the
peronei (that are everters) the foot may be inverted. There is
loss of sensation in the areas of skin supplied by the deep
peroneal and superficial peroneal nerves.
FEMORAL SHEATH, FEMORAL CANAL

AND FEMORAL HERNIA
Fig. 15.2. Scheme to show the location of
the femoral canal. Note boundaries of
In the upper part of the femoral triangle the femoral artery and femoral ring.
vein are enclosed in a funnel-like covering of fascia that is called
the femoral sheath. The sheath is formed by prolongations of
fascia from within the abdomen. The anterior wall is formed
by the fascia transversalis (that lines the inner aspect of the
anterior abdominal wall). The posterior wall is formed by the
fascia iliaca (fascia covering the ilio-psoas muscle) (Fig. 15.1).
The cavity within the femoral sheath is divisible into three parts.
The lateral part contains the femoral artery (Fig. 15.2). (It also
contains the femoral branch of the genitofemoral nerve). The
middle part contains the femoral vein. The medial part is
occupied only by some lymph nodes and some areolar tissue:
this part is called the femoral canal.
The upper end of the femoral canal is called the femoral ring.
The ring is bounded anteriorly by the inguinal ligament,
medially by the free margin of the lacunar ligament, laterally
by the femoral vein, and posteriorly by the pectineus and its
fascia (Fig. 15.2). The extraperitoneal tissue filling the femoral Fig. 15.3. Pubic region seen from
ring is called the femoral septum. The importance of the femoral behind to show the course of an
canal is that it can be site of hernia. abnormal obturator artery in relation to
In case of strangulation of a femoral hernia the surgeon has to the femoral canal. The usual position of
this artery is shown at x. When the
enlarge the femoral ring. This enlargement can only be done
artery is at position y it can be damaged
into the medial wall (lacunar ligament). Cutting of the lacunar
if the femoral canal (a) is widened by
ligament can sometimes result in serious bleeding caused by incision into the medial wall. b=femoral
an abnormal obturator artery. vein; c= junction of external iliac artery
with femoral artery.
163
164
Abnormal obturator artery and femoral canal
The obturator artery lies within the pelvis and is a branch of This abnormal artery is closely related to the femoral ring.
the internal iliac artery. It gives off a pubic branch that Usually it lies in the lateral wall of the ring, near the femoral
anastomoses with the pubic branch of the inferior epigastric vein. Sometimes, however, it lies medial to the ring, along
artery (a branch of the external iliac artery). Sometimes this the edge of the lacunar ligament (Fig. 15.3). When the
anastomosis is very large and blood flow into the obturator abnormal artery is in this position it is likely to be cut when
artery is mainly through this anastomosis: this is referred to as the ring is enlarged medially to relieve a strangulated femoral
abnormal obturator artery. hernia.
BONES AND JOINTS OF THE THORAX
PART 3:THORAX
16 : Bones and Joints of the Thorax
BONES OF THE THORAX
the xiphoid process. The side walls of the thorax are formed
INTRODUCTION
by twelve ribs on either side (Fig. 16.2).
Each rib is a long curved bone that is attached posteriorly to
the vertebral column. It curves round the sides of the thorax.
Skeleton of the thorax
Its anterior end is attached to a bar of cartilage (the costal
cartilage) through which it gains attachment to the sternum.
The skeleton of the thorax forms a bony cage that protects the
This arrangement is seen typically in the upper seven ribs
heart, the lungs, and some other organs (Fig. 16.1). Behind, it
(true ribs). The 8th, 9th and 10th costal cartilages do not
is made up of twelve thoracic vertebrae. In front, it is formed
reach the sternum, but end by getting attached to the next
by a bone called the sternum. The sternum consists of an upper
higher cartilage (false ribs). The anterior ends of the 11th
part, the manubrium; a middle part, the body; and a lower part,
and 12th ribs are free: they are, therefore, called floating
ribs.
The Vertebral Column
Below the skull the central axis of the body is formed by the
backbone or vertebral column (Fig. 16.3). The vertebral
column is made up of a large number of bones of irregular
shape called vertebrae. There are seven cervical vertebrae
in the neck. Below these there are twelve thoracic vertebrae
that take part in forming the skeleton of the thorax. Still
Fig. 16.1. Skeleton of the thorax as seen from the front. Fig. 16.2. Section across thorax.
165
166
lower down there are five lumbar vertebrae that lie in the posterior wall of the
abdomen. The lowest part of the vertebral column is made up of the sacrum,
that consists of five sacral vertebrae that are fused together; and of a small
bone called the coccyx. The coccyx is made up of four rudimentary vertebrae
fused together. There are thus thirty three vertebrae in all. Taking the sacrum
and coccyx as single bones the vertebral column has twenty six bones.
STRUCTURE OF A TYPICAL VERTEBRA
The parts of a typical vertebra are best seen by examining a vertebra from the
mid-thoracic region. Such a vertebra is seen from above in Figure 16.4 and from Fig. 16.3.
behind in figure 16.5. A lateral view of two such vertebrae is shown in figure Skull and
vertebral
16.6. The following parts can be distinguished.
column.
1. The body lies anteriorly. It is shaped like a short cylinder, being rounded
from side to side, and having flat upper and lower surfaces that are attached to
those of adjoining vertebrae through intervertebral discs (Fig. 16.6).
2. The pedicles (right and left) are short rounded bars that project backwards,
and somewhat laterally, from the posterior part of the body.
3. Each pedicle is continuous, posteromedially, with a vertical plate of bone
called the lamina. The laminae of the two sides pass backwards and medially
to meet in the middle line. The pedicles and laminae together constitute the
vertebral arch.
4. Bounded anteriorly by the posterior aspect of the body, on the sides by the
pedicles, and behind by the laminae, there is a large vertebral foramen. Each
vertebral foramen forms a short segment of the vertebral canal that runs through
the whole length of the vertebral column and transmits the spinal cord.
5. Passing backwards (and usually downwards) from the junction of the two
laminae, there is the spine (or spinous process).
ESSENTIALS OF ANATOMY : THORAX
6. Passing laterally (and usually somewhat downwards) from the junction of

each pedicle and the corresponding lamina there is a transverse process. The
spinous and transverse processes serve as levers for muscles acting on the
vertebral column.
When the vertebrae are viewed from the lateral side (Fig. 16.6) we see certain
additional features.
Fig. 16.4. Typical vertebra seen from above. Fig. 16.5. Typical vertebra seen from behind.
7. Projecting upwards from the junction of
the pedicle and the lamina there is, on either
side, a superior articular process; and
projecting downwards there is an inferior
articular process. Each process bears a
smooth articular facet: the superior facet is
directed posteriorly and somewhat laterally,
and the inferior facet is directed forwards
and some what medially.
The superior facet of one vertebra
articulates with the inferior facet of the
vertebra above it. Two adjoining vertebrae,
therefore, articulate at three joints: two
between the right and left articular processes
and one between the bodies of the vertebrae
(through the intervertebral disc).
8. In Figure 16.6, note that the pedicle is
much narrower (in vertical diameter) than
the body and is attached nearer its upper
Fig. 16.6. Typical vertebrae seen from the side.
border. As a result there is a large inferior (Costal facets are present in thoracic vertebrae only)
vertebral notch below the pedicle. The
notch is bounded in front by the posterior
surface of the body of the vertebra, and behind by the inferior a. The transverse process of a cervical vertebra is pierced
articular process. Above the pedicle there is a much shallower by a foramen called the foramen transversarium (Fig. 16.7).
superior vertebral notch. The superior and inferior notches of b. The thoracic vertebrae bear costal facets for articulation
adjoining vertebrae join to form the intervertebral foramina with ribs. These are present on the sides of the vertebral
that give passage to spinal nerves emerging from the spinal bodies and on the transverse processes (Fig. 16.6).
cord. c. A lumbar vertebra (Fig. 16.8) can be distinguished by the
fact that it neither has foramina transversaria nor does it
Distinguishing Features of Typical Cervical, bear facets for ribs. It is also recognized by the large size of
Thoracic and Lumbar Vertebrae its body.
The cervical, thoracic and lumbar vertebrae can be easily Some additional facts about typical thoracic
distinguished from one another because of the following vertebrae
characteristics.
1. In the thoracic region the head of a typical rib articulates
with the sides of the bodies of two vertebrae (Fig. 16.9).
Fig. 16.7. Typical cervical vertebra seen from above. Fig. 16.8. Typical lumbar vertebra seen from above.
167
168
For this purpose each side
of the body of a typical
thoracic vertebra bears
two costal facets, upper
and lower, adjoining its
upper and lower borders
(Fig. 16.6). Each of these is
really only half a facet
(demifacet), the other half
being on the adjoining
vertebra. The upper facet
is large and articulates with
the numerically cor-
responding rib. The lower, Fig. 16.9. Numerical relationship Fig. 16.10. First thoracic vertebra seen
smaller facet articulates of ribs and thoracic vertebrae. from above.
with the next lower rib.
2. The transverse processes of a typical thoracic vertebra are

large (Fig. 16.4). They are directed backwards and laterally.
Each process lies just behind the corresponding rib and bears
a prominent facet for articulation with the rib.
3. In the thoracic region the articular facets are flat, and are
almost vertical. The superior facets face backwards, slightly
upwards and slightly laterally (Fig. 16.5). The inferior facets
face forwards, slightly downwards and slightly medially.
First Thoracic Vertebra
This vertebra can be distinguished from a typical thoracic
vertebra because of the following features (Fig. 16.10). It has
a small body similar in shape to that of a cervical vertebra.
The superior costal facets (on the body) are usually complete
as the first rib articulates wholly with this vertebra. The spine
is long and horizontal.

Tenth, Eleventh and Twelfth Thoracic Vertebrae
These vertebrae can be distinguished from typical thoracic
vertebrae by the fact that they have only one costal facet on
each side of the body. The tenth vertebra (normally) has a costal
facet on each transverse process. The transverse process is large
as in typical thoracic vertebrae. Facets on the transverse
processes are absent in the eleventh and twelfth vertebrae that
have small transverse processes.
THE STERNUM
The sternum lies in the anterior wall of the thorax, in the midline
(Fig. 16.12). It is elongated vertically. It is flat and has anterior Fig. 16.11. Tenth, eleventh and twelfth thoracic
and posterior surfaces. Although it is (by convention) spoken vertebrae seen from the lateral side.
of as a single bone it consists of three separate parts. From
above downwards these are the manubrium, the body, and the
xiphoid process. costal cartilage is attached to the lateral margin of the
The manubrium joins the body at the manubriosternal joint. manubrium. The second costal cartilage is attached partly
The body joins the xiphoid process at the xiphisternal joint. to the manubrium, and partly to the upper end of the body.
The anterior ends of the upper seven costal cartilages are The third, fourth, fifth and sixth cartilages are attached to
attached to the right and left margins of the sternum. The first the lateral margin of the body. The seventh costal cartilage
THE RIBS
TYPICAL RIBS
The ribs are curved long bones that form the side walls of
the thorax (Figs 16.13 and 16.14). There are twelve ribs on
either side. They vary considerably in length: the seventh
rib is the longest, those above and below it becoming
progressively shorter. Adjacent ribs are separated by
intercostal spaces.
The ribs are attached behind to the thoracic vertebrae. The
anterior ends of the upper seven ribs are attached to bars of
Fig. 16.12. Sternum and costal cartilages

seen from the front.
is attached to the lateral side of the xiphisternal joint. The

area of attachment of each cartilage is marked by a notch on
the lateral margin of the sternum.
The upper border of the manubrium articulates, on either side,
with the medial end of the clavicle to form the
sternoclavicular joint. It bears prominent clavicular notches
for this purpose. Between the right and left clavicular notches
there is a median depression called the jugular or suprasternal
notch. The manubrium and the body of the sternum lie at a
slight angle to one another, and because of this fact the
manubriosternal junction projects forwards. This projection
forms a surface landmark and is often referred to as the sternal
angle. The sternal angle forms a useful guide in identifying
individual costal cartilages and ribs in the living subject.
The body of the sternum consists of four parts or sternebrae
that are united by cartilage up to the age of puberty, but fuse
thereafter to form a single bone. The lines of fusion can be
seen on the anterior aspect of the bone.
The manubriosternal joint is a symphysis. The xiphoid process
is cartilaginous in children, but undergoes ossification in the Fig. 16.14. Section across
adult. The junction of the first costal cartilage with the shaft of typical rib.
manubrium is a synchondrosis. The other sternocostal joints
usually have a joint cavity (i.e. they are synovial joints).
The sternum gives attachment to many muscles belonging to

the upper extremity, the head and neck, the thorax and the
abdomen. These will be studied in appropriate sections.
Fig. 16.13. Typical rib seen from below.
169
170
cartilage (costal cartilages) through which they gain
attachment to the sternum. They are called true ribs. The
anterior ends of the eighth, ninth and tenth ribs also end in
costal cartilages. These cartilages do not reach the sternum,
but end by gaining attachment to the next higher costal
cartilage. They are, therefore, called false ribs. The anterior
ends of the eleventh and twelfth ribs have small pieces of
cartilage attached to their ends: these ends are free and these
ribs are, therefore, called floating ribs.
At the posterior end of a typical rib we see a head, a neck and
a tubercle. The head articulates partly with the superior costal
facet on the body of the numerically corresponding vertebra;
and partly with the inferior costal facet on the next higher
vertebra (Fig. 16.9). It is also attached to the intervertebral
disc. The part of the rib immediately lateral to the head is called
the neck. It lies in front of the transverse process of the
numerically corresponding vertebra. It has a sharp upper border
called the crest of the neck. Just lateral to the neck the posterior
aspect of the rib presents an elevation called the tubercle. The
tubercle has a medial articular part which bears a facet that
articulates with the costal facet on the transverse process of
the corresponding vertebra; and a lateral part that is rough for
attachment of ligaments.
The anterior end of the rib shows a cup shaped depression for
attachment of the costal cartilage.
The part of the rib between the anterior and posterior ends is Fig. 16.16. Second rib seen from above.
called the shaft. It is curved like the letter C. The shaft is flat:
it has inner and outer surfaces, and upper and lower borders.
The upper border is rounded. The lower border is sharp. The
ATYPICAL RIBS
inner surface is concave. Just above the lower border the inner
surface shows a costal groove running along the length of the
shaft. The external surface of the shaft is convex. A short The First Rib
distance lateral to the tubercle the rib appears to be bent: this
point is, therefore, called the angle. The first rib (Fig. 16.15) can be distinguished by its small
size, and by the fact that its shaft is broad and flat having
upper and lower surfaces (instead of outer and inner), and
inner and outer borders (instead of upper and lower). The
head has a single facet as this rib articulates only with the
first thoracic vertebra. The tubercle is prominent and
coincides with the angle. The upper surface of the shaft has
two shallow, but wide grooves (for the subclavian artery and
vein). Near the inner border of the rib these two grooves are
separated by a prominence called the scalene tubercle. The
lower surface of the rib is smooth and does not have a costal
groove.
The Second Rib
The second rib can be distinguished from a typical rib by

the fact that when placed on a flat surface the entire rib
touches it. (In a typical rib the posterior end is lifted off the
surface). The external surface is directed outwards and
upwards (Fig. 16.16) (and not directly upwards as in the
first rib). Near its middle it has a prominent rough area. The
inner surface points medially and downwards. A short costal
Fig. 16.15. First rib seen from above.
groove is present on its posterior part.
because each of these ribs articulates only with the
corresponding vertebra. In other respects the tenth rib is
similar to a typical rib. The eleventh and twelfth ribs can be
distinguished from the tenth rib as they are relatively short,
have no necks or tubercles, and their ends are tapering
(in contrast to the broad anterior ends of typical ribs) (Fig.
16.17).
THE COSTAL CARTILAGES
These are bars of hyaline cartilage. The lateral end of each

costal cartilage is attached to the anterior end of one rib.
The medial ends of the upper seven costal cartilages are
attached to the lateral margin of the sternum. The first costal
cartilage is attached to the lateral margin of the manubrium
sterni. The medial end of the second cartilage is attached
partly to the manubrium and partly to the first sternebra.
The 3rd, 4th and 5th cartilages gain attachment to the lateral
edge of the sternum at the points of junction of sternebrae;
Fig. 16.17. Twelfth rib seen from the front. the 6th on the fourth sternebra; and the 7th at the junction of
the fourth sternebra and the xiphoid process.
The medial ends of the 8th, 9th and 10th costal cartilages
are connected to the next higher costal cartilage. The
The Tenth, Eleventh and Twelfth Ribs
cartilages of the 11th and 12th ribs are small and are attached
to the tips of the ribs. Their lateral ends are free.
These ribs can be distinguished from typical ribs as each of
them bears only a single articular facet on the head. This is so
JOINTS OF THE THORAX
The joints between the bones of the thorax are: The bodies, laminae, transverse processes and spinous
1. Intervertebral joints connecting adjacent thoracic vertebrae. processes of adjoining vertebrae are also united by a number
2. Sternal joints between different parts of the sternum. of ligaments.
3. Costovertebral joints between ribs and vertebrae.
4. Costochondral joints between ribs and costal cartilages.
Joints between vertebral bodies
5. Sternocostal joints or chondrosternal joints between costal
cartilages and the sternum.
The lower surface of the body of one vertebra articulates
6. Interchondral joints amongst the lower costal cartilages.
with the superior surface of the body of the next vertebra.
The surfaces are covered by thin layers of hyaline cartilage.
The two plates of hyaline cartilage are united to each other
by a thick intervertebral disc (Fig. 16.18).
INTERVERTEBRAL JOINTS
Intervertebral discs
Adjoining vertebrae are connected to one another through three
main joints. There is a median joint between the vertebral Intervertebral discs are the chief bonds of union between
bodies, and two joints (right and left) between the articular adjoining vertebrae. Each disc consists of an outer part called
processes.
171
172
the annulus fibrosus, and an inner part the nucleus pulposus.
The superficial part of the annulus fibrosus is made up of collagen
fibres. Its deeper part is of fibrocartilage.
In the young the nucleus pulposus is soft and gelatinous, but this
material is gradually replaced by fibrocartilage.
The intervertebral discs are very strong in the young. With advancing
age, however, the annulus fibrosus becomes weak and it then becomes
possible for the nucleus pulposus to burst through it. This is called
prolapse of the disc. A prolapsed nucleus pulposus usually passes
backwards and laterally and may press upon nerve roots emerging
from the spinal cord at that level. Prolapse results in local pain the
back. When nerves are pressed upon there is shooting pain along the
course of the nerve involved. Disc prolapse occurs most frequently
Fig. 16.18. Schematic sagittal section across
in the lumbosacral region and results in pain shooting down the back
vertebral bodies and intervertebral discs.
of the thigh and leg. This is called
sciatica. Prolapse is also frequently seen
in the cervical region.
Intervertebral discs constitute about one
fifth of the length of the vertebral column.
They transmit weight, act as shock
absorbers, and provide resilience to the
spine.
Joints between vertebral articular

processes
Each vertebra has four articular processes

(or zygapophyses): right and left superior,
and right and left inferior. Each process
bears an articular facet. The inferior
articular facets of one vertebra articulate

with the superior articular facets of the
next lower vertebra forming a series of
zygapophyseal joints.
Ligaments connecting adjacent

vertebrae
Adjoining vertebrae are connected by

numerous ligaments. These are as follows
Fig. 16.19. Scheme to show ligaments connecting adjacent vertebrae. (Fig. 16.19).
1. The anterior longitudinal ligament passes from the anterior surface

of the body of one vertebra to that of another.
2. The posterior longitudinal ligament passes from the posterior
surface of the body of one vertebra to that of another. This ligament
lies within the vertebral canal.
3. Intertransverse ligaments interconnect adjacent transverse
processes.
4. Interspinous ligaments connect adjacent spinous processes.
5. Supraspinous ligaments connect the tips of spinous processes.
6. The ligamenta flava (= yellow ligaments) are made up of elastic
Fig. 16.20. Schematic coronal section tissue. They pass from the lower border of the lamina of one vertebra
across a costovertebral joint. to the upper border of the lamina of the next lower vertebra.
JOINTS OF THE STERNUM
We have seen that the sternum consists of three parts, the

manubrium, the body, and the xiphoid process. These three
elements are connected by joints.
Manubriosternal joint
The lower end of the manubrium is attached to the body of the

sternum at the manubriosternal joint. This joint is a symphysis.
The bony surfaces are covered by thin layers of hyaline cartilage
that are connected to each other by fibrocartilage. Bony union
between the two bones takes place in many individuals after Fig. 16.21. Schematic section across the
the age of 30. posterior part of a rib to show costovertebral
and costotransverse joints.
Xiphisternal joint
capsule (See Fig. 29.5). The joint is strengthened by the
This joint is a symphysis, but the two bones generally undergo following ligaments (Figs 29.6 and 29.7).
bony union by the age of 40 years. 1. The lateral costotransverse ligament is attached laterally
to the non-articular part of the tubercle of the rib; and medially
to the tip of the transverse process.
2. The superior costotransverse ligament passes from the
JOINTS OF RIBS WITH upper border of the neck of a rib to the lower border of the
VERTEBRAL COLUMN transverse process of the next higher vertebra.
3. The costotransverse ligament (or inferior costotransverse
ligament) passes from the posterior surface of the neck of
the rib to the front of the transverse process of the
Costovertebral joints corresponding vertebra.
These joints (also called costocorporeal joints) unite the

heads of ribs to the sides of the vertebral column. The head
of a rib bears a facet that is divided into upper and lower parts
by a ridge. The lower part of the facet articulates with the
demifacet on the superior border of the body of the
numerically corresponding vertebra. The upper part of the
facet articulates with the lower demifacet on the next higher
vertebra. The ridge separating the facets is attached to the
intervertebral disc through an intra-articular ligament which
divides the joint cavity into upper and lower parts.
The joint is enclosed in a capsule that is strengthened in
front by fibres that radiate from the head of the rib to the two
vertebrae and to the intervertebral disc. These fibres constitute
the radiate ligament (or triradiate ligament).
Costovertebral joints of the 1st, 10th, 11th and 12th ribs are
atypical in that these ribs articulate only with the
corresponding vertebrae.
Costotransverse joint
A short distance lateral to the head, each rib bears a tubercle

that is divisible into a medial articular part and a lateral non-
articular part. The medial part bears a facet that articulates
with a facet on the front of the transverse process of the Fig. 16.22. Some ligaments of costovertebral and
corresponding vertebra. The joint surfaces are enclosed in a costotransverse joints seen from the front.
173
174
JOINTS BETWEEN RIBS, COSTAL MOVEMENTS OF RIBS
CARTILAGES AND STERNUM
The movements taking place at the joints of the thorax allow
for rhythmic expansion and contraction of the thoracic wall
Costochondral joints
during respiration. The precise nature of the movements is
complex and differs in different ribs, but the two fundamental
The anterior end of each rib bears a depression into which the
movements to be understood are as follows:
rounded lateral end of a costal cartilage is fixed. The two are
held in position by continuity of the periosteum of the rib with
a. The anterior ends of the ribs can move up or down by
the perichondrium of the cartilage.
rotation at the costovertebral and costotransverse joints.
During inspiration the anterior end moves upwards in an
Chondrosternal joints arc. This increases the anteroposterior diameter of the thorax.
These are joints between the (medial ends of) the 1st to 7th b. The second movement of the ribs occurs on an axis that is
costal cartilages and the sternum. The first costal cartilage is roughly anteroposterior. In expiration the middle of the rib is
united to the manubrium through a plate of fibrocartilage. lower than its ends. In inspiration it is raised (like a bucket
The joints between the 2nd to 7th costal cartilages and the handle). This increases the transverse diameter of the thorax.
sternum are synovial joints. They are held together by During quiet breathing the movements of the ribs described
continuity of perichondrium and periosteum. They are above are produced by intercostal muscles. Other muscles
strengthened anteriorly and posteriorly by fibres that radiate attached to the ribs come into play in deep inspiration.
from the costal cartilage on to the sternum. Remember that the most important role in respiration is that
of the diaphragm.
Interchondral joints
The 6th to 9th costal cartilages come into contact with one
another and form a number of small interchondral synovial
joints.
17 : Walls of the Thorax
beyond which they are replaced by the posterior intercostal

MUSCLES OF THORAX
membranes. The external intercostals reach the costo-
transverse ligaments posteriorly, but they are deficient in
front: between the costal cartilages they are replaced by the
Intercostal Muscles
anterior intercostal membranes.
The innermost layer is made up of three distinct muscles as
The intercostal muscles fill the intervals between adjacent ribs.
follows.
They are arranged in three layers: external, internal and
innermost (Fig. 17.3). There being twelve ribs on either side, a. The intercostalis intimi (or innermost intercostal muscle)
and eleven intercostal spaces between them, we have eleven is seen only in the middle two fourths of the intercostal
sets of external and internal intercostal muscles. space (Fig. 17.3B).
The innermost layer is often deficient in the upper intercostal b. The subcostales are present only over the posterior part
spaces. Each intercostal space extends, posteriorly, up to the of the intercostal space (near the angles of the ribs).
superior costotransverse ligaments (extending between the c. In the anterior part of the thoracic wall the innermost layer
neck of the rib and the transverse process of the vertebra next is formed by a muscle called the sternocostalis.
above it). Anteriorly the space extends to the sternum. The The intercostal nerves and vessels run between the muscles
internal intercostal muscles do not extend over the entire length of the second and third layer. They supply all the muscles
of the space: anteriorly they extend right up to the sternum, mentioned above. The intercostal muscles are lined on the
but posteriorly they end at the level of the angles of the ribs inside by the costal pleura.
WALLS OF THE THORAX
Attachments of intercostal muscles:
Each external intercostal muscle arises from the lower border of the
rib above, and is inserted into the upper border of the rib below (Fig.
Fig. 17.1. Schematic
17.1). The fibres of the muscle run obliquely from one rib to the other,
section through
the upper attachment being nearer the vertebra and the lower attachment intercostal spaces.
nearer the sternum. Therefore, on the back of the thorax the fibres run The wall is gradually
downwards and laterally (Fig. 17.3A), and on the front of the thorax built up and all
the fibres are directed downwards and medially. Each internal structures present are
intercostal muscle arises from the costal groove of the rib above and is shown only in the
inserted into the upper border of the rib below (Fig. 17.1). Its fibres lowest space.
run at right angles to those of the external intercostal: on the front of
the thorax they pass downwards and laterally.
The innermost intercostal muscles are attached both above and below
to the inner surfaces of adjoining ribs (Fig. 17.1). The direction of
their fibres is the same as that of the internal intercostal. They are
separated from the internal intercostals by the intercostal nerves and
vessels.
The subcostales are well developed only in the lower part of the thorax.
Each muscle arises from the inner surface of a rib near its angle. It runs
downwards crossing two or three intercostal spaces before being
attached to the inner surface of another rib. The direction of the
fibres is the same as that of the internal intercostals (Fig. 17.2).
Actions of intercostal muscles:
The external intercostal muscles are generally regarded as
elevators of ribs, and the internal intercostal muscles as
depressors. However, the role played by these muscles in
respiratory movements is highly controversial. Their main
importance seems to be to provide strong, but elastic, supports
that prevent the thoracic wall from bulging inwards or outwards
as a result of pressure changes associated with inspiration or
expiration.
Nerve Supply:
The intercostal and subcostal muscles are supplied by the
intercostal nerves of the spaces concerned.
Sternocostalis
This muscle is also called the transversus thoracis. The

sternocostalis lies behind the sternum and costal cartilages (Fig.
17.4). It arises from the posterior aspect of (a) the lower one-
third of the body of the sternum, (b) the xiphoid process, and
(c) the adjoining parts of the costal cartilages. From this origin
the fibres pass upwards and laterally to be inserted into the Fig. 17.2. Diagram of the posterior ends of
2nd, 3rd, 4th, 5th and 6th costal cartilages (d). The intercostal some intercostal spaces (internal aspect) to
vessels and nerves lie between the sternocostalis and the internal show the subcostales. Some layers have been
removed from the 2nd and 3rd spaces drawn.
intercostal muscle.
Action:
The muscle depresses the costal cartilages into which it is
inserted.
Nerve supply: Intercostal nerves.
175
176
SOME MUSCLES OF THORAX
SEEN ON THE BACK
In additional to muscles seen in

relation to the intercostal spaces some
small muscles are present on the back,
superficial to the thoracic cage. These
are as follows:
Serratus Posterior Superior
This muscle is present on the back
deep to the trapezius and rhomboideus
muscles. It arises from the lower part
of the ligamentum nuchae, and from
upper few thoracic spines. Its fibres
run downwards and laterally to be
inserted into the 2nd, 3rd and 4th ribs.
Serratus Posterior Inferior
This muscle lies in the back deep to Fig. 17.3. Schematic longitudinal
the latissimus dorsi, and superficial to section along an intercostal space to
show muscles in it.
the thoracolumbar fascia. It arises from
the lower thoracic and upper lumbar
spines. The fibres of the muscle pass
laterally and upwards to be inserted
into the lower four ribs.
Levatores Costarum
The levatores costarum are a series of
twelve small muscles placed on either
side of the back of the thorax just
lateral to the vertebral column
Fig. 17.4. Scheme to show attachments of the

sternocostalis. Fig. 17.5. Scheme to show the levatores costarum
muscles.
WALLS OF THE THORAX
(Fig. 17.5). Each muscle arises from the end of a transverse and from the intervening intervertebral discs. The left crus
process. The fibres pass downwards and laterally to be inserted arises similarly from vertebrae L1 and L2. The medial margins
into rib next below. of the two crura are joined to each other (at the level of the
lower border of vertebra T12) to form the median arcuate
Nerve Supply:
ligament. The descending aorta passes from thorax to
Dorsal rami of thoracic spinal nerves.
abdomen under cover of this ligament. The lateral arcuate
Actions: ligament represents a thickened band of the fascia over the
These muscles elevate the ribs to which they are attached. quadratus lumborum (a muscle in the posterior wall of the
abdomen). It is attached laterally to the twelfth rib and
medially to the transverse process of the first lumbar vertebra.
The medial arcuate ligament is a thickened band of the
THE DIAPHRAGM fascia covering the psoas major. It is attached laterally to
the transverse process of the first lumbar vertebra. Medially
it becomes continuous with the lateral margin of the
The diaphragm is a large muscle that forms a partition between corresponding crus.
the cavities of the thorax and the abdomen. From its extensive origin, described above, the muscular
Attachments of the diaphragm: fibres of the diaphragm run upwards and converge to be
The diaphragm has a more or less circular origin from the inserted on the margins of a large, flat, central tendon that
thoracic outlet (Fig. 17.6). The origin of the diaphragm can be is located just below the pericardium and heart.
divided into sternal, costal and vertebral parts. The sternal part The upper convex part of the diaphragm is called its dome.
consists of two slips, right and left, that arise from the back of The central part of the dome is formed by the central tendon
the xiphoid process. The costal part consists of broad slips one and lies at the level of the xiphisternal joint. It is placed
from the inner surface of each of the lower six ribs and their somewhat lower than the right and left muscular convexities
costal cartilages. (or cupolae). The right cupola is slightly higher than the
The lumbar part consists of two crura (right and left) that arise left because of the presence of the liver below it. The level
from the bodies of lumbar vertebrae; and of fibres that arise of the dome rises and falls with expiration and inspiration
(on either side) from two tendinous arches called the lateral respectively. It is also influenced by posture; being highest
and medial arcuate ligaments (Fig. 17.6). The right crus is larger when the body is supine, intermediate while standing and
than the left: it arises from the bodies of vertebrae L1, L2, L3 lowest while sitting.
Fig. 17.6. Scheme to show attachments of the diaphragm.
177
178
The upper surface of the diaphragm is related to thoracic prevents regurgitation of the contents of the stomach. The
contents including the heart and pericardium in the middle and oesophageal aperture also transmits the right and left gastric
the lungs and pleura on the sides. nerves that are continuations of the vagus nerves. The left
The inferior surface is related to abdominal contents including nerve is placed anteriorly and the right posteriorly.
the peritoneum, the liver, the stomach, the spleen, the right Oesophageal branches of the left gastric artery also pass
and left kidneys and the right and left suprarenal glands. through the oesophageal aperture.
3. The opening for the inferior vena cava lies in the central
Apertures in the diaphragm:
tendon at the level of the eighth thoracic vertebra (lower
Many structures passing from thorax to abdomen (or vice versa)
border). The opening is quadrilateral. The wall of the vena
pass through apertures in (or around) the diaphragm. They can
cava is adherent to the opening: this helps to expand the
be fully understood only after the study of the thorax and
vessel during inspiration and facilitates venous return through
abdomen has been completed. However, they are listed here
the vessel. The vena caval opening also transmits the right
for completeness.
phrenic nerve (Fig. 17.7).
There are three large apertures, one each for the aorta, the
Many other structures pass through small apertures in the
oesophagus and the inferior vena cava, and several smaller
diaphragm. These are:
ones (Fig. 17.7).
Nerves: left phrenic, 8th to 11th intercostal, subcostal,
1. The aortic aperture lies behind the median arcuate ligament,
splanchnic and sympathetic trunk.
and in front of the disc between vertebrae T12 & L1. The aorta,
Blood vessels: Lower intercostal, subcostal, superior
therefore, passes behind the diaphragm rather than through it.
epigastric, musculophrenic; and many small veins.
During inspiration the pull of fibres of the muscle on the median
arcuate ligament ensures that the aorta is not compressed. Actions of the Diaphragm:
The aortic aperture also transmits the thoracic duct (that lies The diaphragm is the chief muscle of respiration. There are
to the right side of the aorta); and sometimes the azygos and two phases of its action. In the first phase it acts from its
hemiazygos veins. origin (the ribs being fixed by other muscles). As a result
2. The aperture for the oesophagus is elliptical in shape. It is the central tendon is pulled downwards increasing the vertical
situated at the level of the tenth thoracic vertebra. It is formed diameter of the thorax. In the second phase, the central tendon
by splitting of the fibres of the right crus a little below their is fixed as described above. The lower ribs are now drawn
attachment to the central tendon. Because the oesophagus is upwards. Through them the sternum is pushed forwards. As
surrounded by muscle it is compressed during expiration: this a result the transverse and
anteroposterior diameters of the thorax
are also increased.
Acting along with the muscles of the

anterior abdominal wall, the diaphragm
helps to increase intra-abdominal
pressure during acts like urination,
defaecation or vomiting. Acts requiring
forcible expulsion of air from the lungs
like sneezing or laughing are preceded
by a deep inspiration (diaphragm)
followed by contraction of the expiratory
muscles.
Nerve supply:
The diaphragm receives a double nerve
supply. Motor innervation is through the
right and left phrenic nerves. The
diaphragm is also supplied by the lower
six intercostal nerves that provide a
sensory supply to the peripheral part of
the muscle.
Fig. 17.7. Schematic diagram to show apertures in the diaphragm. INV=

Intercostal nerve and vessels. v= small vein. r7 to r12= 7th to 12th ribs.
WALLS OF THE THORAX
Fig. 17.9. Scheme to show the origin of the superior
intercostal artery.
Fig. 17.8. Scheme to show course and branches of a

typical posterior intercostal artery. end of the intercostal space. Here they anastomose with
two anterior intercostal arteries (see below).
c. A number of muscular branches supply intercostal
muscles, and some other muscles lying over the thoracic
ARTERIES OF THORACIC WALL wall. The lower two posterior intercostal arteries continue
into the abdominal wall and help to supply it.
d. A lateral cutaneous branch arises about midway between
Posterior Intercostal Arteries the anterior and posterior ends of the intercostal space. It
divides into anterior and posterior branches that supply
The posterior intercostal arteries for the lower nine intercostal skin over the thorax (and part of abdomen).
spaces arise from the back of the thoracic aorta. The e. The second, third and fourth posterior intercostal arteries
corresponding arteries for the first and second spaces arise from give branches to the mammary gland. These are large in
the superior intercostal artery. the female.
f. The right bronchial artery arises from the right third
Each posterior intercostal artery runs backwards on the side of
posterior intercostal artery.
the body of the numerically corresponding vertebra to reach
the corresponding intercostal space. Here it comes to lie in the
costal groove of the rib forming the upper boundary of the Superior Intercostal Artery
intercostal space (Fig. 17.8).
In the space the artery lies between the internal intercostal The importance of this artery is that it gives off the posterior
muscle (second layer) and the innermost intercostal muscle intercostal arteries for the first and second intercostal spaces.
(third layer). It is accompanied by the corresponding vein (that The origin of this artery is shown in Figure 17.9. Note that
lies above it) and by the intercostal nerve (that lies below it). the subclavian artery (lying in the lower part of the neck, in
Each posterior intercostal artery gives off a number of branches front of the cervical pleura) gives off the costocervical trunk.
that are shown in Figure 17.8. This trunk runs upwards in front of the cervical pleura, and
a. Before entering the intercostal space the artery gives off a reaching the neck of the first rib it divides into the superior
dorsal branch that supplies muscles and skin of the back. The intercostal and deep cervical branches.
dorsal branch gives off a spinal branch that supplies the spinal The superior intercostal artery runs downwards behind the
cord and vertebrae. cervical pleura. It descends across the neck of the first rib to
b. The collateral branch arises near the angles of the ribs reach the first intercostal space. Here it gives off the first
concerned. It then runs parallel to the main artery, but along posterior intercostal artery. The artery then descends across
the upper border of the rib below the intercostal space. The the second rib and becomes the second posterior intercostal
main artery and the collateral branch reach near the anterior artery.
179
180
Subcostal arteries
The subcostal arteries correspond to the posterior

intercostal arteries but lie below the twelfth rib. On each
side the artery runs across the lateral side of the twelfth
thoracic vertebra. After a short course in the thorax the
artery enters the abdomen by passing under cover of the
lateral arcuate ligament (Fig. 17.10). Its course in the
abdomen will be studied at a later stage.
The subcostal artery supplies some muscles in the walls
of the thorax and abdomen. The artery gives off a dorsal
branch the distribution of which is similar to that of the
corresponding branches of the posterior intercostal
arteries.
Internal thoracic artery and

Anterior Intercostal arteries
Fig. 17.10. Scheme to show the course of the subcostal artery.
The internal thoracic artery is also called the internal
mammary artery. It arises (in the lower part of the neck)
from the first part of the subclavian artery. It descends
behind the clavicle and behind the first to sixth costal
cartilages (lying about 1 cm lateral to the sternal margin).
It terminates by dividing into the musculophrenic and
superior epigastric arteries. It also gives various other
branches that are as follows (Fig 17.11).
a. Along its course the internal thoracic artery gives off a
series of anterior intercostal arteries. Two arteries are
given off to each of the upper six spaces. Similar branches
to the 7th, 8th and 9th spaces arise from the
musculophrenic branch. In each space the upper of the

two anterior intercostal arteries anastomoses with the
main stem of the posterior intercostal artery; and the lower
anterior intercostal artery anastomoses with the collateral
branch.
The anterior intercostal arteries supply intercostal
muscles, pectoral muscles, breast and skin.
b. The pericardiophrenic branch is given off near the
upper end of the internal thoracic artery. It runs
downwards along the phrenic nerve to reach the
diaphragm. It also gives branches to pleura and
pericardium.
c. The perforating branches pass forwards through the
thickness of the upper five or six intercostal spaces to
supply the pectoralis major muscle and the breast
(specially arteries in the 2nd to 4th spaces). These arteries
are large in the female.
d. The musculophrenic artery is the lateral terminal
branch of the internal thoracic artery. It passes downwards
and laterally deep to the costal margin and enters the
abdominal wall by passing through an aperture in the
diaphragm. It gives off anterior intercostal branches to
the 7th, 8th and 9th intercostal spaces.
e. The superior epigastric artery is the medial terminal Fig. 17.11. Internal thoracic artery and its branches.
branch of the internal thoracic artery. Soon after its origin
its passes from the thorax into the abdomen through the
WALLS OF THE THORAX
interval between the costal and xiphoid origins of thoracic vertebrae. Its upper end turns to the right in front of the body
the diaphragm. Its course in the abdomen will be of the 8th thoracic vertebra and ends by joining the azygos vein (Fig.
considered later. 17.13).
The accessory hemiazygos vein descends vertically on the left side of
the bodies of upper thoracic vertebrae. The lower end of the vein turns
to the right across the front of the 7th thoracic vertebra and ends by
joining the azygos vein.
VEINS OF THE THORACIC WALL
The thoracic wall is drained anteriorly by the internal

thoracic vein and posteriorly by the azygos system
of veins.
Internal thoracic vein
The internal thoracic vein accompanies the

corresponding artery and has tributaries
corresponding to the branches of the artery (See
above).
AZYGOS SYSTEM OF VEINS
The Azygos and Hemiazygos Veins
The azygos vein is present only on the right side. It

begins (in the abdomen) by the union of the lumbar
azygos, the right subcostal and the right ascending
lumbar veins (Fig. 17.12).
The azygos vein enters the thorax by passing behind
the right crus of the diaphragm or through its aortic
orifice. It then ascends vertically along the right side
of the vertebral column up to the level of the fourth
thoracic vertebra (Fig. 17.13). Here it arches
forwards above the root of the right lung and ends
in the superior vena cava.
The hemiazygos vein is present only on the left side.
It is formed in the same manner as the azygos vein.
It ascends on the left side of the bodies of the lower
Fig. 17.12. Scheme to show formation of Fig. 17.13. Azygos and hemiazygos veins. Note the termination of
azygos vein. posterior intercostal veins.
181
182
Posterior Intercostal Veins Near the anterior end of the space the nerve pierces the
internal intercostal muscle and other structures superficial
Each intercostal space is drained by a posterior intercostal to to become the anterior cutaneous nerve of the thorax.
vein which corresponds to the posterior intercostal artery. The In the intercostal space the nerve lies immediately below
termination of these veins is as follows (Fig. 17.13): the intercostal artery.
(1) On either side (right or left) the vein of the first space (called Typical intercostal nerves are distributed to both muscles
the highest intercostal vein) ascends in front of the neck of and skin through a number of branches. The main branches
the first rib, and arches over the cervical pleura to end in the are the collateral branch and the lateral cutaneous branch
corresponding brachiocephalic vein. (Compare its course with (Fig. 13.14). They are both given off near the posterior end
that of the superior intercostal artery). of the intercostal space. The collateral branch runs forwards
(2) The veins of the 2nd and 3rd spaces (and sometimes those in the lower part of the intercostal space. The lateral
of the 4th) join to form the superior intercostal veins. The left cutaneous branch runs along the parent nerve for some
superior intercostal vein runs upwards and forwards on the distance. It then turns laterally and becoming subcutaneous
left side of the arch of the aorta and ends in the left divides into anterior and posterior branches that supply the
brachiocephalic vein. The right superior intercostal vein joins skin over the thoracic wall. Each intercostal nerve gives
the terminal part of the azygos vein. several branches that supply the intercostal muscles. They
(3) On the right side the remaining posterior intercostal veins also supply some other muscles shown in the scheme in
end directly in the azygos vein. Figure 17.15.
(4) On the left side of the veins from the 4th to 8th spaces end
in the accessory hemiazygos vein.
Lower Intercostal Nerves
(5) The veins of the 9th, 10th and 11th spaces (on the left side)
end in the hemiazygos vein.
The initial parts of the seventh, eighth, ninth, tenth and
The subcostal veins are in series with the posterior intercostal
eleventh intercostal nerves resemble those of typical
veins. On the right side they end (as already mentioned) in the
intercostal nerves described above. However, on reaching
azygos vein. On the left side the subcostal vein joins the
the anterior end of the intercostal space concerned each nerve
corresponding ascending lumbar vein to form the hemiazygos
passes deep to the costal margin to enter the abdominal wall,
vein.
where they will be studied later.
NERVES OF THORACIC WALL

VENTRAL RAMI OF THORACIC NERVES
There are twelve pairs of thoracic nerves, each pair

emerging from the vertebral canal below the
corresponding vertebra. Each nerve divides into a
dorsal ramus and a ventral ramus. The dorsal rami pass
backwards and divide into medial and lateral branches
that supply muscles and skin of the back. The ventral
rami are considered below.
Typical Intercostal Nerves
The ventral rami of the thoracic nerves run into the

thoracic wall as the intercostal and subcostal nerves
(Fig. 17.14). There being twelve ribs on either side,
there are eleven intercostal spaces, and each space has
one intercostal nerve. The intercostal nerves are
numbered from above downwards. The twelfth pair of
nerves lie below the twelfth ribs and are called the
subcostal nerves.
The course of the third, fourth, fifth and sixth intercostal
nerves can be regarded as typical. They run forwards
in the intercostal spaces lying between the second and
third layers of muscles. Fig. 17.14. Course and relations of a typical intercostal nerve.
WALLS OF THE THORAX
Fig. 17.16. Fate of ventral rami of the first and second
thoracic nerves.
Second thoracic nerve
The ventral ramus of the second thoracic nerve gives a

contribution to the brachial plexus. Most of it, however,
forms the second intercostal nerve (Fig. 17.16). This nerve
Fig. 17.15. Scheme to show muscles supplied by
ventral rami of thoracic nerves. differs from the typical intercostal nerves described below
only in that its lateral cutaneous branch forms the intercosto-
brachial nerve that enters the upper limb and supplies the
skin on the medial side of the upper part of the arm.
First thoracic nerve

Subcostal nerve
The greater part of the ventral ramus of the first thoracic nerve
ascends into the neck to join the brachial plexus (Figs 17.16) The subcostal nerve is the ventral ramus of the twelfth
and is distributed through it to some muscles and some part of thoracic nerve. Its course is similar to that of the subcostal
the skin of the upper limb. The remaining part of the nerve runs artery. It runs along the lower border of the twelfth rib and
forwards in the first intercostal space as the first intercostal enters the abdomen by passing behind the lateral lumbocostal
nerve. arch. Its further course will be studied in the abdomen.
183
184
18 : The Thoracic Cavity

Trachea, Bronchi and Lungs
the oropharynx (that is continuous with the posterior end
of the oral cavity); and a lower part the laryngopharynx. Air
from the nose enters the nasopharynx and passes down
through the oropharynx and laryngopharynx. Air can also
pass through the mouth directly into the oropharynx and from
there to the laryngopharynx. Air from the laryngopharynx
enters a box like structure called the larynx. The larynx is
placed on the front of the upper part of the neck. Apart from
being a respiratory passage it is the organ where voice is
produced: it is, therefore, sometimes called the voice-box.
Inferiorly the larynx is continuous with a tube called the
trachea that passes through the lower part of the neck into
the upper part of the thorax. At the level of the lower border
of the manubrium sterni the trachea bifurcates into the right
and left principal bronchi, that carry air to the right and left
lungs. Within the lung each principal bronchus divides, like
the branches of a tree, into smaller and smaller bronchi that
ultimately end in microscopic tubes that are called
bronchioles. The bronchioles open into microscopic sac-
like structures called alveoli. The walls of the alveoli contain
a rich network of blood capillaries. Blood in these capillaries
is separated from the air in the alveoli by a very thin
Fig. 18.1 Simplified diagram showing membrane through which oxygen can pass into the blood
intercommunications between the nasal cavities, the and carbon dioxide can pass into the alveolar air.
mouth, the pharynx, the larynx and the oesophagus.
INTRODUCTION TO
THE RESPIRATORY SYSTEM
The respiratory system is meant, primarily, for the

oxygenation of blood. The chief organs of the
system are the right and left lungs. Oxygen
contained in air reaches the lungs by passing
through a series of respiratory passages, that also
serve for removal of carbon dioxide released from
the blood.
The respiratory passages are shown in Figures
18.1 and 18.2. Air from the outside enters the body
through the right and left anterior nares (or
external nares) that open into the right and left
nasal cavities. At their posterior ends the nasal
cavities have openings called the posterior nares
(or internal nares) through which they open into
the pharynx. The pharynx is divisible, from above
downwards, into an upper part the nasopharynx
Fig. 18.2. Larynx, trachea and lungs seen from the front.
(into which the nasal cavities open); a middle part
TRACHEA, BRONCHI AND LUNGS
Fig. 18.3. Transverse section through the thorax showing important contents.
THE THORACIC CAVITY
To understand the arrangement of contents of the thoracic cavity sterni corresponds to the level of the intervertebral disc
we will begin by examining a transverse section through the between T2 and T3).
cavity (Fig. 18.3). First note the shape of the thoracic cavity. It b. The diaphragm is attached anteriorly to the xiphoid
is more or less oval, the transverse diameter being distinctly process, and passes backwards to reach the vertebral column
greater than the anteroposterior diameter. Next, observe that at level T12.
the vertebral column projects forward into the cavity, and that c. The vertical extent of the mediastinum is greater
on each side of it the thoracic cavity extends backwards to the posteriorly than anteriorly (as is true for the thoracic cavity
level of the transverse processes of vertebrae. The backward as well).
extensions of the thoracic cavity, on either side of the vertebral d. The mediastinum can be divided into upper and lower
column, are called the paravertebral grooves. parts by a horizontal plane passing from the lower end of
Now turn to Figure 18.4 which is a coronal section through the the manubrium sterni (sternal angle) to the intervertebral
thoracic cavity. Note the lateral walls formed by ribs and disc between vertebrae T4 and T5.
intercostal muscles; and the dome shaped diaphragm closing The part of the mediastinum lying between this plane and
the cavity inferiorly. the inlet of the thorax is called the superior mediastinum.
In Figures 18.3 and 18.4, you will see that the thoracic cavity Note that the trachea, oesophagus, and several large vessels
can be divided into three parts. To the right and left sides there lie in it.
are large spaces that are almost completely filled by the The part of the mediastinum lying below the superior
corresponding lungs. Separating the spaces for the right and mediastinum is divided into three parts as follows:
left lungs there is a thick median partition that is called the 1. The greater part of the area is occupied by the heart and
mediastinum. The most important structure in the mediastinum by great vessels near it. This part is the middle mediastinum.
is the heart. 2. The part of the mediastinum in front of the heart (is the
In Figure 18.5, we see a sagittal section across the mediastinum. anterior mediastinum. Its most important content is the
Note the following. thymus.
a. The inlet of the thorax slopes downwards and forwards. 3. The part behind the heart is the posterior mediastinum).
(Remember that the level of the upper border of the manubrium Note that its main contents are the aorta and the oesophagus.
185
186
THE TRACHEA
The trachea is a wide tube lying more or less in the

midline, in the lower part of the neck and in the
superior mediastinum of the thorax (Fig. 18.2). The
trachea enters the thorax through its superior aperture.
Its upper end is continuous with the lower end of the
larynx: the junction lies opposite the lower part of
the body of the sixth cervical vertebra.
At its lower end the trachea ends by dividing into the
right and left principal bronchi. The level of
bifurcation corresponds to the lower border of the
manubrium sterni, or to the lower border of the fourth
thoracic vertebra. The lumen of the trachea is kept
patent because of the presence of a series of
cartilaginous rings in its wall. The rings are deficient
posteriorly: hence the posterior part of the wall of
the trachea is flat while the rest of it is rounded.
Important Relations
of the Trachea in the Thorax
The trachea is related to a large number of structures

in the neck and in the thorax. The relations in the Fig. 18.4. Schematic coronal section through thorax to show
neck will be considered later. The relations in the its main contents.
thorax are as follows.
1. Posteriorly the trachea is related to the oesophagus
that runs vertically behind it, and separates it from
the bodies of the upper four thoracic vertebrae. (Figs
18.6 and 18.7).

2. The arch of the aorta lies in close contact with the
trachea near its lower end: it is first anterior to the
trachea and then on its left side (Fig. 18.6).
3. The brachiocephalic trunk is at first in front of the
trachea, but as it passes upwards it reaches the right
side of the trachea. The right common carotid artery
ascends along the right side of the cervical part of
the trachea.
4. The left common carotid artery is at first in front of
the trachea. As it passes upwards it reaches the left
side of the trachea.
5. The left subclavian artery arises from the part of
the arch of the aorta that lies to the left of the trachea.
It ascends (for some distance) along the left side of
the trachea lying behind the left common carotid
artery.
6. The left brachiocephalic vein crosses in front of
the trachea just above the arch of the aorta. The right
brachiocephalic vein and the superior vena cava lie
to the right side of the thoracic part of the trachea.
7. The left recurrent laryngeal nerve lies in the groove
between the trachea and the oesophagus.
8. The right vagus nerve is closely applied to the right Fig. 18.5. Schematic sagittal section through the thorax to show
side of the thoracic part of the trachea. the subdivisions of the mediastinum
9. On either side (right or left) the trachea is
overlapped by the corresponding pleura and lung.
Fig. 18.6. Some relations of the trachea seen
from the front.
THE PRINCIPAL BRONCHI
We have seen that at its lower end the trachea divides into the the left lung. Further subdivisions of the lobar bronchi are
right and left principal bronchi. Thus, each principal bronchus considered along with the lungs.
begins opposite the (lower border of the body of the) fourth
thoracic vertebra. It passes downwards and laterally to enter
the corresponding lung (Fig. 18.2).
There are some important
differences between the right
and left principal bronchi.
The right bronchus is wider,
shorter, and more vertical
than the left bronchus (Fig.
18.8). It is about 2.5 cm
(1 inch) long, while the left
bronchus is approximately
double this length (5 cm).
The right principal bronchus
ends by dividing into three
lobar bronchi, superior,
middle and inferior. In
contrast the left principal
bronchus ends by dividing
into two lobar bronchi,
superior and inferior, Fig. 18.7. Transverse section through the superior mediastinum just above the summit of
corresponding to the lobes of the arch of the aorta, to show some relations of the trachea.
187
188
in an inferior border by which
they are separated from the
base. The surface of the lung
is free all round and is covered
by pleura (visceral layer)
except at an area of the medial
surface called the hilum. The
principal bronchus and the
pulmonary artery enter the
lung, and the pulmonary veins
leave it, at the hilum.
Fissures and Lobes

of the Lungs
Both the right and left lungs
have a prominent oblique
fissure. The right lung has an
additional horizontal fissure.
The part of the left lung above
and in front of the oblique
fissure is called the superior
Fig. 18.8. Diagram showing the right and left principal bronchi and their relations.
lobe.
Fig. 18.10.
Coronal
section
through a lung
to show its
surfaces.
Fig. 18.9. Relationship of bronchi, artery and veins at the
hilum of the right and left lungs
THE LUNGS
The right and left lungs lie in the corresponding halves of the
thorax. They are separated from each other by structures in
the mediastinum (including the heart, the great vessels, the Fig. 18.11.
trachea, and the oesophagus). A general idea of the shape of Transverse
the lungs can be had from Figure 18.2 in which both lungs are section through
shown as seen from the front. A basic idea of the surfaces and left lung to show
borders of the lungs can be obtained from Figures. 18.10 and its surfaces and
18.11. borders
Each lung has a relatively narrow upper end, or apex; a much
broader inferior surface or base; a rounded lateral or costal
surface; and a medial surface. The costal surface meets the
medial surface, in front at the anterior border and behind at
the posterior border. The costal and medial surfaces end, below,
Important Structures Related to
Medial Surface of Right Lung
These are listed below.
1. Heart (right atrium, right ventricle).
2. Subclavian artery.
3. Veins: superior vena cava, inferior vena cava, vena
azygos, right brachiocephalic vein.
4. Nerves: Right vagus and right phrenic nerves.
Important Structures Related to
Medial Surface of Left Lung
1. Heart (left ventricle).
2. Aorta
3. Left subclavian and left common carotid arteries.
4. Oesophagus.
5. Thoracic duct.
6. Left phrenic and left vagus nerves.
Intrapulmonary Bronchi and
Bronchopulmonary segments
We have seen that the left lung is divided into two lobes
superior and inferior; and that the right lung is divided into
three lobes superior, middle and inferior. We have also
seen that each lobe receives a lobar bronchus arising from
the principal bronchus. Each lobe is divisible into two or
more bronchopulmonary segments (Fig. 18.16); each
Fig. 18.12. Fissures and lobes of lungs. A. Anterior
segment is supplied by a segmental bronchus that is branch
aspect. B. Medial aspect. S=superior lobe; M=middle
of the lobar bronchus. The bronchopulmonary segments of
lobe; I=inferior lobe; OF=oblique fissure; HF=horizontal
fissure; L=lingula. the right and left lungs are summarised in the table.
The part below and behind the oblique fissure is called the
inferior lobe. In the right lung the inferior lobe corresponds to
that of the left lung. Because of the presence of the horizontal
fissure the part of the right lung in front of and above the oblique
fissure is subdivided into a part above the horizontal fissure
(called the superior lobe) and a part below the fissure (called
the middle lobe). The anterior margin of the left lung has a
deep cardiac notch: because of the presence of this notch the
lowest part of the superior lobe of this lung has the appearance
of a tongue like projection: this projection is called the lingula
(L in Figure 18.12A).
The costal surface of the lung is rounded to conform to the
Further divisions of bronchi:
shape of the ribs (and intercostal spaces).
Each segmental bronchus divides into several generations
The medial surface consists of an anterior (or mediastinal) part
of branches that ultimately end in very small tubes called
that is deeply concave, and a posterior (or vertebral) part that
brochioles. The bronchioles also undergo repeated
is convex. The concavity is meant to accommodate the heart.
branching and ultimately end in microscopic passages that
The convex part fits into the space between the lateral side of
connect them to the alveoli of the lungs (Fig. 18.13).
the vertebral bodies and the posterior parts of the ribs.
The base of the lung is deeply concave (to fit over the
corresponding cupola of the diaphragm). The apex of the lung Blood Vessels of the Lungs
is rounded. It lies about one inch (2.5 cm) above the medial The blood supply of the lungs is peculiar in that two sets of
part of the clavicle. arteries carry blood to them.
1. The pulmonary arteries convey deoxygenated blood from
the right ventricle. This blood circulates through a capillary
189
190
plexus intimately related to the
walls of the alveoli, and receives
oxygen from the alveolar air. This
blood that is now oxygenated is
returned to the heart (left atrium)
through the pulmonary veins.
2. The lungs also receive oxy-
genated blood like any other tissue
in the body. This is conveyed
through the bronchial arteries. This
blood supplies the walls of the
bronchi and the connective tissue
of the lung. Some of this blood
passes into the pulmonary veins,
Fig. 18.13. Scheme to show the terms used to describe the terminal
but the rest of it is drained through
ramifications of the bronchial tree.
bronchial veins.
Within each lung the pulmonary
artery divides into branches that
follow the branching pattern of the bronchi. Each THE PLEURA
bronchopulmonary segment has its own artery. As a rule the
arteries lie posterolateral to the corresponding bronchi. In The right and left pleurae (singular = pleura) are thin serous
contrast to the arteries, the pulmonary veins tend to run between membranes that are closely related to the corresponding lungs
adjacent bronchopulmonary segments: each vein may therefore and to the corresponding half of the thoracic wall. The
drain more than one segment. arrangement of the pleura is best understood by thinking of
it as a closed sac that is invaginated (from the medial side)
by the corresponding lung. As a result of this invagination
the pleura of each side comes to have an inner or visceral
Fig. 18.14. Right lung viewed from the medial side showing areas related to various structures.
Fig. 18.15. Left lung viewed from the medial side showing areas related to different structures.
Fig. 18.16A. Scheme to show the bronchial tree as seen from the front.
191
192
Figs 18.16 B to E. Bronchopulmonary segments of the right and left lungs.

layer that is closely adherent to the surface of the lung; and an The parietal and visceral layers of pleura are in contact with
outer, or parietal layer that lines the wall of the thorax. Apart each other being separated only by a potential space that is
from lining the surfaces of the lung, the visceral pleura dips called the pleural cavity. Under certain diseased conditions
into the fissures and lines the contiguous sides of the lobes.
Fig. 18.17. Schematic transverse section through the left Fig. 18.18. Schematic coronal section through one half
half of the thorax to show some features of the pleura. of the thorax to show some features of the pleura.
fluid or air may be present in the pleural
cavity thus separating the parietal and
visceral layers.
The parietal pleura can be subdivided into
the following parts.
a. The costovertebral pleura lines the inner
aspect of the ribs and intercostal spaces,
part of the inner surface of the sternum,
and the sides of thoracic vertebrae (Fig.
18.17).
b. The diaphragmatic pleura lines the upper
surface of the diaphragm (Fig. 18.18).
However, the pleura is not as extensive as
the diaphragm so that some parts of the
latter are not covered by pleura.
(c) The mediastinal pleura (Fig. 18.19)
lines structures on the corresponding side
of the mediastinum.
The mediastinal pleura extends as a tube
over the structures passing between the
mediastinum and the lung (bronchus,
pulmonary artery, pulmonary veins) and
becomes continuous with the visceral
Fig. 18.19. Scheme to show the relationship of lines of pleural reflection
pleura at the hilum of the lung. This pleura
(red line) and of the lungs (blue line), to the skeleton of the thorax.
extends for some distance below the hilum
forming a double layered fold that stretches
from the mediastinum to the lung and is called the pulmonary behind the sternoclavicular joint. From here it runs
ligament. downwards and medially to reach the midline at the level of
From Figure 18.17 it will be seen that, when traced anteriorly, the sternal angle. On the right side the line runs downwards
the costovertebral pleura reaches the sternum (posterior aspect) in the mid-line to reach the xiphisternal joint. On the left side
and bends sharply to become continuous with the mediastinal the line runs downwards in the mid-line up to the level of the
pleura. The line along which bending occurs is called the line fourth costal cartilage. It then passes downwards and
of costomediastinal reflection of the pleura. When traced laterally to reach the lateral margin of the sternum and runs
backwards, the costovertebral pleura passes from the sides of downwards a short distance lateral to this margin to reach
the vertebral bodies on to the mediastinum. From Figure 18.18 it the sixth costal cartilage about 3 cm from the mid-line.
will be seen that when the costovertebral pleura is traced The lower ends of the lines of costomediastinal reflection
downwards. It bends sharply to become continuous with (described above) are continuous with the anterior ends of
diaphragmatic pleura. The line along which this bending takes the lines of costodiaphragmatic reflection that are as follows.
place is called the line of costodiaphragmatic reflection. When On the right side this reflection begins behind the xiphoid
traced upwards the costal pleura extends up to the inner margin process. It then winds round the anterior, lateral and posterior
of the first rib. aspects of the thorax forming a curve convex downwards.
Above this level it covers the apex of the lung (that lies in the In the midclavicular line, the line of reflection is at the level
root of the neck) and is called the cervical pleura. The cervical of the eighth rib; in the midaxillary line at the level of the
pleura extends upwards up to the level of the neck of the first tenth rib; and at its posterior end the reflection lies at the
rib. It is covered by a sheet of fascia called the suprapleural level of the spine of the twelfth thoracic vertebra about 2 cm
membrane (that stretches from the transverse process of the from the midline. On the left side the line of
seventh cervical vertebra to the inner border of the first rib. costodiaphragmatic reflection begins at the sternal end of
the sixth costal cartilage (i.e. about 2 cm lateral to the mid-
Surface Projection of the Pleura line). Thereafter, it follows a course similar to that on the
right side.
The costal surface of the lung, and the costal pleura come in The line along which the posterior part of the costovertebral
contact with the external wall of the thorax. As seen from the pleura gets reflected on to the mediastinum can be
front, the cervical pleura can be represented by a line that is represented by a vertical line about 2 cm from the middle
convex upwards, and lies above the medial one-third of the line. It extends, above up to the level of the spine of the
clavicle. The summit of the line rises 2.5 cm above the clavicle second thoracic vertebra; and below to the level of the spine
(Fig. 18.19). The line of costo-mediastinal reflection begins of the twelfth thoracic vertebra.
193
194
Surface Projection of the Lung above). In the midaxillary line it lies over the eighth rib. Its
The outline of the apex of the lung corresponds to that of the posterior end lies at the level of the tenth thoracic spine
cervical pleura. (2 cm lateral to the midline). Note that there is a difference
The anterior border of the right lung corresponds to the of two ribs in the levels of the lung and pleura over both
costomediastinal reflection of the pleura already described. In these lines.
the left lung the upper part of the anterior border (up to the The posterior border of the lung lies 2 cm from the midline.
fourth costal cartilage) follows the pleura, but below this level It extends below to the level of the tenth thoracic spine: and
the border falls considerably short of the pleura because of the above to the level of the second thoracic spine. When seen
presence of the deep cardiac notch. From the midline (at the from behind the apex of the lung lies at level of the first
level of the fourth costal cartilage) the border passes sharply spine about 5 cm from the midline.
to the left and downwards so that at the level of the fifth costal
cartilage it is about 3.5 cm lateral to the sternal margin (or to
Development of the Respiratory System
the line for the pleura). It then curves downwards and medially
The larynx and trachea are derived from a respiratory
to reach the sixth costal cartilage a short distance lateral to the
diverticulum arising from the foregut (endoderm). The
line for the pleura (i.e., about 4 cm from the midline).
diverticulum divides into right and left lung buds from which
The inferior border of the lung follows a curved line lying
bronchi and lungs are formed. The pleural cavities are
above that for the costodiaphragmatic reflection of the pleura.
derived from pleuroperitoneal canals (part of
On each side the line representing this border begins
intraembryonic coelom).
(anteriorly) at the lower end of the anterior border (described
19 : The Heart and Pericardium
Introduction to Heart and Pericardium distribute blood to tissues of the entire body. It is returned
to the heart (right atrium) through the venae cavae, thus
The heart is a muscular pump designed to ensure the circulation completing the circuit.
of blood through the tissues of the body. Both structurally and The heart (and great vessels in the middle mediastinum) are
functionally it consists of two halves, right and left. The right enclosed in the pericardium. The pericardium consists of
heart circulates blood only through the lungs for the purpose an outer fibrous layer, and two layers (visceral and parietal)
of oxygenation (i.e. through the pulmonary circulation). The of serous pericardium. The visceral serous pericardium lines
left heart circulates blood to tissues of the entire body (i.e.
the external surface of the heart, while the parietal serous
through the systemic circulation).
pericardium lines the inside of the fibrous pericardium. As in
Each half of the heart consists of an inflow chamber called the
the case of the pleura, the two layers are separated by a thin
atrium, and of an outflow chamber called the ventricle (Fig.
19.1). The right and left atria are separated by an interatrial film of fluid that prevents friction during contractions of the
septum. The right and left ventricles are separated by an heart. We have seen above that the fibrous pericardium is
interventricular septum. The right atrium opens into the right adherent to the central tendon of the diaphragm.
ventricle through the right atrioventricular orifice: this orifice
is guarded by the tricuspid valve. The left atrium opens into
the left ventricle through the left atrioventricular orifice: this
orifice is guarded by the mitral valve.
EXTERIOR OF THE HEART
The right atrium receives deoxygenated blood from tissues of
the entire body through the superior and inferior venae cavae.
This blood passes into the right ventricle. It leaves the right Surfaces of the Heart
ventricle through a large outflow vessel called the pulmonary
trunk. This trunk divides into right and left pulmonary arteries The heart has an anterior or sternocostal surface, a posterior
that carry blood to the lungs. Blood oxygenated in the lungs is surface or base, and right and left surfaces (Fig. 19.2). In
brought back to the heart by four pulmonary veins (two right addition to these there is a diaphragmatic surface (Fig. 19.4).
and two left) that end in the left atrium. This blood passes into The sternocostal surface (Fig. 19.3) is made up (from right to
the left ventricle. The left ventricle pumps this blood into a left) by the right atrium, the right ventricle and the left
large outflow vessel called the aorta: the aorta and its branches ventricle. The contribution of the right ventricle to this
THE HEART AND PERICARDIUM
Fig. 19.3. Sternocostal surface of the heart. The aorta and
Fig. 19.1. Schematic diagram of the heart to show pulmonary trunk have been cut just above their origins to
its chambers and their communications. show the left atrium that is hidden behind them.
Fig. 19.4. Schematic vertical section passing

through the left half of the heart.
aorta and the pulmonary trunk that lie in front of it. A

small appendage arises from the upper and anterior
Fig. 19.2. Schematic transverse section through the heart to
show relative position of its chambers. part of the right atrium and overlaps the right side of
the lower part of the aorta: it is called the auricle of the
right atrium (c in Fig. 19.3). A similar appendage arising
surface is much greater than that of the left ventricle. The two from the left atrium (auricle of the left atrium) (d in
ventricles are separated by the anterior interventricular groove (b). Fig. 19.3) overlaps the left side of the root of the
The right atrium and ventricle are separated by the anterior part of pulmonary trunk.
the atrioventricular groove (a), also called the coronary sulcus. The The inferior or diaphragmatic surface (Fig. 19.5) is
sternocostal surface is bounded below by a sharp inferior border, formed in greater part (two-thirds) by the left ventricle,
that separates it from the diaphragmatic surface. and to a lesser degree (one-third) by the right ventricle.
The region where the inferior border meets the left margin of the The two ventricles are separated from each other by
heart is called the apex. The apex is formed by the left ventricle. The the posterior interventricular groove (b). They are
upper border of the heart is formed mainly by the left atrium. In the separated from the corresponding atria by the posterior
intact heart this border is obscured from view by the parts of the part of the atrioventricular groove (a).
195
196
Fig. 19.5. Heart seen from below to

show the diaphragmatic surface.
Fig. 19.6. Heart seen from behind to show its base.
The posterior surface or base of the heart (Fig. 19.6) is formed major openings there are numerous small apertures in the
mainly by the left atrium. A small part of it is formed by the wall of the atrium for small veins called the venae cordis
posterior part of the right atrium. minimae.
The atrioventricular or coronary sulcus separates the atria The sinus venarum and the atrium proper meet along a line
from the ventricles. that is marked, on the internal surface of the atrial wall, by a
The interventricular grooves mark the position of attachment muscular ridge called the crista terminalis. The crista
of the ventricular septum to the outer wall of the heart. The terminalis is a C-shaped ridge. The position of the crista
anterior interventricular groove separates the right and left terminalis corresponds to a groove, the sulcus terminalis
ventricles on the sternocostal surface. The posterior (or inferior) present on the external surface of the atrium. The wall of the
interventricular groove separates the same chambers on the atrium proper shows the presence of a number of transversely
diaphragmatic surface. running muscular ridges called the musculi pectinati. These
ridges start from the crista terminalis and run forwards.
INTERIOR OF THE HEART
Interior of the Right Atrium
The right atrium can be divided into two main parts (Fig. 19.7).
The posterior part is smooth walled and is called the sinus
venarum. The anterior part, or atrium proper is rough walled.
In addition the right atrium has an appendage called the auricle.
The auricle arises from the upper and anterior part of the atrium
proper, and is related to the right side of the ascending aorta.
All the large veins entering the right atrium open into the sinus
venarum part. The opening of the superior vena cava is situated
in its upper and posterior part, and that of the inferior vena
cava into its lower part, close to the interatrial septum. The
opening of the inferior vena cava is bounded by a semilunar
fold of endocardium called the valve of the inferior vena cava.
The sinus venarum presents a third opening: that of the coronary
sinus. This opening is present just to the left of the opening of
the inferior vena cava. This opening is also guarded by a valve,
the valve of the coronary sinus. In addition to these three Fig.19.7. Interior of right atrium viewed from the right side.
Fig. 19.9.
Transverse
section across the
ventricles of the
heart.
The outflow part of the left ventricle is called the aortic

vestibule. It becomes continuous with the ascending aorta,
the two being separated by the aortic valve.
When we study a cross-section across the lower parts of
the two ventricles (Fig. 19.19) we find that the walls of the
left ventricle are much thicker than those of the right
ventricle. The outline of the left ventricle is roughly circular.
Fig. 19.8. Transverse section through the upper parts
of the atria. In contrast the cavity of the right ventricle is crescentic in
outline.
The right atrium is separated from the left atrium by the interatrial
septum. When viewed from within the right atrium the septum Atrioventricular Orifices
shows some features of interest. On its lower part there is an
oval depression called the fossa ovalis. The upper margin of The right and left atrioventricular orifices are oval apertures.
the fossa is thickened to form a curved ridge called the limbus Each opening is guarded by a valve that allows flow of blood
fossa ovalis. from atrium to ventricle, but not in the reverse direction.
The right atrium opens into the right ventricle through the right The valves are made up of thin leaflets of tissue called cusps.
atrioventricular orifice that is guarded by the tricuspid valve. The apex and margins of the cusps give attachment to
delicate tendinous strands called the chordae tendinae.
The chordae tendinae are also attached to the ventricular
Interior of the Left Atrium surfaces of the cusps that are, therefore, rough in contrast to
the atrial surfaces that are smooth. At their other end the
The left atrium is a thin walled cavity (Fig. 19.8). Most of the chordae tendinae are attached to the apices of papillary
wall is smooth. Musculi pectinati are present only in the auricle muscles. Each papillary muscle is attached (through chordae
of the atrium. The cavity is separated from that of the right
atrium by the interatrial septum. The left atrium receives four
pulmonary veins, two right and two left, from the corresponding
lungs. The atrium opens into the left ventricle through the left
atrioventricular orifice that is guarded by the mitral valve.
Interior of the Ventricles
Each ventricle has an inflow part and an outflow part. The

inflow part of each ventricle has a rough inner surface because
of the presence of numerous bundles of cardiac muscle called
trabeculae carneae. In addition to the trabeculae carneae the
wall gives off finger like processes attached to the ventricular
wall at one end, but free at the other. These are called papillary
muscles. They are functionally related to the atrioventricular
valves.
In contrast to the rough walls of the inflow parts, the outflow
parts of the two ventricles are smooth. The outflow part of the
right ventricle is called the infundibulum. Its upper end
becomes continuous with the pulmonary trunk, the two being Fig. 19.10. Scheme to show cusps and papillary
separated by the pulmonary valve. muscles of the tricuspid valve.
197
198
tendinae) to adjoining parts of two cusps. As a result
the adjoining margins of the two cusps are drawn
together when the papillary muscle contracts.
The Tricuspid Valve
The right atrioventricular orifice is larger than the left.

The right orifice is said to be large enough to admit the
tips of three fingers. In contrast the left orifice is said to
admit only two fingers.
The tricuspid valve made up of three cusps. These cusps
are anterior, posterior and septal (Fig. 19.10).
The chordae tendinae attached to these cusps arise from:
(a) a large anterior papillary muscle; (b) a large posterior
papillary muscle; and (c) directly from the
interventricular septum or from small papillary muscles
attached to the septum. The chordae tendinae arising
from the anterior papillary muscle are attached to the
Fig. 19.11. Schematic diagram to show the main features in the anterior and posterior cusps; those from the posterior
interior of the right ventricle. muscle to the posterior and septal cusps; and those from
the septal muscles to the anterior and septal cusps.
The base of the anterior papillary muscle is connected
to the interventricular septum by a special band of cardiac
muscle called the septomarginal trabecula (also called
the moderator band).
The Mitral Valve
The mitral valve has the same basic features as those of

the tricuspid valve. It has two cusps anterior and
posterior (Fig. 19.13). The papillary muscles connected

to the cusps of the mitral valve are also termed anterior
and posterior (a and p respectively in Fig. 19.13). The
anterior muscle arises from the sternocostal wall of the
ventricle near its lower end (Fig. 19.12). The posterior
muscle arises from the diaphragmatic wall near its
anterior end.
The chordae tendinae arising from each papillary muscle
Fig. 19.12. Schematic diagram to show the main features in pass to adjoining parts of the two cusps of the mitral
the interior of the left ventricle. valve.
Aortic and Pulmonary Orifices
These orifices are located at the upper ends of the outflow

parts of the left and right ventricles respectively. Each
orifice is circular. The pulmonary orifice is somewhat
larger than the aortic orifice, the diameters of the orifices
being about 3 cm and 2.5 cm respectively. The aortic
orifice is placed in front and to the right of the mitral
orifice (Fig. 19.14). The pulmonary orifice is placed
above and to the left of the tricuspid orifice, the aortic
orifice intervening between them.
The aortic orifice is guarded by the aortic valve, and the
Fig. 19.13. Scheme to show the cusps
and papillary muscles of the mitral valve pulmonary orifice by the pulmonary valve. Each valve
consists of three semilunar cusps. The pulmonary valve
has one posterior cusp and two anterior cusps; whereas the
aortic valve has one anterior cusp and two posterior cusps.
The Interventricular Septum
We have seen that this septum separates the right and left
ventricles. Its position, relative to the surfaces of the heart,
corresponds to the anterior and inferior interventricular grooves.
The greater part of the septum is thick and muscular, but a small
area near the posterior margin is membranous (Fig. 19.15). The
septal cusp of the tricuspid valve is attached vertically on this
part of the septum and divides it into an anterior part that
separates the right and left ventricles, and a posterior part that
separates the left ventricle from the right atrium. The latter
part is, therefore, referred to as the atrioventricular septum.
Fig. 19.14. Heart viewed from the posterosuperior

aspect after removing the atria.
CONDUCTING SYSTEM OF THE HEART
For proper working of the heart it is essential that the chambers membrane lines the outside of the heart: this is the visceral
contract in a definite sequence. The sequence is controlled by serous pericardium.
the conducting system. The rate at which the heart contracts is The aorta and pulmonary trunk are enclosed in a common
determined by a small area of specialised tissue called the tube of pericardium. They lie in front of the atria from which
sinuatrial node (commonly abbreviated to SA node). It is they are separated by a tubular recess of the pericardial cavity
located in the right atrium along the anterior margin of the called the transverse sinus (Figs 19.16 and 19.17).
opening of the superior vena cava. Impulses originating here The oblique sinus is a pouch like recess of the pericardial
spread out into the atrial musculature. Some of these impulses cavity lying behind the heart (Figs 19.16 and 19.17). Its
reach another node of specialised tissue called the boundaries are as follows:
atrioventricular node (or AV node). This node lies in the wall 1. anteriorly: visceral serous pericardium lining the left
of the right atrium formed by the interatrial septum, just above atrium.
the opening of the coronary sinus. Arising from this node there 2. posteriorly: parietal serous pericardium lining the fibrous
is the atrioventricular bundle. This bundle divides into right pericardium.
and left branches. The branches break up into a plexus of the
fine Purkinje fibres that spread out deep to the
endocardium to reach all parts of the ventricles,
including the bases of papillary vessels.
THE PERICARDIUM
The heart, and some parts of the great vessels

attached to it, are surrounded by a sac called the
pericardium. The pericardium has an outer
fibrous layer called the fibrous pericardium.
The fibrous pericardium surrounds the heart like
a bag. Its upper end is continuous with the fibrous
tissue covering the aorta and the pulmonary trunk.
Inferiorly, it is partially fused to the central tendon
of the diaphragm. The inner surface of the fibrous
pericardium is lined by a thin serous membrane,
the parietal serous pericardium. A similar Fig. 19.15. Schematic view of the interior of the heart to show
parts of the conducting system.
199
200
Fig. 19.16. Schematic transverse section through the

upper part of the heart and pericardium.
Fig. 19.17. Schematic sagittal section through
the heart and pericardium.
Fig. 19.18. Surface projection of the heart.

3. above: by continuity of the parietal and visceral layers along fourth costal cartilage. Its lower part inclines slightly to the
the upper margin of the left atrium. right and reaches the level of the fifth costal cartilage.
4. to the left: by continuity of the parietal and visceral layers
along the upper and lower left pulmonary veins.
Development of the Heart
5. to the right: by continuity of these layers along the superior
The heart develops from mesoderm of the cardiogenic area
vena cava, the upper and lower right pulmonary veins and the
(that lies near the cranial end of the embryonic disc). Two
inferior vena cava.
heart tubes (right and left) fuse to form a single tube that
The oblique sinus opens into the rest of the pericardial cavity
later shows the following subdivisions (cranial to caudal).
below and to the left.
1. Truncus arteriosus.
2. Conus.
3. Ventricle.
SURFACE PROJECTION OF THE HEART 4. Atrioventricular canal.
5. Atrium.
6. Sinus venosus with right and left horns.
The borders of the heart can be projected on to the surface of
the body by using the points A, B, C and D, shown in Figure The truncus arteriosus is partitioned to form the ascending
19.18, as landmarks. aorta and the pulmonary trunk.
The right border can be drawn by joining points A and B by a The conus and ventricle fuse to form one chamber that is
line convex to the right, the convexity being greatest in the divided into right and left ventricles by formation of the
fourth space. The left border can be drawn by joining points C interventricular septum.
and D by a line that is convex to the left. The upper border can The atrium is partitioned by formation of the interatrial
be drawn by joining points A and C. The lower border is formed septum that has two components: septum primum and the
by joining points B and D. The line is slightly convex downwards septum secundum. A passage, the foramen ovale, exists
at its right and left ends, and concave downwards in the middle between the two and allows blood to flow from right atrium
part. It passes through the xiphisternal joint. to left atrium during fetal life.
The valves of the heart lie along a line that joins points B and C. The left atrium is derived from the left half of the primitive
The pulmonary valve (p) is about 2.5 cm broad and lies partly atrium, the left half of the A.V canal and absorbed pulmonary
behind the left third costal cartilage, and partly behind the veins.
sternum. The aortic valve (a) is about 2.5 cm broad. It is placed The right atrium is derived from the right half of the
obliquely behind the left half of the sternum at the level of the primitive atrium, the right half of the A.V canal, and the
third intercostal space. The mitral valve (m) is about 3 cm wide. sinus venosus. The part derived from the sinus venosus forms
It is placed obliquely deep to the left half of the sternum at the the sinus venarum.
level of the fourth costal cartilage. The tricuspid valve (t) is The pericardium develops from a part of the intraembryonic
about 4 cm broad. It is placed almost vertically behind the coelom lying in the midline cranial to the prochordal plate
sternum. Its upper end lies in the midline at the level of the (close to the cardiogenic area).
201
202
20 : Blood Vessels of the Thorax
THE PULMONARY TRUNK AND ARTERIES
The Pulmonary Trunk

The pulmonary trunk arises from the right ventricle, the junction between the
two being guarded by the pulmonary valve. The trunk runs upwards and
backwards and ends by dividing into the right and left pulmonary arteries
(Fig. 20.1).
The lower part of the trunk lies in front of, and to the left of, the ascending
aorta; and higher up on its left side. The two vessels are enclosed in a common
sheath of serous pericardium. They are separated from the left atrium by the
transverse sinus of pericardium.
Development
The pulmonary trunk is derived from the truncus arteriosus.
The Right Pulmonary Artery

The right pulmonary artery arises from the upper end of the pulmonary trunk
(Fig. 20.1) and runs to the right to reach the hilum of the right lung. Here it
divides into two main branches. The upper branch supplies the upper lobe of
the lung, and the lower branch supplies the lower lobe. Each of these branches
subdivides to accompany the branches of the corresponding bronchi.
The Left Pulmonary Artery

The left pulmonary artery arises from the upper end of the pulmonary trunk
(Fig. 20.1) and runs to the left to reach the hilum of the left lung. Here it
divides into two main branches that are distributed to the two lobes of the left
lung.
Development
The right and left pulmonary arteries are derived from the corresponding sixth Fig. 20.2. Subdivisions of the aorta seen
arch artery. from the left side.
THE AORTA
The heart distributes blood to the entire body through an

elaborate arterial tree. The main stem of this tree is called
the aorta. The aorta arises from the left ventricle of the heart,
the junction between the two being guarded by the aortic
valve. For convenience of description it is divided into the
ascending aorta, the arch of the aorta and the descending
aorta. The descending aorta is divisible into the descending
thoracic aorta and the abdominal aorta (Fig. 20.2).
The Ascending Aorta
Fig. 20.1. Diagram to show the pulmonary trunk and The junction of the ascending aorta (a in Figs 20.2 and 20.3)
pulmonary arteries, and their relationship to the aorta. with the left ventricle is situated behind the left half of the
BLOOD VESSSELS OF THE THORAX
Fig. 20.3. Ascending aorta
and arch of aorta seen from
the front.
Fig. 20.4. Transverse section through the arch of the aorta to show its relations.
Fig. 20.5. Diagram to show structures lying above and

below the arch of the aorta.
Fig. 20.6. Aorta and oesophagus seen

body of the sternum at the level of the third intercostal space (Fig. 20.3). From from the front.
here it passes upwards, forwards and to the right up to the junction of the body
of the sternum with the manubrium sterni. The ascending aorta, thus, lies within
The ascending aorta is enclosed in a tube
the middle mediastinum. It is surrounded by pericardium.
of serous pericardium common to it and the
The following additional points may be noted. Just above the aortic valve the
pulmonary trunk.
wall of the ascending aorta is marked by three dilatations called the aortic
sinuses; one anterior, and right and left posterior (Fig. 20.8). The only branches Development
of the ascending aorta are the right and left coronary arteries that supply the The ascending aorta is derived from the
heart. truncus arteriosus.
203
204
is continuous with the lower end of the arch. It descends in front of
the thoracic vertebrae gradually passing from the left side towards
the median plane. At the level of the lower border of the twelfth
thoracic vertebra it passes through the aortic orifice of the
diaphragm to enter the abdomen.
The descending thoracic aorta becomes continuous with the
abdominal aorta (d in Fig. 20.2) that descends in front of the lumbar
vertebrae. It terminates in front of the fourth lumbar vertebra by
dividing into two terminal branches called the common iliac arteries.
The abdominal aorta will be studied in detail when we consider the
abdomen.
Some relations of Descending Aorta
Anterior relations:
(1) Root of left lung. (2) The left atrium of the heart. (3) The
oesophagus. (4) The diaphragm.
Structures to right
1. Oesophagus. 2. Vena azygos. 3. Thoracic duct. 4. Right lung
and pleura.
Fig. 20.7. Some relations of descending

thoracic aorta.
The Arch of the Aorta
The arch of the aorta (b in

Figs 20.2 and 20.3) passes

backwards and to the left
forming a convexity direct-
ed upwards. The summit of
the arch reaches the level of
the middle of the manu-
brium. Its posterior end lies
on the left side of the lower
border of the fourth thoracic
vertebra.
Relations of arch of aorta:
These are shown in Figures
20.4 and 20.5.
Development
The arch of the aorta is
formed from the aortic sac,
its left horn, and the left
fourth arch artery.
The Descending Aorta
The descending thoracic

aorta (c in Figs 20.2 and 20.3) Fig. 20.8. Branches of the aorta in the thorax.
(Fig. 20.8). For convenience of description the artery may be divided
into three parts.
The first part passes forwards for a short distance between the
pulmonary trunk (to its left) and the auricle of the right atrium (to
its right). The second part runs downwards on the ocostal surface
of the heart between the right atrium and right ventricle (i.e. in the
anterior part of the atrioventricular groove: Fig. 20.9). Reaching the
inferior (or acute) margin of the heart the artery curves round it to
become the third part, that lies in the posterior part of the
atrioventricular groove (between the right atrium and ventricle). It
runs upwards and to the left and ends by anastomosing with the
circumflex branch of the left coronary artery (see below). Just before
its termination it gives off the posterior interventricular branch
that runs downwards, forwards and to the left in the posterior
interventricular groove (Fig. 20.9).
The branches of the right coronary artery are considered below.
Course of Left Coronary Artery
The left coronary artery arises from the left posterior sinus of the
ascending aorta (Fig. 20.8). It passes to the left between the
pulmonary trunk and the left atrium and appears on the sternocostal
surface of the heart after passing deep to the auricle of the left atrium
(Fig. 20.9). Here the artery divides into two main branches that are
more or less equal in diameter: these are the circumflex and anterior
Fig. 20.9. Scheme to show the coronary interventricular arteries. The circumflex branch runs to the left in
arteries and their interventricular the anterior part of the atrioventricular groove (between the left
branches. atrium and the left ventricle: Fig. 20.9).
It then curves round the left border of the heart and runs downwards
Structures to the left and to the right in the posterior part of the same groove. It ends by
Left lung and pleura. anastomosing with the terminal part of the right coronary artery.
The anterior interventricular branch runs downwards and to the left
Posteriorly in the anterior interventricular groove (i.e. between the right and
1. Vertebral column. 2. The hemiazygos veins pass from left ventricles). Near the apex of the heart it curves round the lower
left to right between the aorta and the vertebral column. border and runs for a short distance in the posterior interventricular
Development of Descending aorta: groove where it ends by anastomosing with the posterior
It is derived from the left dorsal aorta, and from the interventricular branch of the right coronary artery (Fig. 20.9).
fused right and left dorsal aortae.
BRANCHES OF THE AORTA
THE CORONARY ARTERIES
The coronary arteries supply the heart. There

are two of them: right and left. The
importance of a knowledge of their course
and branches has increased considerably in
recent years as these arteries are often
visualized in the living (coronary
angiography) for diagnosis of possible
obstruction to them.
Course of Right Coronary Artery
The right coronary artery arises from the
ascending aorta, from its anterior sinus Fig. 20.10. Distribution of the right coronary artery.
205
206
Branches of the
Right Coronary Artery
From first part:
(1) Right conus artery.
(2) Artery of the sinuatrial node.
From second part:
The second part of the artery gives off a
series of branches to the right atrium (Fig.
20.10), and to the anterior wall of the right
ventricle. The largest of these branches
runs along the lower border of the heart
and is called the marginal branch.
From third part:
The third part of the artery also gives off
atrial and ventricular branches to the right
atrium and to the diaphragmatic wall of
the right ventricle. Fig. 20.11. Distribution of the left coronary artery.
The posterior interventricular branch
gives off branches to the diaphragmatic The circumflex branch gives off several branches to the
wall of the right ventricle; and some to the left ventricle. Some wall of the left ventricle. One of these branches is specially
branches run upwards and forwards into the posterior one- prominent. It is called the left marginal artery. It runs down
third of the interventricular septum. along the rounded left margin of the heart and supplies it.
Branches of the Left Coronary Artery The circumflex artery also gives some branches to the
The anterior interventricular branch gives off several large diaphragmatic surface of the left ventricle. The left atrium
branches to the anterior wall of the left ventricle (Fig. 20.11). is supplied, almost wholly, by branches of the circumflex
The anterior interventricular branch also gives off a few small artery.
branches to the right ventricle. One of these ramifies on the From the foregoing descriptions of the distribution of the
infundibulum and is called the left conus artery. The anterior right and left coronary arteries it is seen that the right atrium
interventricular branch sends several branches downwards into and ventricle are supplied mainly by the right coronary artery,
the interventricular septum: they supply the anterior two thirds and the left atrium and ventricle by the left coronary artery.
of the septum. However, some parts of each ventricle, and of the left atrium
are supplied by the artery of the opposite side. The anterior
two thirds of the interventricular septum is supplied by the
left coronary artery, and its posterior one third by the right
coronary artery. The S.A node, the A.V node, the A.V bundle
and the proximal parts of its right and left branches are
supplied by the right coronary artery. The distal parts of the
bundle branches are supplied by the left coronary artery.
BRANCHES OF THE
ARCH OF THE AORTA
Brachiocephalic artery
This is the first branch of the arch of the aorta. Its origin lies
more or less in the median plane, in front of the trachea.
From here it runs upwards and backwards and as it does so
it winds round the trachea to reach its right side. Its ends
behind the right sternoclavicular joint by dividing into the
right common carotid and right subclavian arteries.
Development
Fig. 20.12. Branches of the arch of the aorta. The brachiocephalic artery develops from the right horn of
the aortic sac.
Left common carotid artery
The left common carotid artery arises from the arch a little to
the left of the brachiocephalic artery. Its origin also lies in front
of the trachea. From here it passes upwards winding around
the trachea to reach its left side. It enters the neck by passing
deep to the left sternoclavicular joint.
Development
The right and left common carotid arteries develop from part
of the corresponding third arch artery.
Left Subclavian Artery
The left subclavian artery arises from the arch of the aorta a
little to the left of and behind the left common carotid artery,
the origin lying to the left of the trachea. The artery runs almost
vertically along the left side of the trachea to enter the neck at Fig. 20.13. Scheme to show the bronchial arteries.
the level of the left sternoclavicular joint, where it lies behind
the common carotid artery.
Development VEINS OF THE THORAX
The left subclavian artery is a derivative of the left seventh
cervical intersegmental artery. (The right subclavian artery is
The veins of the thorax are as follows:
derived from the right fourth arch artery and the right seventh
cervical intersegmental artery). (1) Veins that drain the wall of the thorax
These include the intercostal and subcostal veins, the azygos
and hemiazygos veins, and the internal thoracic vein.
BRANCHES OF DESCENDING (2) Veins that drain the heart itself.
THORACIC AORTA These are the coronary sinus and its tributaries; and some
small veins.
The descending thoracic aorta has been described on page (3) Large veins present in the mediastinum
204. Its branches are shown in Figure 20.8. Apart from several These are the superior vena cava, the right and left
small branches to the oesophagus, the pericardium, the brachiocephalic veins, the inferior vena cava, and the
diaphragm (phrenic branches) and to lymph nodes in the pulmonary veins.
posterior mediastinum (mediastinal branches) it gives off the The veins of the thoracic wall have already been described.
bronchial, posterior intercostal and subcostal arteries. The others are described below.
The posterior intercostal and subcostal arteries have been
described on pages 179,180. The bronchial arteries are described
below.
VEINS OF THE HEART
The Bronchial Arteries
These arteries supply the bronchi, the connective tissue of the
The Coronary Sinus
lungs and related lymph nodes. (Note that in contrast the blood
Most of the veins draining the heart wall end in a wide vein,
reaching the lungs through the pulmonary arteries passes
about two centimeters long, called the coronary sinus (Fig.
through capillaries related to the alveoli where oxygenation
20.14). This sinus lies in the posterior and left part of the
takes place). Generally, there are two left bronchial arteries,
atrioventricular groove, i.e. along the posterior edge of the
upper and lower, that arise from the front of the thoracic aorta;
diaphragmatic surface of the left ventricle. Its right end opens
and one right bronchial artery (Fig. 20.13). The latter may arise
into the right atrium.
from the upper left bronchial artery or from the third right
The coronary sinus receives the following veins: (1) the great
posterior intercostal artery.
cardiac vein; (2) the small cardiac vein; (3) the middle
cardiac vein; (4) the posterior vein of the left ventricle; and
Other arteries in the thorax (5) the oblique vein of the left atrium (Fig. 20.14).
The Great Cardiac Vein
The internal thoracic artery, and the superior intercostal artery
The great cardiac vein is seen mainly on the sternocostal
arise in the neck and descend into the thoracic wall. They are
aspect of the heart (Fig. 20.14). It ascends in the anterior
described in relation to the thoracic wall.
interventricular groove (parallel to the anterior
interventricular branch of the left coronary artery). At the
207
208
the posterior interventricular branch of the right coronary
artery. The vein ends in the coronary sinus near its
termination.
Other Veins of the Heart
The posterior vein of the left ventricle lies on the
diaphragmatic surface of the ventricle.
The oblique vein of the left atrium lies behind this chamber.
Some anterior cardiac veins lying on the right ventricle open
into the right atrium. A number of small venae cordis
minimae drain directly into the chambers of the heart.
The Pulmonary Veins
There are four pulmonary veins, two each (superior and

inferior), on the right and left sides. Each pulmonary vein is
formed by union of smaller veins draining the alveoli of the
lungs. On the left side the superior and inferior veins drain
the upper and lower lobes of the lung, respectively. On the
Fig. 20.14. Scheme to show the veins of the heart right side the upper and middle lobes drain through the
as seen from the front.
superior vein and the lower lobe through the inferior vein.
upper end of the groove the vein turns to the left in the coronary
sulcus (alongside the circumflex branch of the left coronary The Superior Vena Cava
artery), winds round the left margin of the heart and ends in
the left extremity of the coronary sinus. The superior vena cava is formed by the union of the right
and left brachiocephalic veins (Fig. 20.15). Its upper end is
The Small Cardiac Vein
situated at the lower border of the first right costal cartilage.
The small cardiac vein is situated at the junction of the base of
It descends behind the first intercostal space, the second
the heart and its diaphragmatic surface (Fig. 20.14). It lies in
costal cartilage and the second intercostal space to end at
the posterior and right part of the coronary sulcus. It thus runs
the level of the third right costal cartilage by opening into
alongside the terminal part of the right coronary artery. The
the right atrium. The vessel is about 7 cm long. The lower
small cardiac vein ends by joining the coronary sinus near its
half of the vessel is enclosed within the fibrous pericardium.
termination.
Apart from the brachiocephalic veins the vena cava receives
The Middle Cardiac Vein the azygos vein that joins it on the right side about its middle.
The middle cardiac vein begins near the apex of the heart and
runs backwards on the diaphragmatic surface (Fig. 20.14). It Relations:
lies in the posterior interventricular groove, i.e. it accompanies 1. To the right side: right lung and
pleura, right phrenic nerve.
2. Anteromedially: ascending aorta.
3. Posteromedially: trachea, right
vagus nerve.
Development of Superior vena
cava
The superior vena cava is derived
from part of the right anterior
cardinal vein, and from the right
common cardinal vein.
Fig. 20.15. Large veins draining into the superior vena cava.
OESOPHAGUS, THYMUS, LYMPHATICS AND NERVES
Right Brachiocephalic Vein
This vein is formed by union of the

right internal jugular and subclavian
veins (Fig. 20.15). It ends by joining
the left brachiocephalic vein to form
the superior vena cava. The vein is
about 2.5 cm long. Its upper end
(beginning) lies behind the sternal
end of the right clavicle; while its
lower end (termination) lies at the
level of the lower border of the first
right costal cartilage (Fig. 20.15).
The tributaries of the right

brachiocephalic vein are:
(1) Right vertebral vein. Fig. 20.16. Tributaries of right and left brachiocephalic veins.
(2) Right internal thoracic vein.
(3) An inferior thyroid vein.
(4) Right first intercostal vein.
left clavicle (Fig. 20.15). This vein is about twice as long as
Left Brachiocephalic Vein the right brachiocephalic vein as it has to run obliquely
behind the manubrium to reach its termination at the lower
This vein is formed by union of the left internal jugular and border of the first right costal cartilage. Here it joins the
subclavian veins: the vein begins behind the sternal end of the right brachiocephalic vein to form the superior vena cava.
21 : The Oesophagus, The Thymus,

Lymphatic and Nerves of the Thorax
THE OESOPHAGUS
The oesophagus (Fig. 21.1) is a tubular structure that starts (in the neck) at
the lower end of the oropharynx (i.e. in front of the sixth cervical vertebra).
It descends through the lower part of the neck, and enters the thorax through
its inlet.
Within the thorax the oesophagus descends first through the superior
mediastinum, and then through the posterior mediastinum. It leaves the
thorax by passing through an aperture in the diaphragm: this aperture lies
at the level of the tenth thoracic vertebra. After a very short course in the
abdomen the oesophagus ends by joining the stomach. The junction with
the stomach lies at the level of the eleventh thoracic vertebra.
The upper end of the oesophagus lies in the midline (Fig. 21.1). Its lower
end is distinctly to the left of the midline. Here its position corresponds to
that of the left seventh costal cartilage 2.5 cm from the junction of the Fig. 21.1. Lateral curvatures of the oesophagus
latter with the sternum. and the levels of its upper and lower ends.
209
210
descending thoracic aorta (and in front of the vertebral
column), but lower down it gradually passes anterior to the
aorta (Fig. 21.2).
As the oesophagus and aorta descend through the posterior
mediastinum they both lie first behind the heart, and then
behind the posterior part of the diaphragm. In the upper part
of the posterior mediastinum the oesophagus is in contact
with the right lung, but is separated from the left lung by the
aorta. In the lower part of the mediastinum the oesophagus
crosses to the left (in front of the aorta) and it, therefore,
comes into contact with the left lung. Some other relations
of the oesophagus are shown in Figures 20.12 and 21.2.
Development
The oesophagus is derived from the foregut.
THE THYMUS
The thymus consists of two pear shaped lobes, right and

left, that may be joined to each other by connective tissue.
These lobes are placed just behind the sternum. A cord like
prolongation from each lobe may extend into the neck,
reaching the lower border of the thyroid gland.
The size of the thymus increases till the age of puberty.
Thereafter it retrogresses in size and the lymphoid tissue in
it is gradually replaced with fat.
Each lobe of the thymus has a connective tissue capsule.
Connective tissue septa passing inwards from the capsule
Fig. 21.2. Scheme to show posterior relations of the

oesophagus (that is drawn as if transparent).
The transverse diameter of the oesophagus is about 2.5 cm

(one inch). Its total length is about 25 cm (10 inches).
Relations in the Thorax
The oesophagus first lies in the superior mediastinum and then
in the posterior mediastinum. In the superior mediastinum the
oesophagus lies in front of the vertebral column and behind
the trachea (Fig. 20.4). On either side it is related to the
corresponding pleura and lung. As the oesophagus enters the
lower part of the superior mediastinum it passes behind and to Fig. 21.3. Diagram to show location of the thymus
the right of the arch of the aorta. Descending into the posterior in a person at puberty.
mediastinum the oesophagus first lies to the right of the
Fig. 21.5. Scheme to show the area of the body
draining through the thoracic duct.
LYMPHATICS OF THE THORAX
Thoracic Duct
The thoracic duct is the largest lymph vessel in the body. It

is about 40 cm long. It begins in the abdomen as the upward
continuation of a sac called the cisterna chyli (Fig. 21.4). It
enters the thorax by passing through the aortic opening of
the diaphragm. Having entered the thorax the thoracic duct
ascends between the aorta and the vena azygos up to the
fifth thoracic vertebra. It then inclines towards the left side
and passes deep to the arch of the aorta. The thoracic duct
now comes to lie along the left margin of the oesophagus: in
this position it runs upwards through the superior
mediastinum and into the lower part of the neck. The thoracic
duct ends by opening into the junction of the left subclavian
Fig. 21.4. Course and relations of the thoracic duct
vein and the internal jugular vein (Figs. 21.4).
as seen from the front.
Area of drainage:
As a generalization it may be said that the thoracic duct
incompletely subdivide the lobe into a large number of lobules. carries lymph from both sides of the body below the
Each lobule has an outer cortex and an inner medulla. Both the diaphragm, and from the left side above the diaphragm. In
cortex and medulla contain epithelial cells and lymphocytes other words it carries lymph from both lower limbs, the
(thymocytes). The lymphocytes undergo a process of maturation pelvis, the abdomen, the left half of the thorax, the left half
in the thymus where they become immunologically competent of the head and neck, and the left upper limb (Fig. 21.5).
T-lymphocytes.
Tributaries of thoracic duct:
Development Most of the lymph from the abdomen reaches the thoracic
The thymus develops from the endoderm of the third pharyngeal duct through the cisterna chili. Near its termination the
pouch. thoracic duct receives the left subclavian trunk from the
211
212
left upper limb and a left jugular trunk from the left half of the
head and neck. It may also receive the left bronchomediastinal
trunk from the upper part of the thorax, but this trunk usually
enters the subclavian vein independently.
Right bronchomediastinal trunk
Lymph from the right half of the thorax is drained by the right
bronchomediastinal lymph trunk. It ascends into the neck where
it joins the right jugular trunk from the right half of the head
and neck, the right subclavian trunk from the right upper limb,
to form the right lymphatic duct.
Fig. 21.6. Scheme to show lymphatic drainage of

Lymph Nodes of the Thorax skin and deeper tissues of thoracic wall.
The lymph nodes of the thorax may be divided into those

present in relation to the thoracic wall and those present in
relation to the contents of the thorax. The thoracic surface is drained (through diaphragmatic
lymph nodes) to the parasternal nodes, nodes around the
A. Nodes present in relation to thoracic wall: oesophagus and around the thoracic aorta.
1. The parasternal nodes lie at the anterior ends of the Lymphatics from the abdominal surface of the diaphragm
intercostal spaces, along the course of the internal thoracic drain into lymph nodes within the abdomen.
artery.
2. The intercostal lymph nodes lie at the posterior ends of the Lymphatic drainage of the lungs
intercostal spaces. The lungs are drained by two sets of vessels, superficial
3. The diaphragmatic lymph nodes lie on the thoracic surface and deep (Fig. 21.7). The superficial vessels lie near the
of the diaphragm. surface of the lung. Curving around its surfaces, borders and
fissures they converge on to the bronchopulmonary nodes
B. Nodes present in relation to contents of the thorax: (lying near the hilum of the lung). The deep vessels follow
1. The brachiocephalic lymph nodes lie in the superior the bronchi. They drain first into the pulmonary nodes (in
mediastinum, in front of the brachiocephalic veins. the substance of the lung) and then into the
2. The posterior mediastinal lymph nodes are present in bronchopulmonary nodes. Vessels arising from the
relation to the oesophagus and the descending thoracic aorta. bronchopulmonary nodes pass to the tracheo-bronchial nodes
3. The tracheobronchial lymph nodes lie along the trachea and from there into the bronchomediastinal trunk.
and bronchi. They consist of the following subgroups. The
paratracheal nodes lie on either side of the trachea. The Lymphatic drainage of the heart
superior tracheobronchial nodes lie in the angle between the The lymphatics of the heart drain into the brachiocephalic
trachea and the principal bronchus (right or left). The inferior nodes and the inferior tracheobronchial nodes.
tracheobronchial nodes lie below the bifurcation of the
trachea. The broncho-pulmonary nodes are situated at the
hilum of the right and left lungs. The pulmonary nodes lie
along the bronchi within the substance of the lungs.
Lymphatic Drainage of the Thoracic Wall
a. The skin overlying the thorax drains mainly into the axillary
lymph nodes. The vessels from the back of the thorax end in
the posterior group, while those from the front end in the
anterior group. The skin near the sternum is drained into the
parasternal nodes (Fig. 21.6).
b. The deeper tissues (including muscles covering the chest
wall, and the costal pleura) drain anteriorly into the parasternal
nodes and posteriorly into the intercostal nodes (Fig. 21.6).
c. The diaphragm is drained by separate sets of lymph vessels
on its thoracic and abdominal surfaces.
Fig. 21.7. Lymphatic drainage of the lungs.
Fig. 21.8. Lymphatic drainage of trachea. Fig. 21.9. Lymphatic drainage of oesophagus.
Lymphatic drainage of thymus The thoracic part of the trachea drains into the right and
The thymus drains into the parasternal, brachiocephalic and left superior tracheobronchial nodes and into the inferior
tracheobronchial nodes. tracheobronchial nodes.
Lymphatic drainage of Trachea Lymphatic drainage of Oesophagus
The cervical part of the trachea drains into the deep cervical The cervical part of the oesophagus drains into the deep
nodes directly and also through the pretracheal and cervical nodes (Fig. 21.9). The thoracic part of the
paratracheal nodes (Fig. 21.8). oesophagus drains into the posterior mediastinal lymph
nodes. The abdominal part of the oesophagus drains into
nodes present in relation to the left gastric artery.
NERVES OF THE THORAX
The Phrenic Nerves a. Above the arch of the aorta the nerve lies in the interval
between the left common carotid and left subclavian arteries.
The phrenic nerves are amongst the most important nerves in b. The nerve then crosses the aortic arch. Here the nerve
the body as they are the only motor supply to the diaphragm. crosses superficial to the left superior intercostal vein.
Each nerve (right or left) arises from spinal nerves C3, C4 and c. Below the arch of the aorta the phrenic nerve crosses in
C5. front of the structures comprising the root of the left lung,
The nerve descends vertically through the lower part of the and then descends across the heart (left ventricle) lying
neck, and then through the mediastinum of the thorax to reach between the parietal pericardium and the mediastinal pleura.
the diaphragm. The relations of the right phrenic nerve are as follows (Fig.
The relations of the left phrenic nerve are as follows (See 18.14).
Fig. 18.15): After entering the thorax the nerve lies over (lateral to) the
right brachiocephalic vein, the superior vena cava, the right
atrium, and finally, the inferior vena cava.
213
214
PRELIMINARY
REMARKS ON THE
AUTONOMIC
NERVOUS SYSTEM
The autonomic nervous system is

responsible for the nerve supply of
viscera and blood vessels. It is
subdivided into two main parts.
These are the sympathetic and
parasympathetic nervous systems.
Both these divisions contain
efferent as well as afferent fibres.
The efferent fibres supply smooth
muscle throughout the body. The
influence of these nerves may be
either to cause contraction or
relaxation. In a given situation the
sympathetic and parasympathetic
nerves generally produce opposite
effects. For example, sympathetic
stimulation causes dilatation of
the pupil, whereas parasym-
pathetic stimulation causes
Fig. 21.10. Basic plan of the sympathetic and parasympathetic
constriction. In addition to the
nervous systems.
supply of smooth muscle,
autonomic nerves supply glands:
such nerves are described as secretomotor. The secretomotor
nerves to almost all glands are parasympathetic. The only The autonomic plexuses to be seen in the thorax are as
exception are the sweat glands that have a sympathetic supply. follows:
In the thorax, the parasympathetic nervous system is (a) Cardiac plexuses:

represented by the vagus nerve; and the sympathetic nervous Superficial cardiac plexus.
system by the right and left sympathetic trunks and their Deep cardiac plexus.
branches. (b) Pulmonary plexuses:
Anterior pulmonary plexus.
Basic Arrangement of Efferent Autonomic Pathways Posterior pulmonary plexus.
A pathway for supply of smooth muscle or gland always (c) Oesophageal plexuses:
consists of two neurons that synapse in a ganglion. The cell Anterior and posterior.
body of the first, or preganglionic, neuron is located within
the brain or spinal cord. Its axon enters a peripheral nerve and
after a variable course it ends in a ganglion. The cell body of
the second, or postganglionic, neuron is located in the ganglion. Basic Arrangement of Parasympathetic Pathways
Its axon reaches the smooth muscle or gland and supplies it.
These remarks apply to both sympathetic and parasympathetic The parasympathetic nervous system consists of a cranial
pathways. part and a sacral part (Fig. 21.10).
Preganglionic neurons of the cranial part are located in
Autonomic Plexuses the brainstem (general visceral efferent nuclei of the cranial
Autonomic fibres, both sympathetic and parasympathetic, reach nerves). Details of these will be considered in the section on
the thoracic and abdominal viscera through a number of the head and neck. The preganglionic fibres arising from
plexuses. Although they are called plexuses they contain them pass through the third, seventh, ninth and tenth cranial
numerous neurons and are in fact equivalent to ganglia. Most nerves. They collectively constitute the cranial
of the sympathetic fibres passing through them are parasympathetic outflow. The only fibres of this outflow
postganglionic (having relayed in ganglia on the sympathetic relevant to the thorax and abdomen are those that travel
trunk). Some are preganglionic and relay in the plexuses. through the vagus nerve.
Parasympathetic fibres reaching the plexuses (through the Postganglionic neurons of the cranial part of the
vagus) are entirely preganglionic. The neurons in the plexuses parasympathetic nervous system are located in a number of
are mostly parasympathetic postganglionic neurons. ganglia present in association with branches of the cranial
nerves concerned. They will be studied in the head and neck.
Postganglionic neurons related to the vagus nerve are scattered
in the autonomic plexuses mentioned above.
Preganglionic neurons of the sacral part of the parasympathetic
nervous system are located in the sacral segments of the spinal
cord (intermediolateral grey column in spinal segments S2, S3
and S4). Their axons constitute the sacral parasympathetic
outflow (Fig. 21.10). They are concerned with the innervation
of some viscera in the abdomen and pelvis and will be dealt
with later.
THE VAGUS NERVE
The vagus nerve arises from the brain (medulla oblongata). It

descends vertically in the neck in close relationship to the
internal or common carotid artery and the internal jugular vein. Fig. 21.11. Course of right vagus nerve in the
In the lower part of the neck the nerve crosses anterior to the superior mediastinum.
first part of the subclavian artery, and enters the thorax.
Course and relations of vagus nerve in the thorax
In the superior mediastinum the right vagus nerve lies on the

right side of the trachea (Fig. 21.11). Here it is posteromedial
first to the right brachiocephalic vein and then to the superior
vena cava. The nerve passes deep to the vena azygos to reach
the posterior side of the root of the right lung.
In the superior mediastinum the left vagus nerve descends
between the left common carotid and left subclavian arteries
(Figs 27.3 and 21.12). It crosses the left side of the arch of the
aorta to reach the posterior aspect of the root of the left lung.
Having reached the root of the lung each vagus nerve (right or
left) divides into a number of branches. The distribution of the
vagus nerves in the thorax as follows.
Branches of the Vagus Nerve to structures in the Thorax
Note at the outset that some branches arising from the vagi, in
the neck, descend into the thorax. These will also be considered Fig. 21.12. Course of left vagus nerve in the
here. superior mediastinum.
1. Recurrent laryngeal nerve:
The course of the recurrent laryngeal nerve is different on the The recurrent laryngeal nerves provide the motor supply to
right and left sides (Fig. 21.13). most of the intrinsic muscles of the larynx. The nerves also
On the right side the nerve is confined to the neck and does not provide the sensory supply to the mucous membrane of the
enter the thorax. It arises from the vagus as the latter passes in lower half of the larynx.
front of the subclavian artery. It passes backwards below the
2. Cardiac branches and cardiac plexuses:
artery and then upwards behind the artery forming a loop. The
nerve then runs upwards and medially to reach the side of the The superficial cardiac plexus is formed by (1) the inferior
trachea. cervical cardiac branch of the left vagus nerve, and (2) the
On the left side the recurrent laryngeal nerve arises from the superior cervical cardiac branch of the left sympathetic trunk.
vagus in the thorax, as the latter crosses lateral to the arch of The deep cardiac plexus is situated in front of the bifurcation
the aorta. The nerve winds below the arch of the aorta of the trachea. The nerves taking part in its formation are as
(immediately behind the ligamentum arteriosum) and then follows.
passes upwards and medially to reach the side of the trachea 1. Branches from vagus nerves.
(Fig. 21.13). The nerve ascends in the groove between the a. Right superior and inferior cervical cardiac branches.
trachea and the oesophagus, and passes into the neck. b. Left superior cervical cardiac branch.
215
216
Fig. 21.13. Course of recurrent laryngeal nerves on the

right and left sides.
c. Branches from right and left vagi arising in the thorax.

d. Branches from the right and left recurrent laryngeal nerves.
2. Branches from sympathetic trunks
a. Left middle and inferior cervical.
b. Right superior, middle and inferior cervical.
c. Branches from thoracic part of sympathetic trunk.

Branches from the superficial and deep cardiac plexuses supply
the heart.
3. Pulmonary branches:
On reaching the root of the lung each vagus divides into a
number of branches that form the anterior and posterior
Fig. 21.14. Branches of the thoracic part of the
pulmonary plexuses. Each plexus also receives several sympathetic trunk.
branches from the sympathetic trunk. Branches from these
plexuses supply smooth muscle in the walls of bronchi.
4. Oesophageal branches: Basic Arrangement of Sympathetic Pathways
Fibres of the right and left vagus nerves emerge from the
posterior pulmonary plexuses and descend on the oesophagus The ganglia related to the sympathetic nerves are located
forming an anterior and a posterior oesophageal plexus. mainly in the sympathetic trunk (right or left). Each trunk is
Branches from these plexuses supply the oesophagus. a long nerve cord placed on either side of the vertebral
Fibres emerging from the lower end of the anterior oesophageal column and extending from the base of the skull above, to
plexus collect to form the anterior vagal trunk that is made the coccyx below. The sympathetic ganglia are seen as
up mainly of fibres from the left vagus. Similarly fibres arising enlargements along the length of the trunk.
from the posterior oesophageal plexus (mainly right vagus) Basically there is one ganglion corresponding to each spinal
collect to form the posterior vagal trunk. The anterior and nerve, but in many situations the ganglia of adjoining
posterior vagal trunks enter the abdomen where they are segments fuse so that they appear to be fewer in number
distributed to many abdominal viscera. than the spinal nerves. The ventral primary ramus of each
spinal nerve receives fibres from a sympathetic ganglion
through a delicate communication called the grey ramus
communicans. In the case of spinal nerves T1 to L2 (or L3)
there is, in addition to the grey ramus, a white ramus
communicans through which fibres pass from the spinal nerve In the cervical region there are usually three ganglia: superior,
to the ganglion. middle and inferior. The first thoracic ganglion is usually
The cell bodies of sympathetic preganglionic neurons are fused to the inferior cervical ganglion the two forming the
located in the intermediolateral grey column of the spinal cervicothoracic ganglion. There are usually eleven ganglia
cord in spinal segments T1 to L2. Their axons leave the spinal in the thorax, four in the lumbar region, and four or five in
cord through the anterior nerve root to enter the corresponding
the sacral region. The lower fused ends of the right and left
spinal nerve. After a short course through the ventral primary
sympathetic trunks are thickened by the presence of a midline
rami these fibres pass into the white rami communicantes and
reach the sympathetic ganglia. These preganglionic fibres ganglion called the ganglion impar.
leaving the spinal cord through spinal nerves T1 to L2
collectively form the thoracolumbar outflow (Fig. 21.10).
Sympathetic postganglionic neurons are located primarily in Thoracic Part of Sympathetic Trunk
ganglia located on the sympathetic trunks. Some are located in
peripheral autonomic plexuses. They supply: The ganglia on the thoracic part of the sympathetic trunk
1. Sweat glands and arrectores pilorum muscles of the skin
give off medial and lateral branches. Lateral branches arising
(through communications with spinal or cranial nerves)
from each ganglion connect it to the corresponding spinal
2. Blood vessels.
3. Viscera. nerve by white and grey rami communicantes as already
described.
The medial branches arising from the ganglia supply viscera.
The Sympathetic Trunk Fibres for the heart, lungs and oesophagus pass through
cardiac, pulmonary and oesophageal plexuses described
The sympathetic trunk (right or left) is a long nerve cord
above.
extending from the base of the skull to the coccyx. It bears a
The lower thoracic ganglia give origin to prominent medial
number of ganglia along its length.
In the neck the trunk lies posterior to the carotid sheath, anterior branches called the greater, lesser and lowest splanchnic
to the transverse processes of the cervical vertebrae. In the nerves (Figs 21.14). All these nerves pass through the
thorax the trunk descends in front of the heads of the ribs, and diaphragm and enter the abdomen. From Figure 21.14
in the abdomen it is anterolateral to the lumbar vertebrae. Lower observe that the greater splanchnic nerve ends mainly in
down, the trunk descends anterior to the sacrum. Passing the coeliac ganglion; the lesser splanchnic nerve ends in
medially as they descend the right and left sympathetic trunks the aorticorenal ganglion; and the lowest splanchnic nerve
join each other in front of the coccyx. ends in the renal plexus.
217
218

Correlations of the Thorax
SURFACE MARKING
The most important organs within the thorax are the heart and Pulmonary valve and pulmonary trunk
lungs. The surface projection of the pleura and lungs has The pulmonary valve is about 2.5 cm broad. It lies
already been described on page 193. The surface projection of transversely, partly behind the left third costal cartilage and
the borders and valves of the heart has been described on page partly behind the sternum. This gives us the lower end
201. The surface marking of some other structures is described (beginning) of the pulmonary trunk. From here draw two
below. vertical parallel lines upwards to the level of the left second
costal cartilage. This gives us the level at which the
Surface marking of the trachea
pulmonary trunk divides into the right and left pulmonary
Draw two vertical lines parallel to each other, and about 2 cm arteries.
apart, starting just below the cricoid cartilage and ending at Ascending aorta and Aortic valve
the level of the sternal angle. The trachea ends at this level by The aortic valve is placed obliquely behind the left half of
dividing into the right and left principal bronchi. the body of the sternum at the level of the third intercostal
Surface marking of right principal bronchus
space. It is about 2.5 cm broad (Fig. 20.3). From the ends of
The upper end of the right principal bronchus lies, more or the line representing the valve draw two parallel lines passing
less in the midline, at the level of the sternal angle. Its lower upwards and to the right to reach the sternal angle (right
end lies over the sternal end of the right third costal cartilage. half).
The bronchus is marked by drawing two lines 1 cm apart, Arch of the aorta
running downwards and to the right, joining these two levels. The projection of the arch on to the anterior wall of the
The bronchus is about 2.5 cm long. thorax is shown in Figure 20.3. Note the following points.
Surface marking of left principal bronchus
1. The lower end of the arch of the aorta corresponds to the
This bronchus is 5 cm long. Its upper end lies at the level of the upper end of the ascending aorta described above. In other
sternal angle. Its lower end lies over the left third costal words the anterior end of the arch lies behind the right half
cartilage, 4 cm from the median plane. It is marked by two of the sternal angle.
lines, 1 cm apart joining these two levels. 2. The posterior end of the arch also lies at the level of the
sternal angle. It lies partly behind the left half of the sternal
Surface marking of oesophagus angle and partly behind the second left costal cartilage. (Do
The upper end the oesophagus lies at the lower border of the not forget that the posterior end really lies against the
cricoid cartilage. From here draw two lines, 2.5 cm apart, posterior wall of the thorax, at the level of the lower border
descending to the upper border of the manubrium sterni. of the fourth thoracic vertebra).
Continue the two lines downwards till they reach the sternal 3. The summit of the arch reaches up to the level of the
angle. middle of the manubrium sterni.
To mark the part of the oesophagus that lies in the posterior
Descending thoracic aorta
mediastinum continue the same lines downwards, but with a
distinct inclination to the left side. The lines should end at the The upper end of the descending thoracic aorta corresponds
level of the left 7th costal cartilage. Here the centre of the to the lower end of the arch of the aorta. It lies at the level of
oesophagus should be 2.5 cm to the left of the midline. the lower border of the fourth thoracic vertebra. Its projection
on to the anterior wall of the thorax lies over the left part of
Internal thoracic artery the sternal angle and the adjoining part of the second left
The upper end of this artery lies in the neck, 1 cm above the costal cartilage. In other words the upper end of the
sternal end of the clavicle, 3.5 cm from the median plane. The descending aorta lies to the left of the midline.
lower end of the artery lies in the sixth intercostal space The lower end has to be marked at the level of the lower
1.2 cm from the lateral border of the sternum. border of the twelfth vertebra. This level lies over the anterior
abdominal wall. To mark it you have to first mark the transpyloric of that of the left common carotid i.e. it is near the left border
plane. (This is an imaginary transverse line drawn on the anterior of the manubrium sterni. The artery is marked by two parallel,
abdominal wall midway between the upper end of the sternum vertical, lines that extend to the left sternoclavicular joint.
and the upper border of the pubic symphysis. It lies roughly a
Superior vena cava
hands breadth below the xiphoid process). Take a point 2.5 cm
above this plane, in the midline. Remember that the lower end The vena cava can be represented by two parallel and vertical
of the thoracic aorta is about 2.5 cm broad and lies in the median lines 2 cm apart. Its upper end (beginning) lies over the lower
plane. border of the first right costal cartilage. Its lower end
The vessel can now be marked merely by drawing two parallel (termination) is at the level of the upper border of the third
lines, 2.5 cm apart joining the upper and lower ends. As the right costal cartilage.
vessel descends it gradually passes from the left side to a median Right brachiocephalic vein
position. The upper end of the vein lies behind the medial end of the
Branches of arch of aorta clavicle (See Fig. 20.15). The lower end (termination) of this
To mark any of these arteries first mark the upper border of the vein corresponds to the upper end of the superior vena cava
arch of the aorta as described above. (and lies over the lower border of the first right costal
cartilage). The lines representing the vein should be vertical
Brachiocephalic artery
and 1.5 cm apart.
Its lower end lies over the centre of the manubrium sterni. Its
upper end lies behind the right sternoclavicular joint. Left brachiocephalic vein
The upper end of the vein lies deep to the medial end of the
Left common carotid artery in thorax
Its origin from the arch of the aorta lies just to the left of the left clavicle. The lower end of this vein (termination)
centre of the manubrium (i.e. just to the left of the origin of the corresponds to the upper end of the superior vena cava (and
brachiocephalic artery). From here it passes upwards and to lies over the lower border of the first right costal cartilage).
the left to reach the left sternoclavicular joint. The vein is represented by two lines 1.5 cm apart joining
these two levels (See Fig. 20.15). Note that the vein runs
Left subclavian artery in thorax obliquely and crosses behind the left sternoclavicular joint
The origin of this artery from the arch of the aorta is to the left and the manubrium sterni.
As the thorax contains the heart and lungs it is a region of great border of the upper limb, and there may be atrophy of small
clinical importance. This section seeks to introduce the beginner muscles of the hand. Vascular symptoms are also present.
to the more important clinical conditions to be encountered 5. Sternal puncture: This is a procedure in which specimens
here. of bone marrow can be obtained by passing a canula into
the manubrium sterni. Examination of bone marrow is useful
Some conditions in relation in diagnosis of anemias, leukaemias, and some other
to the Thoracic Skeleton diseases.
1. Deformities may involve the thoracic spine. The spine may Intercostal spaces
be bent forwards (kyphosis), or to one side (scoliosis).
2. In the condition called ectopia cordis the sternum and the 1. Cold abscess: Cold abscesses may be seen in relation to
adjoining of parts of costal cartilages and ribs are missing, so intercostal spaces. They result from tuberculous infection
that the heart can be seen from the outside. of intercostal lymph nodes, or of vertebrae. Pus from these
3. Accessory ribs may be present. Such a rib may be attached sources can pass along intercostal nerves and vessels for
to the 7th cervical vertebra (cervical rib) or to the first lumbar considerable distances. It generally becomes superficial at
vertebra (lumbar rib). The clinical importance of a cervical rib sites where the lateral or anterior cutaneous branches emerge.
is discussed on page 74 2. Paracentesis thoracis: Fluid in the pleural cavity can be
4. Thoracic outlet syndrome: This syndrome is caused by aspirated by passing a needle into an intercostal space
pressure on spinal nerve T1 and on the subclavian artery as (usually the 6th) in the midaxillary line. Remember that the
they cross the first rib. There is pain radiating along the ulnar neurovascular bundle of each intercostal space lies along
219
220
the upper border of the space, and injury to it can be avoided Oesophageal varices
by passing the needle through the lower part of the space. The lower end of the oesophagus is a site of communication
of portal and systemic veins. In some diseases the
anastomoses enlarge and are called oesophageal varices.
They can be a source of bleeding into the stomach and can
The Diaphragm
lead to haematemesis (vomiting of blood).
Barium swallow
Congenital diaphragmatic herniae
The lumen of the oesophagus can be visualised in the living
Parts of the diaphragm may fail to develop resulting in gaps in
subject by taking a skiagram immediately after the subject
the muscle. Abdominal contents may pass through these gaps
swallows a meal containing a suitable barium salt. The
to produce herniae. Depending on the sites of the gap the
procedure is referred to as barium swallow.
diaphragmatic herniae may be (a) posterior, (b) posterolateral,
(c) retrosternal or (d) central. Dysphagia
The oesophagus may be compressed by a mass in the
Hiatus hernia:
mediastinum. Compression causes difficulty in swallowing
This is a hernia through the oesophageal opening of the
(dysphagia).
diaphragm. Three varieties are described.
Sliding hiatus hernia
In this variety the oesophagus is short. The cardio-oesophageal
The Trachea
junction and the adjoining part of the stomach pass through
the hiatus and lie in the posterior mediastinum.
Tracheostomy
Paraoesophageal hiatus hernia
This is an operation to create an artificial opening in the
In this variety the oesophagus is of normal length and the
trachea (in the neck). It is used to provide an alternative
cardio-oesophageal junction remains in the abdomen. A part
route for supply of air to the lungs when there is obstruction
of the stomach passes through the hiatus and lies within the
in the larynx or upper end of the trachea.
posterior mediastinum parallel to the oesophagus.
Pleura
The Oesophagus
1. The visceral pleura is supplied by autonomic nerves (that
Congenital malformations reach it through the lung). It is relatively insensitive to pain.

The oesophagus may show congenital stenosis (narrowing) In contrast the parietal pleura is supplied by cerebrospinal
or atresia (non-development of a segment). Atresia is often nerves (intercostal, phrenic) and is very sensitive to pain.
accompanied by abnormal communications (fistulae) between The lower part of the costal pleura is supplied by the lower
the oesophagus and the trachea. intercostal nerves. We have seen that these nerves pass into
the abdominal wall and supply skin and muscles there.
Constrictions Because of this fact pain arising from the lower part of the
The lumen of the oesophagus normally shows constrictions costal pleura (in pleurisy or pneumonia) can be referred to
at the following sites. the front of the abdomen.
1. At its upper end. 2. Inflammation of the pleura is referred to as pleurisy or
2. Where it is crossed by the arch of the aorta. pleuritis. Pleurisy may be dry or may be accompanied by
3. Where it is crossed by the left principal bronchus. effusion of fluid into the pleural cavity. In dry pleurisy the
4. Where it pierces the diaphragm. pleura is covered by a fibrinoid exudate that makes it rough.
For the purpose of passing a tube through the oesophagus it During respiration the two layers of pleura rub against each
is important to know that these constrictions lie 6", 9", 11", other resulting in pain. The friction produces a sound (pleural
and 15" from the incisor teeth. rub) that can be heard through a stethoscope.
3. We have seen that normally the pleural cavity is a potential
Cardio-oesophageal junction space containing a thin film of serous fluid that separates
The junction of the lower end of the oesophagus and the visceral and parietal pleura. Fluid or air can accumulate in
stomach is guarded by a sphincteric mechanism that prevents the pleural cavity. Presence of air in the pleural cavity is
regurgitation of stomach contents into the oesophagus, called pneumothorax. Presence of serous fluid is referred
Neuromuscular incoordination at the lower end of the to as pleural effusion. Presence of blood in the pleural cavity
oesophagus may cause difficulty in passage of food from is called haemothorax, and presence of pus is called
oesophagus to stomach (achalasia cardia or cardiospasm). empyema.
Lungs and Bronchi Echocardiography
Echocardiography is a technique in which the structure of
1. The interior of the trachea and bronchi can be seen through the heart and its functioning can be seen on a screen using
an instrument called a bronchoscope. ultrasound waves.
2. Bronchography is a procedure in which X-ray pictures of
the bronchi can be obtained after instilling a radio-opaque
Some Congenital Malformations
substance into them.
3. Inflammation of bronchi is called bronchitis. It may be acute Patent ductus arteriosus
or chronic. In the fetus the ductus arteriosus connects the left pulmonary
4. In some cases there is localised or more widespread artery to the arch of the aorta just distal to the origin of the
dilatations of bronchi which become seats of infection. This left subclavian artery. Normally, the ductus is obliterated
condition is called bronchiectasis. very soon after birth. If the ductus remains patent after birth
5. Inflammation in the lung is referred to as pneumonia or blood from the aorta enters the pulmonary arteries.
pneumonitis. In some cases serious lung infections lead to
Coarctation of the aorta
formation of a lung abscess and cavities within the lungs.
This term refers to a condition in which the aorta is
6. In bronchial asthma spasm of bronchial muscle causes
abnormally narrow near the attachment of the ligamentum
considerable difficulty in breathing. It is usually a result of
arteriosum.
allergy.
7. Difficulty in breathing is referred to as dyspnoea. This can Aortic and pulmonary valves
be a feature of any serious lung disease. These orifices may be too narrow (stenosis) or may show
8. If a clot forming in any vein breaks loose it travels through regurgitation.
the blood stream into the right side of the heart and from there
Atrial septal defects
into pulmonary arteries. Depending upon its size such a clot
This may be:
would get lodged in one of the ramifications of a pulmonary
1. Patent foramen ovale.
artery. The effects of pulmonary embolism depend on the size
2. Septum secundum defect.
of the vessel blocked.
3. Septum primum defect..
9. An operation for removal of an entire lung is
pneumonectomy. Removal of one lobe is lobectomy, and Ventricular septal defect
removal of one bronchopulmonary segment is called segmental Most of the defects involve the membranous part of the
resection. septum that is close to the aortic and pulmonary valves. As
a result, ventricular septal defects are often found in
Congenital anomalies of lungs and bronchi
association with abnormalities of these orifices.
1. Part of a lung, or even an entire lung may be missing.
2. Various abnormalities in formation of lobes and fissures of Fallots tetralogy
the lungs may be seen. The four features that make up this tetralogy are as follows:
3. Accessory lobes may be present. 1. There is an interventricular septal defect.
A part of the upper lobe of the right lung may lie medial to the 2. There is pulmonary stenosis.
azygos vein. This part is called the azygos lobe. 3. The aortic opening over-rides the free upper edge of the
ventricular septum. In other words the aorta communicates
with both the right and left ventricles.
4. There is hypertrophy of the wall of the right ventricle.
The Heart and Pericardium
Acquired Valvular Diseases

Cardiac catheterization and angiography
Inflammation of the endocardium is referred to as
A fine catheter introduced into the brachial or femoral artery
endocarditis, and that of the myocardium as myocarditis.
can be made to pass into the left side of the heart. Similarly a
Bacterial endocarditis often follows rheumatic infection in
catheter introduced into the femoral vein can reach the right
childhood and can damage cusps of valves. Most frequently
side of the heart. The procedure is done under X-ray control.
it affects the mitral and aortic valves.
Cardiac catheterization is used to collect samples of blood from
individual chambers for analysis. Pressures within the chambers Mitral valve disease
can also be recorded. Dyes can be injected into specific parts As a result of infection, and of subsequent fibrosis, the cusps
to obtain angiograms. The coronary vessels and their branches become thickened with reduced mobility, and often fuse with
can also be visualised (coronary angiography) and sites of each other. This leads to a narrowed mitral orifice (mitral
narrowing determined. stenosis). Mitral stenosis is often combined with
regurgitation (some blood flowing back from ventricle to
atrium). Mitral stenosis can be corrected surgically.
221
222
Aortic valve disease The pericardial cavity may be filled by fluid (pericardial
The aortic valve may undergo stenosis, or may show effusion).
regurgitation. Pericardial fluid can be drained by passing a needle
immediately to the left of the xiphoid process (i.e., in the
Ischaemic Heart Disease
angle between the xiphoid process and left costal margin).
With increasing age all arteries of the body undergo
atherosclerosis as a result of which their lumen becomes
narrower. This process also takes place in the coronary arteries
reducing oxygen supply to the myocardium. The Mediastinum
Narrowing of coronary arteries produces no symptoms as long
as enough oxygen is available to meet the requirements of the
Mediastinal shift
person. When the oxygen supply becomes insufficient at certain
The mediastinum may be displaced to the opposite side if
levels of activity (like exercise, or climbing stairs) this leads to
there is a large collection of air or of fluid in a pleural cavity.
severe pain (angina pectoris). The pain is predominantly in
the region of the sternum. It can radiate to the left shoulder and Mediastinitis
arm, into the neck and jaw, or to the back. Inflammation in the mediastinum is called mediastinitis.
Complete blockage of a branch of a coronary artery leads to
Mediastinal masses
death of the part of the myocardium supplied by that branch
A mediastinal mass may be a tumour, an aneurysm, a cyst,
(myocardial infarction). Myocardial infarction (or heart attack
or a mass of enlarged lymph nodes. An enlarged thyroid may
in laymans language) can result in death.
extend into the mediastinum (retrosternal goitre).
The state of the coronary arteries can be determined by
coronary angiography. Sites of narrowing, or occlusion, of Aortic aneurysms
the arteries can be determined. A dilatation of a segment of the aorta is referred to as
In suitable cases coronary bypass surgery can enable a person aneurysm.
with ischaemic heart disease to lead a much more normal life.
Obstruction of superior vena cava
Cardiac arrest In obstruction to the superior vena cava the azygos vein
This term is used to describe stoppage of the beating of the becomes an important channel for maintaining venous return
heart. Cardiac arrest may result from a wide range of causes. A from the upper part of the body. In this context it is very
patient with cardiac arrest can be saved if immediate important to remember that at its lower end the azygos vein
resuscitative measures are taken. usually communicates with the inferior vena cava; and at its
upper end it opens into the superior vena cava at about its
Cardiac transplantation
middle.
The heart of one person can be transplanted into another person.
The procedure is attempted only on persons who are likely to
die in the absence of an implant (because of advanced disease
that cannot be treated by other means). The Thymus
Pericarditis
Enlargement of the thymus (or the presence of a tumour in
Inflammation of the pericardium is called pericarditis. It may
it) is often associated with a disease called myasthenia
be acute or chronic. In some cases a pericardial rub may be
gravis.
heard on ausculation .
INTRODUCTION TO THE ABDOMEN : BONES AND JOINTS
PART 4:ABDOMEN AND PELVIS
23 : Introduction to the Abdomen:

Bones and Joints
Extent of the abdominal cavity (i.e. the part of the pelvis above the pelvic brim). It is directly
continuous with the cavity of the true pelvis.
The cavity within the abdomen can be divided into a large
upper part, the abdominal cavity proper; and a lower part, the The walls of the abdomen
pelvic cavity, that lies within the true pelvis (Figs 23.1 and
23.2). The pelvic cavity is the part that lies below and behind The constitution of the anterior and posterior walls of the
the pelvic brim. abdomen can be understood by examining a transverse
Superiorly, the abdominal cavity is bounded by the diaphragm, section through the wall (Fig. 23.3). The posterior
that separates it from the cavity of the thorax. We have seen abdominal wall is made up, in the median plane, by the
that the domes of the diaphragm reach much above the level of lumbar vertebrae. Lying along each side of the vertebral
the costal margin. As a result of this fact a considerable part of bodies there is the psoas major muscle. Still more laterally
the abdominal cavity lies deep to the thoracic cage. the posterior wall is formed by a muscle called the quadratus
The abdominal organs lying in this part of the cavity are lumborum.
separated from pleurae and lungs only by the diaphragm. The part of the abdominal wall extending all the way from
Inferiorly, the abdominal cavity extends into the false pelvis the midline (in front) to the lateral edge of the quadratus
Fig. 23.1. Schematic sagittal section to show extent Fig. 23.2. Schematic coronal section through
and walls of the abdominal cavity. abdominal cavity to show its extent and its walls.
223
224
lumborum is referred to as the
anterior abdominal wall. However,
note that it is not confined to the
anterior aspect of the abdomen, but
covers it from the lateral side as well.
Next to the midline, the wall is
formed by the rectus abdominis
muscle that runs vertically. This
muscle is seen in transverse section
in Figure 23.3. Between the lateral
edge of the rectus abdominis and the
lateral edge of the quadratus
lumborum the anterolateral wall is
made up of three layers of muscle.
From outside to inside these layers
are formed by the external oblique,
internal oblique and transverse
muscles of the abdomen.
The innermost layer of muscle is
lined by a fascia called the fascia
transversalis. The fascia transver-
ESSENTIALS OF ANATOMY : ABDOMEN AND PELVIS
salis is covered on the inside by

parietal peritoneum, the two being
separated by a layer of extra-
peritoneal fat.
Regions of the Abdomen
The abdomen can be divided into

nine regions by using two transverse
and two vertical planes that are as Fig. 23.3. Schematic transverse section through abdominal wall to show its layers.
follows (Fig. 23.4):
1. The upper transverse plane is called the transpyloric plane. We have seen that the upper limit of the abdomen is
This lies midway between the upper border of the manubrium demarcated by the diaphragm. Roughly it can be said to lie
sterni (suprasternal notch) and the upper border of the at the level of the lower end of the body of the sternum. The
symphysis pubis. The plane is roughly midway between the lower limits of the abdominal cavity (excluding the true
lower end of the body of the sternum (not of xiphoid process) pelvis) are marked by the right and left inguinal ligaments.
and the umbilicus; or a hands breadth below the lower end of Keeping in mind the planes and limits defined above the
the body of the sternum. The transpyloric plane passes through abdomen can be divided into the following nine regions
the lower part of vertebra L1 (body). It cuts the costal margin (Fig. 23.4).
at the tip of the ninth costal cartilage. In the midline from above downwards there are the
2. The lower transverse plane is called the transtubercular epigastrium (EPG); the umbilical region (UMB); and the
plane. It lies at the level of the tubercles of the iliac crests. hypogastrium (HYG) that is also called the pubic region.
(These are prominences on the outer lip of each iliac crest about Lateral to the epigastrium there is the right hypochondrium
5 cm behind the anterior superior iliac spines). The (RH) and the left hypochondrium (LH). Lateral to the
transtubercular plane passes through the upper part of vertebra umbilical region there is the right lumbar region (RL) and
L5 (body). the left lumber region (LL). The lumbar regions are also
3. The vertical planes used for subdividing the abdomen into called lateral regions. Lateral to the hypogastrium there is
regions are the right and left lateral planes. On the anterior the right inguinal region (RI), also called the right iliac
aspect of the body they are represented by the right and left fossa; and the left inguinal region (LI), also called the left
lateral lines. The upper end of each line is at the midpoint iliac fossa.
between the medial and lateral ends of the clavicle. Its lower The midline of the anterior abdominal wall is marked by a
end is midway between the anterior superior iliac spine and slight groove. When skin over the midline is removed a white
the pubic symphysis. The right and left lateral lines are line is seen in this situation. It is called the linea alba.
commonly referred to as the midclavicular lines.
Fig. 23.4. Regions of the abdomen and the lines demarcating them.
The umbilicus is a prominent feature on the anterior abdominal divided, (rather arbitrarily) into three parts. These are the
wall, but is not a useful landmark because of variability in its duodenum, the jejunum and the ileum (in that order). The
position. In the healthy young adult it usually lies at the level small intestine is followed by the large intestine. The large
of the intervertebral disc between L3 and L4. The umbilicus intestine is about one and a half meters long. (It is described
marks the point at which the umbilical cord is attached during as large because it has a wider diameter). Its main
fetal life. subdivisions are the caecum, the ascending colon, the
transverse colon, the descending colon, the sigmoid (or
pelvic) colon, the rectum and the anal canal. These are
CONTENTS OF THE ABDOMEN shown in Figure 23.5. The anal canal opens to the exterior at
the anus.
Closely related to the alimentary canal there are several
The organs to be seen in the abdomen and pelvis belong mainly
accessory organs. In the abdomen we have two large glands:
to the alimentary, urinary and reproductive systems.
the liver and the pancreas. The liver occupies the upper
Alimentary system right part of the abdomen. It is a very important organ having
The parts of the alimentary (digestive) system encountered are numerous functions. The pancreas lies transversely on the
as follows. The terminal part of the oesophagus passes through posterior wall of the abdomen. It produces digestive juices
the diaphragm and joins the stomach. The stomach is a large that are poured into the duodenum and help in digestion. It
sac-like organ that acts as a store of swallowed food. After this is also an important endocrine organ.
food is partially digested it passes into the small intestine. The Another large organ present in the upper part of the abdomen
small intestine is in the form of a tube about 5 meters long. It is is the spleen. This is the largest lymphoid organ in the body.
225
226
Large blood Vessels
Closely related to the posterior wall of the abdomen
there are large blood vessels, the most important of
which are the abdominal aorta and the inferior vena
cava. At its lower end the aorta bifurcates into right
and left common iliac arteries. Each of these divides
into internal and external iliac arteries. The external
iliac artery continues into the thigh as the femoral artery.
The aorta gives numerous branches to the stomach and
intestines, the liver, the spleen and the kidneys.
BONES AND JOINTS SEEN IN

RELATION TO THE ABDOMEN
The bones to be encountered in relation to the abdomen

are as follows.
1. Part of the vertebral column made up of the lumbar
vertebrae, the sacrum and the coccyx.
2. The bony pelvis formed by the right left hip bones,

along with the sacrum and coccyx.
3. The lower ribs and costal cartilages and the sternum.
A general description of the vertebral column has been
given in Chapter 16. Here we will consider some
aspects of the lumbar vertebrae, the sacrum and coccyx.
The hip bones have been described in Chapter 9, and
an introduction to the pelvis as a whole has been given
there. The sternum and ribs are considered in Chapter
16.
Fig. 23.5. Diagram to show the main parts of the
digestive system. Some Features of Lumbar Vertebrae
A lumbar vertebra can be distinguished from thoracic

Urinary system and cervical vertebrae by the fact that it neither has
The organs of the body that are concerned with the formation foramina transversaria nor does it have facets for ribs.
of urine and its elimination from the body are referred to as It is also recognised by the large size of its body. Some
urinary organs. Urine is produced in the right and left kidneys other features are as follows:
that lie on the posterior wall of the abdomen. This urine passes The vertebral foramen is triangular. Pedicles are thick
through narrow tubes, the right and left ureters, to reach a sac and short, and are directed backwards and laterally.
like reservoir called the urinary bladder. The urinary bladder Laminae are short and broad and do not overlap those
lies in the true pelvis. It is connected to the exterior by a tube of adjoining vertebrae. Spinous processes are large and
called the urethra. quadrangular. They are horizontal and have a thick
posterior edge.
Male Reproductive Organs The transverse processes are small and tapering. The
The male gonads are the right and left testes (singular = testis). posteroinferior aspect of the transverse process bears
The right and left testes (and some ducts arising from them), an elevation called the accessory process.
lie in a sac like structure covered by skin: this sac is called the The articular facets are vertical and are curved from
scrotum. The penis is the male external genital organ. side to side. The superior facets are slightly concave
Female Reproductive Organs and face backwards and medially. The inferior facets
The female gonads are the right and left ovaries. The female are slightly convex and are directed forwards and
internal genital organs are the uterus, the uterine tubes and laterally. Each superior facet bears a projection called
the vagina. the mamillary process on its posterior aspect.
Fifth Lumbar Vertebra
The fifth lumbar vertebra is
the largest of lumbar
vertebrae. We have that the
transverse processes of
typical lumbar vertebrae are
small and tapering. In
contrast the transverse
processes of the fifth
lumbar vertebra are very
large: they form a dis-
tinguishing characteristic of
this vertebra.
The Sacrum
The sacrum lies below the

fifth lumbar vertebra. It is
made up of five sacral
vertebrae that are fused
together (Figs 23.6 and
23.7). It is wedged between
the two hip bones and takes
part in forming the pelvis. Fig. 23.6. Sacrum seen from
As a whole the bone is the front.
triangular. It has an upper
end or base that articulates with the fifth lumbar vertebra; a laminae meet there is a small tubercle representing the spine.
lower end or apex that articulates with the coccyx; a concave Arising from the junction of the pedicles and laminae there
anterior (or pelvic) surface; a convex posterior or (dorsal) are the superior articular facets that articulate with the
surface (Fig. 23.7); and right and left lateral surfaces that inferior articular facets of the fifth lumbar vertebra. Lateral
articulate with the ilium of the corresponding side. to the body we see the superior surface of the lateral part,
that is also called the ala.
When viewed from the front (Fig. 23.6) the pelvic
surface of the sacrum shows the presence of four
pairs of anterior sacral foramina. The first
foramen is the largest and the fourth the smallest.
The foramina separate the medial part of the bone
from the lateral part. The medial part is formed by
the fused bodies of the sacral vertebrae, while the
lateral part represents the fused transverse
processes, including the costal elements. The
anterior sacral foramina, seen on the pelvic surface,
are continued into the substance of the bone and
become continuous posteriorly with the posterior
sacral foramina that open on to the dorsal surface.
The canals connecting the anterior and posterior
foramina open medially into the sacral canal that
is a downward continuation of the vertebral canal.
When viewed from above the base of the sacrum
is seen to be formed by the first sacral vertebra in
which we can recognise a large oval body that
articulates with the body of the fifth lumbar
vertebra. The body has a projecting anterior margin
called the sacral promontory. Behind the body
there is a triangular vertebral (or sacral) canal
bounded by thick pedicles and laminae. Where the Fig. 23.7. Sacrum seen from behind.
227
228
we see two small downward projections called the sacral
cornua. They represent the inferior articular processes of
the fifth sacral vertebra. They are connected to the coccyx
by ligaments.
When the sacrum is viewed from the side we see that the
pelvic aspect of the bone is concave forwards, while the
dorsal aspect is convex backwards. The lateral surface bears
a large L-shaped auricular area (or facet) for articulation
with the ilium. (It is so called because its shape resembles
that of the auricle or pinna). The area behind the auricular
surface is rough and gives attachment to strong ligaments
that connect the sacrum to the ilium.
Fig. 23.8. Coccyx seen from the front.

The Coccyx
When the sacrum is viewed from behind (Fig. 23.7) we see the The coccyx consists of four rudimentary vertebrae fused
dorsal surface. We can again distinguish medial and lateral together (See Fig. 6.30).
parts separated by four pairs of posterior sacral foramina. The It has pelvic and dorsal surfaces. The base or upper end has
medial part of the dorsum of the sacrum is formed by the fused an oval facet for articulation with the apex of the sacrum.
laminae of sacral vertebrae. Lateral to the facet there are two cornua that project upwards
The laminae of the fifth sacral vertebra (sometimes also of the and are connected to the cornua of the sacrum by ligaments.
fourth) are deficient leaving an inverted U-shaped or V-shaped The first coccygeal vertebra has rudimentary transverse
gap called the sacral hiatus. The midline is marked by a ridge processes. The remaining vertebrae are represented by
called the median sacral crest on which four spinous tubercles nodules of bone.
(representing the spines) can be recognised. Just medial to the
dorsal sacral foramina we see four small tubercles that represent Some Attachments on the Sacrum and Coccyx
fused articular processes: they collectively form the (a) The iliacus arises from the anterolateral part of the upper
intermediate crest. Lateral to the foramina we see a prominent surface of the ala (or lateral part).
lateral sacral crest formed by the fused transverse processes. (b) The piriformis arises from the pelvic surface. The medial
The crest is marked by tubercles that represent the tips of the part of the origin is in the form of three digitations that arise
transverse processes. from the areas between the sacral foramina.
The lower end of the bone (apex) bears an oval facet for (c) The gluteus maximus arises from the lateral margin of
articulation with the coccyx. At the sides of the sacral hiatus the lowest part of the sacrum, and that of the coccyx.
(d) The area around the auricular
surface gives attachment to the
ventral, dorsal and
interosseous ligaments of the
sacroiliac joint.
(e) The sacrotuberous ligament
is attached to the lower lateral
part of the dorsal surface of the
sacrum.
(f) The sacrospinous ligament
is attached to the lower part of
the lateral margin of the sacrum
and to the adjoining lateral
margin of the coccyx.
Fig. 23.9. Attachments on the

pelvic aspect of the sacrum and
coccyx. Some related structures
are also shown.
Fig. 23.11. Upper part of lateral surface of
sacrum showing the auricular surface that
articulates with the ilium.
Fig. 23.10. Posterior part of ilium viewed from the
medial side to show the auricular surface that articulates
with the sacrum.
JOINTS AND LIGAMENTS OF THE PELVIS
Pubic Symphysis
The two pubic bones are united in front at the pubic symphysis.
This joint corresponds in structure to that of a secondary
cartilaginous joint. Each bone end is covered by a thin layer of
hyaline cartilage. The two layers of hyaline cartilage are united
by fibrocartilage.
Sacroiliac joints
Fig. 23.12. Posterior aspect of the pelvis showing the
The sacrum articulates on each side with the corresponding attachments of the sacrotuberous and sacrospinous
ilium forming the right and left sacroiliac joints. These are ligaments.
synovial joints. The iliac and sacral articular surfaces are shown
in Figures 23.10 and 23.11. They are both shaped like the auricle
(pinna) and are, therefore, called auricular surfaces.
The surfaces are covered by cartilage, but because of the Two other ligaments that connect the sacrum to the hip bone
presence of a number of raised and depressed areas the joint are the sacrotuberous and the sacrospinous ligaments that
allows little movement. The capsule of the joint is attached have been encountered in the gluteal region (Fig. 23.12).
around the margins of the articular surfaces. It is thickened in The sacrotuberous ligament is large and strong. It has a
its anterior part to form the ventral sacroiliac ligament. The broad upper medial end and a narrower lower lateral end.
main bond of union between the sacrum and ilium is, however, The upper end is attached (from above downwards) to the
the interosseous sacroiliac ligament that is attached to rough posterior superior and posterior inferior iliac spines, the
areas above and behind the auricular surfaces of the two bones. lower part of the posterior surface of the sacrum and the
The posterior aspects of the sacrum and ilium are connected by lateral margin of the lower part of the sacrum and the upper
a strong dorsal sacroiliac ligament that covers the interosseous part of the coccyx. Its lower end is attached to the medial
ligament from behind. margin of the ischial tuberosity.
The stability of the sacroiliac joints is important as body weight The sacrospinous ligament is attached medially to the
is transmitted from the sacrum to the lower limbs through them. sacrum and coccyx and laterally to the ischial spine.
229
230
24 : Anterior Abdominal Wall

Superficial Fascia of Abdomen the muscles of the abdominal wall cannot be understood
To allow the abdominal cavity to expand or contract the fascia unless the student has a clear idea about them.
over it shows some special features. There is no deep fascia.
The superficial fascia over the lower part of the anterior Some features of the pubis:
abdominal wall (and over the perineum) consists of two layers. The pubis forms the anterior part of the hip bone. It consists
There is a superficial fatty layer (also called the fascia of of a body, a superior ramus and an inferior ramus (See Fig.
Camper), and a deeper membranous layer. (The membranous 9.5). The bodies of the two pubic bones meet in the midline
layer is also called the fascia of Scarpa. In the perineum it is to form the pubic symphysis. The upper border of the body
called the fascia of Colles). The fatty layer corresponds to is rounded and rough: it forms the pubic crest. At the lateral
superficial fascia elsewhere in the body. end of the crest there is a prominence called the pubic
When traced upwards the membranous layer ends by merging tubercle. The superior ramus passes laterally and backwards
with the fatty layer. Traced downwards the membranous layer from the body. It is triangular in cross-section (See Fig. 9.6),
passes into the upper part of the thigh across the inguinal having three surfaces and three borders. The pectineal
ligament. However, the layer ends a short distance below the (anterior) and pelvic (posterior) surfaces are separated by a
ligament by fusing with deep fascia along a horizontal line sharp ridge called the pecten pubis or the pectinate line
extending laterally from the pubic tubercle. (The line of fusion Medially the pecten pubis reaches the pubic tubercle The
is Holdens line) (Fig. 24.1). pubic symphysis, crest, tubercle and pecten pubis give
These attachments acquire significance in case of rupture of attachment to some muscles of the abdomen.
the urethra in the perineum (Fig. 24.1). The linea alba
This is a tendinous raphe present in the midline of the anterior
abdominal wall. It is attached above to the xiphoid process
and below to the symphysis pubis.
MUSCLES OF ANTERIOR
ABDOMINAL WALL The inguinal ligament
This is a thick curved band of fibres that lies at the junction
of the abdomen and the front of the thigh. It is attached
Preliminary considerations medially to the pubic tubercle and laterally to the anterior
superior iliac spine (Fig. 24.2). It represents the lower border
In considering the muscles of the anterior abdominal wall of the aponeurosis of the external oblique muscle, that is
reference has to be made to a number of structures. These are folded on itself.
briefly considered here because some of the attachments of The lacunar ligament
This is also called the pectineal part of the inguinal
ligament. It is a triangular membrane placed horizontally,
behind the medial most part of the inguinal ligament (Fig.
24.2). The apex of the triangle is directed medially and is
attached to the pubic tubercle. Its anterior margin is
continuous with the inguinal ligament. Its posterior margin
is attached to the medial part of the pecten pubis. Its base,
directed laterally, is free: it forms the medial boundary of
the femoral ring.
Pectineal ligament
Some fibres (continuous with the lacunar ligament) extend
laterally along the pecten pubis beyond the base of the lacunar
ligament. They constitute the pectineal ligament, the fibres
of which are firmly adherent to the pecten pubis.
Fig. 24.1. Diagram to show lines along which the Superficial inguinal ring
membranous layer of superficial fascia is firmly united to Just above the medial part of the inguinal ligament there is
underlying structures. Anterior view. Arrows indicate the an aperture in the aponeurosis of the external oblique muscle
path that can be taken by extravasated urine if the urethra is called the superficial inguinal ring (Fig. 24.3). The so called
ruptured. ring is really an obtuse angled triangle. The base of the
ANTERIOR ABDOMINAL WALL
Fig. 24.4. Diagram to show the position of the
inguinal canal.
to the spermatic cord in the male, and the round ligament of

Fig. 24.2. Diagram to show the inguinal ligament.
the uterus in the female. The ilioinguinal nerve also passes
through it. The boundaries of the canal will be considered
after the muscles of the anterior abdominal wall have been
studied.
The transversalis fascia
This is a thin layer of connective tissue that lines the inner
surface of the transversus abdominis muscle. It is separated
from the peritoneum by a layer of extraperitoneal tissue that
is rich in fat.
The conjoint tendon (or falx inguinalis)
This is made up of some fibres of the aponeuroses of the
internal oblique and transversus abdominis muscles that join
together and descend to be inserted into the pubic crest and
the medial part of the pecten pubis. The conjoint tendon lies
Fig. 24.3. Structure of the superficial inguinal ring. behind the superficial inguinal ring.
Thoracolumbar fascia
This fascia is present in relation to the posterior abdominal
triangle is formed by the pubic crest. The two sides of the
wall. The thoracolumbar fascia has three layers (anterior,
triangle form the lateral (or lower) and the medial (or upper)
middle and posterior) (See Fig. 23.3). The anterior and
margins of the opening: these are referred to as crura. The
posterior layers meet at the lateral edge of the quadratus
lateral crus is nothing but the medial part of the inguinal
lumborum muscle and the fused layers give attachment to
ligament. The medial crus is attached to the front of the
the transversus abdominis and the internal oblique muscles.
symphysis pubis.
The superficial inguinal ring is the external opening of the
inguinal canal.
Obliquus Externus Abdominis (Fig. 24.5)
Reflected part of the inguinal ligament
Origin:
This is made up of fibres that pass upwards and medially from
The muscle arises from (the external surfaces and lower
the lateral crus of the superficial inguinal ring and disappear
borders of) the lower eight ribs (i.e. 5th to 12th). There is
under its medial crus (Fig. 24.3).
one slip from each rib.
The inguinal canal Insertion:
This is an oblique passage through the anterior abdominal wall The fibres of the muscle run downwards and forwards to be
placed a little above the medial part of the inguinal ligament inserted as follows:
(Fig. 24.4). It begins at the deep inguinal ring that is situated in A. With the exception of the fibres arising from the last two
the trasversalis fascia (see below) midway between the anterior ribs all the other fibres end in an extensive aponeurosis. The
superior iliac spine and the pubic symphysis, half an inch above aponeurosis is inserted as follows:
the inguinal ligament. The canal passes downwards and medially a. The upper margin of the aponeurosis passes horizontally
to reach the superficial inguinal ring. The canal gives passage to reach the xiphoid process (a in figure 24.5).
231
232
Obliquus Internus Abdominis
The internal oblique muscle of the abdomen lies between

the external oblique and the transversus abdominis muscles
(Fig. 24.6). The muscle has an origin behind and below,
from which the fibres pass forwards and upwards to their
insertion. The direction of the fibres is thus at right angles
to that of the external oblique (and corresponds with that
of the internal intercostal muscles).
Origin:
a. The uppermost fibres arise from the thoracolumbar
fascia (Fig. 23.3) at the lateral border of the quadratus
lumborum.
b. The middle fibres arise from the iliac crest (anterior two-
thirds of ventral segment).
c. The lowest fibres arise from the lateral 2/3 of the deep
aspect of the inguinal ligament (Fig. 24.7).
Insertion:
The fibres are inserted as follows from above downwards.
a. The fibres arising from the lumbar fascia and the
posterior part of the iliac crest are inserted into the lower
borders of the 10th, 11th and 12th ribs (a in figure 24.6).
b. The fibres from the anterior part of the iliac crest and
from the lateral part of the inguinal ligament fan out and
Fig. 24.5. Lateral view of the trunk to show the

attachments of the external oblique muscle of the
abdomen.
b. Succeeding fibres are inserted into the entire length

of the linea alba, the lowest ones reaching the pubic
symphysis.
c. The next fibres have a bony attachment to the pubic
crest and tubercle.
d. Lateral to the pubic tubercle the aponeurosis has a
free lower border that forms the inguinal ligament; it is
attached laterally to the anterior superior iliac spine
(d in Figure 24.5).
B. The fibres arising from the 11th and 12th ribs descend
almost vertically to be inserted (by fleshy fibres) into
the iliac crest They are inserted into the anterior-half of
the outer lip of the crest.
Fig. 24.6. Lateral view of the trunk to show attachments of
Nerve Supply and Actions the internal oblique muscle of the abdomen.
See below.
a. The upper fibres arise from the inner aspect of the lower
six costal cartilages, near the costal margin.
b. The middle fibres arise from the thoracolumbar fascia.
c. The lower fibres arise from the ventral segment of the iliac
crest (anterior two-thirds of inner lip) (Fig. 24.8).
d. The lowest fibres arise from the lateral one-third of the
inguinal ligament, from its upper grooved surface.
Insertion:
The fibres end in an aponeurosis that is inserted chiefly into
the linea alba. The lowest part of the aponeurosis joins that
of the internal oblique to form the conjoint tendon (Fig. 24.9)
through which it is inserted into the pecten pubis and the
pubic crest.
The aponeurosis of the transversus abdominis muscle takes
part in forming the sheath for the rectus abdominis muscle
along with those of the external and internal oblique muscles.
Fig. 24.7. Diagram to show relationship of the
internal oblique muscle to the inguinal canal. Nerve supply of anterolateral muscles of abdomen
The external oblique, the internal oblique and the transversus
abdominis muscles are all supplied by the lower six thoracic
end in an aponeurosis. Its upper part is attached to the costal
spinal nerves (i.e. 7th, 8th, 9th, 10th and 11th intercostal
margin (b in figure 24.6). Its lower part is attached to the entire
nerves and by the subcostal nerve). The internal oblique and
length of the linea alba (c in figure 24.6).
transversus abdominis are also supplied by the first lumbar
c. The fibres arising from the middle one-third of the inguinal
nerve.
ligament are closely related to the inguinal canal (d in figure
24.7). They first pass upwards and
medially in front of the lateral part
of the canal (forming its anterior
wall); then turn backwards and Fig. 24.8. Lateral
medially above the canal (forming view of the trunk to
show the
its roof) and finally dip
attachments of the
downwards and medially behind
transversus
it. Here the fibres become abdominis muscle.
tendinous and join those of the
transversus abdominis to form the
conjoint tendon through which
they are attached to the pubic crest
and the pecten pubis. The
conjoint tendon forms the medial
part of the posterior wall of the
inguinal canal.
Transversus Abdominis
The transversus abdominis is the

deepest muscle of the antero-
lateral part of the abdominal wall
(Fig. 24.8). It has its origin
posteriorly. From the origin the
fibres run horizontally forwards
around the abdominal wall to their
insertion.
Origin:
The origin can be divided into four
parts from above down-wards.
233
234
Fig. 24.10. Transverse section through the

spermatic cord to show its contents.
Fig. 24.9. Inguinal canal seen from behind.
Spermatic Cord and Its Coverings

Actions of anterolateral muscles of abdomen
The actions of these muscles are as follows: We have seen that the inguinal canal gives passage to the
a. They support the abdominal viscera, counteracting the effect spermatic cord in the male. The structures that constitute
of gravity specially in the sitting or standing position. the spermatic cord are as follows (Fig. 24.10):
b. By active contraction they increase the intra-abdominal a. The ductus deferens is a thick walled tube that carries
pressure that pushes up the diaphragm during expiration: and spermatozoa formed in the testis to the male excretory
helps to expel contents of abdominal viscera in defaecation, passages.
micturition, vomiting and in child birth. b. Arteries: These are the testicular artery to the testis, and
an artery to the ductus deferens. Another artery to the
Boundaries of the Inguinal Canal cremaster muscle descends along the cord.
c. The veins draining the testis and epididymis form a plexus
The inguinal is an oblique passage that passes from the deep around the ductus deferens. This is called the pampiniform
inguinal ring to the superficial ring.. The canal has an anterior plexus. Near the superficial inguinal ring the plexus ends in
wall, a posterior wall, a roof and floor. three or four longitudinal veins that pass through the inguinal
The floor is formed by the grooved upper surface of the inguinal canal.
ligament, and more medially by the lacunar ligament. d. The genital branch of the genitofemoral nerve enters the
The roof of the canal is formed by the fibres of the internal spermatic cord at the deep inguinal ring. It supplies the
oblique and by the fibres of the transversus abdominis (Fig. cremaster muscle and gives some branches to the skin of the
24.9). scrotum. The testicular artery is surrounded by a plexus of
The anterior wall of the inguinal canal is formed by: sympathetic nerves.
1. Fleshy fibres of internal oblique (over lateral one-third of e. The lymphatic vessels from the testis also pass through
canal). the spermatic cord.
2. Aponeurosis of external oblique (over entire length of canal). Coverings of the cord:
3. Skin and superficial fascia. In early embryonic life the testes lie within the abdomen, but
The posterior wall of the canal is formed by: in later months of pregnancy they descend through the
1. The fascia transversalis (over entire extent of canal). inguinal canal into the scrotum. As each testis passes through
2. Conjoint tendon (over medial-half of canal). the abdominal wall it carries extensions from its layers. These
3. Reflected part of inguinal ligament (over medial one-third extensions that form the coverings of the testis, and of the
of canal). cord, are as follows (within outwards) (Fig. 24.11).
Note that the anterior wall is strong where the posterior wall is a. The internal spermatic fascia is a prolongation of
weakened by the deep inguinal ring: and that the posterior wall transversalis fascia from the margins of the deep inguinal
is strong where the anterior wall is weakened by the presence ring.
of the superficial ring. b. The cremasteric fascia is an extension from the internal
The importance of the inguinal canal is that an inguinal hernia oblique muscle. The fascia contains several muscle bundles
can take place through it. Inguinal herniae are discussed in that constitute the cremaster muscle.
Chapter 34. c. The external spermatic fascia is an extension from the
margins of the superficial ring (i.e. from the aponeurosis of
the external oblique).
Fig. 24.11. Schematic diagram to show coverings of the
spermatic cord and of the testis.
Rectus Abdominis
The rectus abdominis runs vertically in the anterior abdominal

wall next to the midline (Fig. 24.12). The muscles of the two
sides are separated by the linea alba. The origin of the muscle
lies at its lower end, and the insertion at its upper end.
Origin:
The rectus abdominis has two tendons of origin. The medial,
more superficial, tendon arises from the front of the pubic Fig. 24.12. Scheme to show the attachments of the
symphysis. The lateral, deeper, tendon arises from the pubic rectus abdominis.
crest. Its attachment may extend laterally to the pubic tubercle
and the pecten pubis.
Pyramidalis
Insertion:
The pyramidalis is a small muscle placed in front of the rectus
The muscle expands as it ascends so that its insertion is broader
abdominis, within its sheath (Fig. 24.12). It is triangular. its
than the origin. Near its upper end the muscle crosses superficial
base (or origin) is attached to the front of the pubis and of
to the costal margin to be inserted on the 5th, 6th and 7th costal
the symphysis pubis. Its apex is inserted into the linea alba.
cartilages along a horizontal line. Note that the most lateral
It is supplied by the subcostal nerve.
fibres are attached to the 5th costal cartilage and the most medial
to the 7th.
A number of tendinous intersections (usually three) run
transversely across the muscle. An occasional intersection may The Rectus Sheath (Fig. 24.13)
be present below the umbilicus.
The rectus abdominis is enclosed in a sheath formed by the
Nerve supply:
aponeuroses of the oblique and transverse muscles. The
The rectus abdominis is supplied by the lower six or seven
manner in which the sheath is formed varies at different
thoracic nerves.
levels.
Actions: 1. The typical arrangement is seen from the level of the
The rectus abdominis can bend the trunk forwards. It assists costal margin above to that midway between the umbilicus
the anterolateral muscles in supporting the abdominal viscera and the pubic symphysis (Fig. 24.13B). On reaching the
and in increasing intraabdominal pressure. lateral margin of the rectus abdominis the aponeurosis of
The lateral border of the rectus abdominis can be made out on the internal oblique muscle splits into anterior and posterior
the surface of the living as a groove called the linea semilunaris. laminae. The anterior wall of the sheath is formed by the
external oblique aponeurosis, and the anterior lamina of the
aponeurosis of the internal oblique. The posterior wall is
formed by the posterior lamina of the aponeurosis of the
235
236
are now brought in front of the muscle. As
a result (a) the lower part of the rectus
abdominis rests directly on transversalis
fascia, the posterior part of the sheath being
deficient; (b) the aponeurosis of the
transversus abdominis, and both laminae of
the internal oblique join the external oblique
aponeurosis in forming the anterior wall of
the sheath, and (c) the posterior part of the
sheath has a lower free margin, called the
arcuate line (Fig. 24.14) lying on the
transversalis fascia.
3. When traced upwards the aponeurosis
of the transversus abdominis and the
posterior lamina of the internal oblique end
by gaining attachment to the costal margin.
Above the level of the costal margin the
rectus abdominis lies directly on the costal
cartilages and intercostal muscles that
separate it from the diaphragm (Fig. 24.13).
The contents of the rectus sheath are shown

in Figure 24.14 in which the posterior wall
of the sheath has been shown after the
muscle has been removed.
The superior epigastric artery enters the
sheath at its upper end by piercing the
posterior wall. The inferior epigastric artery
runs upwards over the transversalis fascia
and enters the sheath by passing anterior
to the arcuate line. The lower intercostal
nerves run forwards between the internal
oblique and the transversus abdominis
muscles. They enter the sheath by piercing
the posterior lamina of the internal oblique
in its lateral part. Note the arcuate line and
the transversalis fascia.
NERVES OF ANTERIOR
ABDOMINAL WALL
The nerves that take part in supplying the

anterior abdominal wall are as follows:
Fig. 24.13. Schematic transverse sections through the rectus abdominis muscle Lower intercostal nerves
and its sheath at upper, middle and lower levels. The initial parts of the seventh, eighth,
ninth, tenth and eleventh intercostal nerves
internal oblique, and the aponeurosis of the transversus resemble those of typical intercostal nerves. However, on
abdominis. reaching the anterior end of the intercostal space concerned
2. To understand the arrangement below this level (Fig. 24.13C) each nerve passes deep to the costal margin to enter the
imagine that the posterior lamina of the aponeurosis of the abdominal wall.
internal oblique, and the aponeurosis of the transversus The intercostal nerves run forward in the abdominal wall
abdominis are cut transversely, midway between the umbilicus lying between the internal oblique and transverses muscles.
and the symphysis pubis. The lower flaps of these aponeuroses Reaching the rectus abdominis the intercostal nerves pierce
arch. It then passes downwards and laterally across the
quadratus lumborum muscle: this part of the nerve lies
behind the corresponding kidney.
At the lateral margin of the quadratus lumborum the nerve
enters the interval between the internal oblique and the
transversus abdominis Its subsequent course is similar to
that of the lower intercostal nerves (described above) (Fig.
24.16). The subcostal nerve gives off a collateral branch
that behaves like that of an intercostal nerve. It also gives
off a lateral cutaneous branch that runs downwards across
the iliac crest to supply the skin of the anterior part of the
gluteal region.
Iliohypogastric nerve
The iliohypogastric nerve (L1) runs a short course within
the substance of the psoas major and emerges from the
muscle at its lateral margin. The nerve then runs downwards
and laterally over the quadratus lumborum: here it lies behind
the corresponding kidney. At the lateral margin of the
quadratus lumborum the nerve enters the interval between
the internal oblique and transversus muscles.
It runs downwards, forwards and medially between these
muscles. The nerve gives off a lateral cutaneous branch that
becomes superficial by piercing the internal and external
oblique muscles a little above the iliac crest: crossing the
Fig. 24.14. Diagram showing contents of the rectus sheath. crest it supplies the skin in the anterior part of the gluteal
region. The rest of the iliohypogastric nerve is called the
anterior cutaneous branch. It runs medially and becomes
superficial by piercing the internal oblique muscle and the
its sheath to enter the muscle. The nerves pass forwards
through the rectus abdominis to reach the skin and supply it.
The course of the seventh and eighth intercostal nerves is
slightly different from that described above because the
anterior ends of the corresponding spaces lie behind the rectus
abdominis. These nerves, therefore, do not travel any part of
their course between the internal oblique and transversus
muscles, but enter the rectus sheath directly.
The seventh to eleventh intercostal nerves give off collateral
branches that run parallel to the main trunks. Like the parent
trunks they enter the abdominal wall, and pierce the rectus
abdominis to reach the skin over it. These intercostal nerves
also give off lateral cutaneous branches that become
superficial by piercing the internal and external intercostal
muscles, or the internal and external oblique muscles of the
abdomen and then divide into anterior and posterior branches
that supply the skin of the trunk.
The lower intercostal spaces turn upwards near the anterior
ends. The seventh and eighth intercostal nerves follow this
curve even after they enter the abdomen so that they run
upwards and medially in the abdominal wall. The course of
the ninth nerve within the abdominal wall is horizontal. The
tenth and eleventh nerves run downwards and medially
(Fig. 24.16).
Subcostal nerve
The subcostal nerve is the ventral ramus of the twelfth thoracic Fig. 24.15. Scheme to show the course of one of the lower
nerve. It runs along the lower border of the twelfth rib and intercostals nerves. The intercostals space and the abdominal
enters the abdomen by passing behind the lateral lumbocostal wall are cut along the course of the nerve.
237
238
Fig. 24.17. Scheme to show the course of the

anterior part of the ilioinguinal nerve.
Fig. 24.16. Course of intercostal nerves as seen from

the lateral side. SC=subcostal nerve.
IH=iliohypogastric nerve.
aponeurosis of the external oblique muscle. It emerges from

the latter a little above the superficial inguinal ring, and ends
by supplying the skin above the pubis.
Ilioinguinal nerve
The ilioinguinal nerve (L1) arises in common with the
iliohypogastric nerve and has a similar course first through
the psoas major, next in front of the quadratus lumborum
(behind the kidney), and then between the transversus
abdominis and the internal oblique muscles. It pierces the
internal oblique a little above the lateral part of the inguinal
ligament to enter the inguinal canal. It leaves the inguinal canal
by passing through the superficial inguinal ring. It ends by Fig. 24.18. Scheme to show the course of the
supplying the skin of the upper and medial part of the thigh, genitofemoral nerve.
over the pubis and the adjoining part of the genitalia.
Genitofemoral nerve part of the artery and enters the inguinal canal through the
The genitofemoral nerve (L1, L2) runs downwards first in the deep inguinal ring. The nerve supplies the cremaster and
substance of the psoas major and then on its anterior surface. dartos muscles, and gives some branches to the skin of the
The nerve passes deep to the ureter. It ends by dividing into scrotum or of the labium majus.
genital and femoral branches. The femoral branch continues to descend on the lateral
The genital branch comes into relationship with the lateral side of the external iliac artery. It passes deep to the inguinal
side of the external iliac artery. It crosses in front of the lower ligament and comes to lie lateral to the femoral artery. It
branches to the 7th to 9th spaces. Piercing the diaphragm
the artery enters the abdominal wall and supplies muscles
there.
Superior epigastric artery
The superior epigastric artery passes into the abdominal
wall by passing through the diaphragm (between slips from
the xiphoid process and from costal cartilages). It enters the
rectus sheath and lies deep to the rectus abdominis. The
artery anastomoses with the inferior epigastric artery.
Inferior epigastric artery
The inferior epigastric artery arises from the external iliac
artery just above the inguinal ligament (Fig. 24.20). Its initial
part is intimately related to the deep inguinal ring: it first
runs medially inferior to the ring and then runs upwards
medial to the ring. The artery continues upwards and
medially and enters the rectus sheath by passing in front of
the arcuate line. It anastomoses with the superior epigastric
Fig. 24.19. Scheme to show innervation of muscles of artery.
the anterior abdominal wall. IN6 to IN11 = 6th to 11th The artery raises a fold of peritoneum called the lateral
intercostal nerves; SCN= Subcostal nerve; umbilical ligament on the back of the anterior abdominal
ILH= Iliohypogastric nerve; ILI= Ilioinguinal nerve; wall.
TR= Transversus abdominis; 10= Internal oblique; The inferior epigastric artery gives off the following
EO= External oblique; RF= Rectus femoris; branches.
PY= Pyramidalis.
becomes superficial and supplies an area of skin over the upper

part of the femoral triangle.
Nerve Supply of Muscles

of Anterior Abdominal wall
The muscles of the anterior abdominal wall are supplied by

branches from the lower six intercostal nerves (T6 to T11), the
subcostal nerve (T12), and the iliohypogastric and ilioinguinal
nerves (both L1). For details see Figure 24.19.
BLOOD VESSELS OF
Fig. 24.20. Course of the inferior epigastric artery.
The various arteries that supply the abdominal wall are as

follows: The cremasteric branch supplies the cremaster muscle.
The pubic branch passes medially and downwards in close
Intercostal and subcostal arteries
relation to the femoral ring. It anastomoses with the pubic
The terminal parts of the lower two (10th and 11th) posterior branch of the obturator artery. Occasionally this branch is
intercostal arteries and the subcostal artery enter the anterior large and the obturator artery then appears to be its
abdominal wall and supply it. continuation (abnormal obturator artery).
Musculophrenic artery Branches are given off to muscles of the anterior abdominal
The musculophrenic artery is a terminal branch of the internal wall and to the skin overlying them.
thoracic artery. It passes downwards and laterally behind the Deep circumflex iliac artery
7th to 9th costal cartilages, and gives anterior intercostal The deep circumflex iliac artery arises from the lateral side
of the external iliac artery. It runs laterally behind the
239
240
Fig. 24.22. Lymphatic drainage of deeper tissues of

Fig. 24.21. Lymphatic drainage of anterior aspect of trunk. anterior abdominal wall.
inguinal ligament to reach the anterior superior iliac spine and

then passes along the iliac crest. It gives branches to the LYMPHATIC DRAINAGE OF THE
muscles of the anterior abdominal wall. ANTERIOR ABDOMINAL WALL

Superficial branches of femoral artery
The superficial circumflex iliac artery, the superficial
A. Lymphatic drainage of the skin
epigastric artery, and the superficial external pudendal arise
a. The skin above the level of the umbilicus (in front) and
from the femoral artery just below the inguinal ligament They
above the iliac crest (at the back) drains into the axillary
contribute to the supply of the lower part of the abdominal
lymph nodes (Figs 24.21 and 24.22).
wall.
b. The skin of the anterior abdominal wall below the umbilicus
Branches from the various arteries described above supply
drains into the superficial inguinal lymph nodes.
muscles in the abdominal wall. The skin of the abdomen is
supplied by lateral cutaneous branches arising from intercostal
and subcostal arteries; by anterior cutaneous arteries arising B. Lymphatic drainage of deeper tissues
from the superior and inferior epigastric arteries; and by The vessels from the upper part of the anterior abdominal
superficial branches of the femoral artery. wall travel along the superior epigastric vessels to reach
parasternal lymph nodes.
The vessels from the lower part of the anterior abdominal
wall travel along the inferior epigastric and circumflex iliac
Veins of Anterior Abdominal Wall
vessels. They reach the external iliac nodes.
The veins of the anterior abdominal wall correspond to the
arteries described above. The veins that accompany the CLINICAL CORRELATIONS
superficial branches of the femoral artery drain into the long Clinical correlations of the anterior abdominal wall are
saphenous vein (not into the femoral vein). discussed in Chapter 34.
THE PERINEUM AND RELATED GENITAL ORGANS
25 : The Perineum
and Related Genital Organs
Introduction to the Perineum
The perineum is the region where the external genitalia and

the anus are located. The boundaries of the perineum
correspond to those of the pelvic outlet (Fig. 25.1). This outlet
is rhomboid in shape. It can be divided into the urogenital
triangle placed anteriorly, and the anal triangle placed
posteriorly.
The apex of the urogenital triangle lies anteriorly and is formed
by the pubic symphysis. On either side the triangle is bounded
by the corresponding ischiopubic ramus. Posteriorly, the base
of the triangle is formed by an imaginary line joining the two
ischial tuberosities. Some genital organs are located in this
region. In the male these are the scrotum (containing the right
and left testis and epididymis), and the penis. In the female we
see the external genitalia that are present around the external
openings of the urethra and the vagina.
The apex of the anal triangle is placed posteriorly, and is
formed by the coccyx. Laterally the triangle is bounded by the
sacrotuberous ligaments. The base of the anal triangle is the Fig. 25.1. Boundaries of the perineum.
imaginary line joining the right and left ischial tuberosities.
The anal canal passes through this triangle to open to the
exterior at the anus.
THE TESTIS AND EPIDIDYMIS

The Scrotum
The scrotum is a sac that is lined on the outside by skin. Closely Each testis (right or left) is an oval shaped structure about
united to the skin there is a layer of smooth muscle that 4 cm in its longest (vertical) diameter. It is about 2.5 cm
constitutes the dartos muscle. Contraction of the muscle broad and about 3 cm in anteroposterior diameter. The two
produces corrugations on the skin and makes it tight. The testes lie in the scrotum (Fig. 25.2). They are placed obliquely
scrotum consists of two halves, right and left that are separated the upper pole being slightly anterior and lateral to the lower
from each other by a septum. The dartos muscle extends into pole. The left testis is usually somewhat lower than the right.
this septum. Deep to the dartos muscle each half of the scrotum For descriptive convenience the surface of the testis is
is lined by the coverings of the testis shown in Figure. 24.11. divided into medial and lateral surfaces that are separated
Each half of the scrotum contains the corresponding testis, by anterior and posterior borders. The anterior border is
epididymis, and the initial part of the ductus deferens. These rounded there being no definite demarcation between the
are described below. The coverings of the testis are described medial and lateral surfaces. The posterior border can be
as additional layers of the scrotum. identified because the epididymis is attached to it.
The scrotum is supplied by the scrotal branches of the internal The epididymis is a mass formed by tortuous tubules (Fig.
pudendal artery and by the superficial and deep external 25.3). Its upper end lies near the upper pole of the testis: it
pudendal branches of the femoral artery. The cremasteric artery is enlarged and is called the head. The middle part of the
(a branch of the inferior epigastric) also reaches the scrotum. epididymis is of medium size and called the body. Its lower
The veins follow the corresponding arteries. part is thin and is called the tail (Fig. 25.2).
The nerves supplying the scrotum are the ilioinguinal; the On each side the testis and epididymis lie in a closed sac
genital branch of the genitofemoral; the posterior scrotal that is called the tunica vaginalis (Fig. 25.3). The wall of
branches of the perineal nerve; and the perineal branch of the the sac is formed by a thin membrane similar in structure to
posterior cutaneous nerve of the thigh. peritoneum. It has a visceral layer lining the testis and a
Lymph vessels from the scrotum end in the superficial inguinal parietal layer. The two layers are separated by a potential
lymph nodes. space. The visceral layer covers the entire surface of the
241
242
twenty to thirty larger straight tubules. These enter the
fibrous tissue of the mediastinum testis. and unite to form a
network called the rete testis. At its upper end the rete testis
gives off twelve to twenty efferent ductules. These ductules
pass from the upper part of the testis into the head of the
epididymis. Within the head these tubules become highly
convoluted. The head of the epididymis is in fact nothing
but a mass of these convoluted tubules. At the lower end of
the head of the epididymis these tubules end in a single tube
called the duct of the epididymis. The body and tail of the
epididymis are formed by convolutions of this duct. At the
lower end of the tail the duct of the epididymis becomes
continuous with the ductus deferens.
Deep to the tunica albuginea there is a layer of vascular tissue
Fig. 25.2. Right testis seen from the lateral side. called the tunica vasculosa. The visceral layer of the tunica
vaginalis, the tunica albugina and the tunica vasculosa
collectively form the capsule of the testis. Apart from this
testis except along its posterior aspect. A recess of the tunica capsule the testis is covered by a number of coverings (Fig.
vaginalis (sinus of the epididymis) lies between the epididymis 24.11).
and the testis.
In Figure 25.3 note that deep to the visceral layer of the tunica Blood Vessels, Lymphatics and Nerves of the Testis
vaginalis, the outermost layer of the testis is formed by a dense The testis is supplied by the testicular artery, a direct branch
fibrous membrane called the tunica albuginea. In the posterior of the abdominal aorta. The artery passes through the inguinal
part of the testis the connective tissue forming the tunica canal (as part of the spermatic cord) to reach the testis.
albuginea is thicker than elsewhere and projects into the The testis is drained through the testicular vein. The vein
substance of the testis: this projection is called the mediastinum travels through the spermatic cord in the form of a plexus
testis. Numerous septa pass from the mediastinum testis to the (pampiniform plexus). At the deep inguinal ring the plexus
tunica albuginea, and divide the substance of the testis into a drains into the testicular vein. The right testicular vein ends
large number of lobules. Each lobule contains one or more in the inferior vena cava, but the left vein ends by joining
highly convoluted seminiferous tubules. These tubules are the left renal vein.
lined by an epithelium the cells of which are concerned with Lymph vessels from the testis pass to the lateral aortic lymph
the production of spermatozoa. Each lobule is roughly conical, nodes. The nerves to the testis are sympathetic.
the apex of the cone being directed towards the mediastinum Descent of the Testis and Processes Vaginalis
testis. Near the apex of the lobule the seminiferous tubules Each testis develops in relation to the posterior abdominal
lose their convolutions and join one another to form about wall, but in later fetal life it descends towards the scrotum
reaching it at about the time of birth. This process
of descent is facilitated by the formation of a pouch
like extension of the peritoneum called the
processus vaginalis. The processus vaginalis
passes through the abdominal wall into the region
of the future scrotum. The passage through the
abdominal wall becomes the inguinal canal. The
testis descends along the posterior margin of the
processus vaginalis (not within it) and gradually
invaginates it from behind. The distal part of the
processus vaginalis (which is invaginated by the
testis) becomes the tunica vaginalis: the remaining
part of the processus is obliterated. As the
processus passes through the inguinal canal it
carries with it a number of coverings that surround
it and the spermatic cord.
The Ductus Deferens
The ductus deferens begins in the scrotum (as a

Fig. 25.3. Schematic coronal section through testis.
continuation of the epididymis). It passes through
THE PENIS
The penis consists of a root that is fixed to the perineum,

and of a free part that is called the corpus (or body). The
free part is lined all round by skin. The apical part of the
penis is enlarged and conical: this part is called the glans
penis (Fig. 25.6). The glans penis has a projecting posterior
margin that is termed the corona glandis. Immediately
proximal to the corona the penis shows a slight constriction
that is referred to as the neck of the penis.
The skin covering the penis is loosely attached except over
the glans. Here it is firmly attached to underlying tissues.
The glans is also covered by a fold of skin that extends from
Fig. 25.4. Scheme to show relationship of ductus the neck of the penis towards the tip. This fold is called the
deferens to inferior epigastric artery. Also note prepuce (Fig. 25.6). The posteroinferior part of the prepuce
relationship of the artery to the deep inguinal ring. is attached to the adjoining part of the glans by a fold called
the frenulum. The prepuce normally covers the greater part
of the glans, but can be retracted to expose the latter. The
the inguinal canal to enter the abdomen. It then runs over the space between the surface of the glans and the prepuce is
lateral wall of the pelvis to reach the posterior aspect of urinary called the preputial sac. For descriptive purposes the surface
bladder. Here the ductus deferens terminates by joining the duct of the penis that is continuous with the anterior abdominal
of the seminal vesicle to form the ejaculatory duct. The part of wall is called the dorsum. The surface towards the scrotum
the ductus deferens that lies in the inguinal canal forms part of is the ventral surface.
the spermatic cord. This cord extends from the upper pole of A transverse section through the free part of the penis is
the testis up to the deep inguinal ring. At the deep inguinal ring shown in Figure 25.5. The substance of the penis is seen to
the ductus deferens enters the abdomen. Here it hooks around be made up of three masses of spongy tissue, two dorsal
the lateral side of the inferior epigastric artery (Fig. 25.4). The and one ventral. The dorsal masses are the right and left
further course of the ductus deferens will be studied in the pelvis. corpora cavernosa (singular = corpus cavernosum). A
The ductus deferens has a very narrow lumen, but has a thick fibrous sheath surrounds each corpus cavernosum. The
wall. When palpated it feels like a cord. Near the seminal vesicle corpus spongiosum is placed in the midline ventral to the
the ductus bears a dilatation called the ampulla; but the terminal corpora cavernosa. It is traversed by the penile part of the
part of the ductus again narrows down before joining the duct urethra. The corpus spongiosum is surrounded by a fibrous
of the seminal vesicle. sheath. In addition there is an outer sheath that is common
Spermatic cord to the corpora cavernosa and the corpus spongiosum. This
This has been described in Chapter 24. sheath is covered on the outside by superficial fascia and
skin.
The substance of the corpora
cavernosa and of the corpus
spongiosum contains numerous
small spaces separated by delicate
partitions. These spaces are in
communication with blood vessels.
Most of them are normally empty,
but during erection of the penis the
spaces become filled with blood
leading to enlargement and rigidity
of the penis.
A longitudinal section through the
penis, a little to one side of the
midline is shown in Figure 25.6.
From this figure it is seen that the
distal part of the corpus
spongiosum is greatly enlarged to
form the substance of the glans
Fig. 25.5. Schematic cross section through the free part of the penis. penis.
243
244
Fig. 25.7. Parts of the root of the penis lying on the

perineal membrane.
Fig. 25.6. Schematic parasagittal section through the penis.
When traced into the perineum (i.e. into the root of the penis)
the right and left corpora cavernosa separate to form the right
and left crura (singular= crus) of the penis. The crura lie in
the superficial perineal space, on the inferior aspect of the
perineal membrane (Fig. 25.7). Each crus is firmly attached to
the corresponding margin of the pubic arch i.e. to the inferior
ramus of the pubis and the ramus of the ischium. Note that this
ramus has a prominent everted edge for attachment of the crus.
The corpus spongiosum also extends into the superficial
perineal space where it is firmly attached to the inferior aspect
of the perineal membrane, in the midline. Its proximal end is
enlarged to form the bulb of the penis. The urethra enters the
bulb after piercing the perineal membrane.
Fig. 25.8. Schematic coronal section through
Vessels and Nerves of Penis urogenital triangle to show formation of superficial
The arteries supplying the penis are the deep and dorsal arteries and deep perineal spaces.
of the penis. The main veins draining the penis are the
superficial and deep dorsal veins.
The lymphatics from the penis drain into the superficial inguinal a. Part of the pelvic fascia, that is continuous laterally with
nodes (upper medial group). Those from the glans penis drain the fascia on the obturator internus, constitutes the superior
into the deep inguinal nodes. fascia of the urogenital diaphragm.
The main nerve to the penis is the dorsal nerve of the penis. It b. The second membrane is the inferior fascia of the
is a branch of the pudendal nerve. urogenital diaphragm. It is thick and is also called the
perineal membrane.
c. The most superficial membrane is the membranous layer
of superficial fascia.
Between the upper and middle membranes there is the deep
THE PERINEUM perineal space (or pouch); and between the middle and lower
membranes there is the superficial perineal space (or
pouch).
UROGENITAL TRIANGLE
The urogenital triangle is placed between the two ischiopubic CONTENTS OF DEEP PERINEAL SPACE
rami. Stretching transversely across the rami there are three
membranes between which are enclosed two spaces as shown The deep perineal space contains two muscles (Fig. 25.9).
in Figure 25.8. From above downwards the membranes are as 1. The sphincter urethrae stretches between the two
follows: ischiopubic rami. It is pierced by the urethra.
Fig. 25.9. Muscles present in
deep perineal space (as seen
in the female).
2. Parallel to the posterior edge of the sphincter

urethrae there are the deep transverse perinei
muscles of the two sides. They are attached Fig. 25.10. A. Diagram to show muscles related to the root of the
laterally to the ramus of the ischium, and penis. B, C and D are transverse sections at levels indicated in A.
medially to the perineal body. The sphincter
urethrae and the deep transverse perinei
muscles, along with the two layers of fascia enclosing them SUPERFICIAL PERINEAL SPACE IN THE FEMALE
constitute the urogenital diaphragm.
The urogenital diaphragm is pierced by the membranous part The superficial perineal space in the female contains the
of the urethra in the male. In the female (Fig. 25.9) the female external genitalia and the muscles associated with
diaphragm is pierced by the urethra and vagina. them.
Other contents of the deep perineal space are as follows:
a. The bulbourethral glands lie on each side of the membranous
urethra in the male. Female External Genitalia
b. Several nerves and vessels pass through the deep perineal
space as described later. The region of the female external genitalia is referred to as
the vulva or the pudendum. It is seen in surface view in
Figure 25.11. When viewed from the surface we see a midline
pudendal cleft. The vagina and the urethra open to the
SUPERFICIAL PERINEAL SPACE IN THE MALE exterior through this cleft.
The cleft is bounded on either side by an elevation called
The superficial perineal space contains parts of the external the labium majus. The right and labia majora are joined
genitalia, and the muscles associated with them. anteriorly by a fold called the anterior labial commissure;
In the male it contains the root of the penis that is made up of and posteriorly by the posterior labial commissure.
(a) the bulb of the penis lying in the median plane, and (b) When the labia majora are separated we see two smaller
right and left crura attached to the ischiopubic rami (Fig. 25.7). and thinner folds of skin deep to them. These are the labia
The bulb becomes continuous, anteriorly, with the corpus minora placed on either side of the vaginal orifice (Fig.
spongiosum of the penis, while each crus becomes continuous 25.11). Posteriorly, the two labia minora are joined together
with the corresponding corpus cavernosum. After piercing the by a fold called the frenulum. Anteriorly, the labia minora
urogenital diaphragm the urethra enters the bulb and passes join each other near the clitoris (see below). The space
forwards in it into the corpus spongiosum. between the right and left labia minora is called the vestibule.
The following muscles are present: The clitoris is a small median rod-like structure placed
a. The bulbospongiosus overlies the bulb of the penis. between the anterior parts of the labia majora. In structure
b. The ischiocavernosus muscle covers the crus of the penis. it resembles a miniature penis with the exception that the
c. The superficial transverse perinei muscle runs transversely urethra does not pass through it. Like the penis it has a glans,
along the posterior margin of the superficial perineal space. a body and a root. The body is made up of corpora cavernosa
All muscles of the urogenital triangle are innervated by the that extend into the perineum as the crura of the clitoris.
perineal branch of the pudendal nerve (S2, S3, S4). The bulb and corpus spongiosum (of the penis) are
represented in the female by two masses of erectile tissue
245
246
The external orifice of the female urethra is
located a short distance in front of the vaginal
opening.
Near the posterior end of each bulb of the
vestibule, there is one greater vestibular gland
(that corresponds to the bulbourethral glands
of the male).
The mons pubis is a surface elevation overlying
the pubic symphysis: it is produced by a mass
of fat present just under the skin.
The female external genitalia are supplied by
the superficial and deep external pudendal
branches of the femoral artery, and by the labial
branches of the internal pudendal artery. The
veins accompany the arteries. Lymph vessels
end in the superficial inguinal lymph nodes.
The nerves supplying the region are the
ilioinguinal nerve, the genital branch of the
Fig. 25.11. Female external genitalia.

The pubic hair are not drawn for sake
of clarity.
placed on either side of the vaginal

orifice. These are called the bulbs of the
vestibule. The crura of the clitoris and
the bulbs of the vestibule are placed in
the superficial perineal space (Fig.
25.12).
Deep to the labia minora the vaginal
orifice is partially closed by a circular
fold of mucous membrane called the
hymen.
Fig. 25.12. Some deeper structures in the female perineum.
genitofemoral nerve, and the perineal branch of the posterior

cutaneous nerve of the thigh.
Muscles associated with female external genitalia
These are similar to those in the male (Fig. 25.13).
a. The bulbospongiosus covers each bulb of the vestibule.
b. The ischiocavernosus muscle of each side covers the crus
of the clitoris.
c. The superficial transverse perinei are similar to those in
the male.
As in the male all muscles of the urogenital triangle are
supplied by the perineal branch of the pudendal nerve (S2,
S3, S4).
Fig. 25.13. Muscles present in the superficial perineal

space in the female.
ANAL TRIANGLE and Ischiorectal Fossa
ISCHIORECTAL FOSSA
The ischiorectal fossa is a wedge shaped space. Its base
(situated inferiorly) is formed by skin overlying the fossa.
To understand the arrangement of structures in the anal triangle
Its medial wall is formed, in its upper part, by fascia lining
it is essential to have a clear picture of two muscles present in
the inferior surface of the levator ani (inferior fascia of the
relation to the true pelvis. One of these is the obturator internus
pelvic diaphragm) (Fig. 25.14). Lower down the medial wall
already studied in the lower limb. The second muscle is the
is formed by the sphincter ani externus.
levator ani.
The lateral wall of the fossa is formed by the ischial
Refer to Figure 25.14 and note that the lateral wall of the true
tuberosity and by the fascia covering the obturator internus
pelvis is lined by the obturator internus muscle. In the same
below the level of the origin of the levator ani. The apex of
figure also note that the levator ani takes origin from the fascia
the wedge lies where the levator ani and the obturator
covering the obturator internus, and runs downwards and
internus meet.
medially towards the midline. The levator ani muscles of the
The posterior boundary of the fossa is formed by the gluteus
right and left sides meet in the midline and form the pelvic
maximus muscle (superficially) and by the sacrotuberous
diaphragm. We can think of the perineum as the region lying
ligament (more deeply). Anteriorly, the space is bounded
inferior to the pelvic diaphragm. The part of the obturator
by the posterior edge of the urogenital diaphragm.
internus lying inferior to the origin of the levator ani comes
In addition to the inferior fascia of the pelvic diaphragm
into direct relationship with some structures in the perineum.
and the obturator fascia the walls of the ischiorectal fossa
The obturator internus is lined by a thick obturator fascia. The
are lined by another fascia called the lunate fascia. The
inferior surface of the levator ani is lined by fascia that is a part
lunate fascia is really the deep fascia of the region that is
of the pelvic fascia.
pushed into the fossa by the thick pad of fat that fills the
fossa.
ANAL TRIANGLE The ischiorectal fossa is often the site of infection.
Refer again to Figure 25.1 and note that the anal canal passes
Pudendal Canal
through the anal triangle to reach the exterior. Here the anal
canal is surrounded by prominent muscle fibres of the external
On the lateral wall of the ischiorectal fossa we see the
anal sphincter (sphincter ani externus). Immediately anterior
pudendal canal (Fig. 25.14). The canal is bounded laterally
to the anal canal there is the perineal body (see below).
by obturator fascia, and medially by the lunate fascia.
Posteriorly, the anal canal is connected to the coccyx by the
anococcygeal ligament. The contents of the canal are as follows:
On either side of the anal canal there is a triangular space called a. The internal pudendal artery.
the ischiorectal fossa described below. b. The pudendal nerve that divides within it into the dorsal
nerve of the penis and the perineal nerve. The medial wall
of the pudendal canal is pierced by the
inferior rectal artery and nerve that run
medially through the ischiorectal fossa.
The Perineal Body
The perineal body (or central tendon

of the perineum) is a fibromuscular
body placed in the median plane at the
junction of the anal and urogenital
triangles. Through the muscles
attached to it can help to maintain the
rectum and vagina in position. Damage
to it during child birth can weaken the
perineum.
Fig. 25.14. Section through the ischiorectal fossa and the pudendal
247
248
Fig. 25.16. Terminal part of internal pudendal artery as seen

in the male perineum (viewed from below).
Compare with Figure 25.15.
The remaining branches are given off by the internal

pudendal artery as it lies in the deep perineal space. It gives

Fig. 25.15. Scheme to show the course and branches a branch to the bulb of the penis (Figs 25.14 and 25.15) and
of the internal pudendal artery. another to the urethra. Finally it divides into the deep and
dorsal arteries of the penis that pass through the inferior
layer of the urogenital diaphragm to enter the superficial
perineal space. The deep artery enters the corresponding crus
VESSELS OF THE PERINEUM of the penis, and runs forwards in the centre of the crus. The
dorsal artery reaches the dorsum of the penis, and runs
The arteries to be seen in the perineum are the superficial and forwards in this situation up to the glans penis.
deep external pudendal branches of the femoral artery and
various branches from the internal pudendal artery that is
described below.
NERVES OF THE PERINEUM
Internal Pudendal Artery
The nerves to be seen in the perineum are as follows.
The internal pudendal artery supplies the external genitalia. 1. Ilioinguinal nerve.
Starting within the pelvic cavity (a in figure. 25.15) the artery 2. Genitofemoral nerve.
passes out of it through the greater sciatic foramen to enter the 3. Perineal branch of posterior cutaneous nerve of the thigh.
gluteal region (b). It descends across the back of the ischial 4. The main nerve of the perineum is the pudendal nerve
spine (c) and leaves the gluteal region through the lesser sciatic that is described below.
foramen (d). It now comes to lie in the lateral wall of the
ischiorectal fossa (e), within the pudendal canal. At the anterior
end of this canal it reaches the posterior end of the deep perineal The Pudendal Nerve
space (f). It runs forwards in the deep perineal space. Its
terminal part enters the superficial perineal space. The pudendal nerve arises from the sacral plexus (S2, S3,
S4). The nerve leaves the pelvis through the greater sciatic
The branches of the artery are as follows: foramen to enter the gluteal region. Here it crosses the
The inferior rectal artery is given off while the internal sacrospinous ligament and disappears into the lesser sciatic
pudendal artery is in the pudendal canal. This branch runs foramen. The nerve now enters the pudendal canal (Fig.
medially through the ischiorectal fossa to supply the anal canal 25.17) in the lateral wall of the ischiorectal fossa (Also see
(Figs 25.15 and 25.14). Figure 25.14). It ends within the canal by dividing into the
The perineal branch arises near the anterior end of the perineal nerve and the dorsal nerve of the penis (or of the
pudendal canal (Figs 25.14 and 25.15). It runs forwards into the clitoris). The branches and distribution of the pudendal nerve
superficial perineal space. It gives off scrotal branches to the are as follows:
scrotum (or labial branches in the female) and a transverse
perineal branch that runs medially along the superficial
transverse perinei muscle.
Fig. 25.18. Branches of the perineal
Fig. 25.17. Scheme to show the course and distribution of the nerve as seen in the male perineum.
pudendal nerve.
A. Sensory branches:
the pudendal nerve. At the anterior end of the pudendal
1. The inferior rectal nerve arises from the pudendal nerve
canal the nerve enters the deep perineal space. Here it
before the latter divides into its terminal branches. It passes
gives off a branch to the crus penis (Fig. 25.17). After
medially through the ischiorectal fossa and supplies the skin
passing through the deep perineal space the nerve reaches
lining the lower part of the anal canal and that around the anus.
the dorsum of the penis, and ends by supplying the glans
2. The perineal nerve is a terminal branch of the pudendal
penis. In the female the nerve is replaced by the much
nerve. At the anterior end of the canal it divides into posterior
smaller dorsal nerve of the clitoris.
scrotal (or posterior labial) branches and into muscular branches
(see below). The posterior scrotal branches are distributed to B. Muscular branches (Fig. 25.18):
the skin of the scrotum. In the female, the scrotal branches are 1. The inferior rectal branch supplies the sphincter ani
replaced by the posterior labial branches that supply the labium externus.
majus. 2. The muscular branches arising from the perineal nerve
3. The dorsal nerve of the penis is the other terminal branch of supply various muscles seen in the perineum.
249
250
26 : Oesophagus, Stomach and Intestines
Abdominal Part of Oesophagus lesser curvature, and the convex lower border is called the
greater curvature.
The orifice in the diaphragm through which the oesophagus The stomach is lined by peritoneum on both its surfaces. At
enters the abdomen is located at the level of the tenth thoracic the lesser curvature the layers of peritoneum lining the
vertebra, slightly to the left of the median plane. The orifice anterior and posterior surfaces meet and become continuous
has muscular walls formed by fibres of the right crus of the with the lesser omentum. At the greater curvature the anterior
diaphragm. From the orifice the oesophagus passes downwards and posterior layers of peritoneum become continuous with
and to the left to end (at the level of the eleventh thoracic the gastrosplenic ligament, and with the greater omentum.
vertebra) by joining the cardiac end of the stomach. The stomach is divided into a number of parts as follows
(Fig. 26.1):
a. At the junction of the left margin of the oesophagus with
the greater curvature of the stomach there is a deep cardiac
notch. Because of the upward convexity of the adjoining
THE STOMACH part of the greater curvature a part of the stomach lies above
the level of the cardio-oesophageal junction. This part of

The stomach is a sac like structure that serves as a reservoir of the stomach is called the fundus.
swallowed food, and plays an important part in digesting it. It b. The upper part of the lesser curvature faces to the right,
has a capacity of about one litre. The cranial end of the stomach while its lower part faces upwards. The junction of these
is continuous with the oesophagus. As this end lies close to the parts of the curvature is often marked by a notch called the
heart it is named the cardiac end. angular incisure. The part of the stomach to the left of the
The caudal end of the stomach is continuous with the incisure is called the body (excluding the part already
duodenum. This end is called the pyloric end, or simply the defined as the fundus).
pylorus. The stomach has two surfaces, anterior and posterior. c. The part of the stomach to the right of the angular incisure
It has two borders. The concave upper border is called the is the pyloric part. It consists of a relatively dilated left part
(continuous with the body) called the pyloric antrum;
and a narrower right part called the pyloric canal.
The position of the stomach relative to the surface of
the body is shown in Figure 26.2. The cardiac end (or
orifice) is situated to the left of the median plane,
behind the left seventh costal cartilage, 2.5 cm (one
inch) from the midline. This point lies at the level of
Fig. 26.1. Subdivisions of the stomach. Fig. 26.2. Surface projection of the stomach.
OESOPHAGUS, STOMACH AND INTESTINES
the eleventh thoracic vertebra. The pylorus (or pyloric orifice) receives short gastric arteries that are branches of the splenic
lies about 1 cm (half inch) to the right of the midline, at the level artery.
of the transpyloric plane. We have seen that this plane lies at The veins from the stomach drain into the splenic and
the level of the lower part of the first lumbar vertebra. The superior mesenteric veins.
highest part of the stomach is the fundus. It reaches the left The lymphatic drainage of the stomach is described in
fifth intercostal space, just below the nipple. Parts of the stomach Chapter 33.
extend into the epigastrium, the umbilical region, the left
hypochondrium and the left lumbar region.
The shape of the stomach can be studied in the living by taking
THE SMALL INTESTINE
skiagrams after giving a meal containing barium sulphate
(barium meal).
The small intestine is a tube about five meters long. It is
Relations of the Stomach
divided into three parts. These are (in cranio-caudal
The main structures related to the anterior surface of the
sequence) the duodenum, the jejunum and the ileum.
stomach are:
(a) Diaphragm that separates the stomach from the left pleura
and lung.
(b) Liver. THE DUODENUM
(c) Anterior abdominal wall.
(d) The extreme left part of what is called the anterior surface The duodenum forms the first 25 cm (10 inches) of the small
really faces backwards and to the left. This part comes into intestine. It is in the form of a roughly C-shaped loop that is
contact with the spleen.
The posterior surface of the
stomach is separated by the
cavity of the lesser sac from
several structures lying on the
posterior abdominal wall.
These structures are
described collectively as
forming the stomach bed.
They include the posterior
part of the diaphragm, the left
kidney, the left suprarenal
gland, the pancreas, the left
colic flexure and the
transverse mesocolon (Fig.
26.3). The spleen (which we
have seen is related to the
anterior surface) is often
included amongst the
structures forming the
stomach bed.
Vessels Supplying the
Stomach
The arteries supplying the
stomach are derived from the
coeliac trunk or one of its
branches. Along the lesser
curvature (within the two
layers of the lesser omentum)
there are the right and left
gastric arteries. Along the
greater curvature (between Fig. 26.3. Scheme to show the structures forming the stomach bed. Note that the spleen is
the two layers of the greater separated from the stomach by the gastrosplenic ligament, and is really related to the
omentum) there are the right anterior surface. The remaining structures are separated from the posterior surface of the
and left gastroepiploic stomach by the lesser sac.
arteries. The stomach also
251
252
The duodenum is subdivided into four parts as follows (Fig.
26.4). The first or superior part begins at the pylorus and
passes backwards, upwards and to the right. It is about 5 cm
long. The second or descending part is about 8 cm long. It
passes downwards (with a slight convexity to the right). The
third or horizontal part is about 10 cm long. It passes from
right to left (with a slight downward convexity) and crosses
the midline at the level of the third lumbar vertebra. The
fourth or ascending part is about 2 cm long. It runs upwards
and to the left and ends by joining the jejunum at the
duodenojejunal flexure. The junction of the superior and
descending parts of the duodenum is called the superior
duodenal flexure; while that between the descending and
horizontal part is called the inferior duodenal flexure.
Some Important Relations of the Duodenum
The duodenum has numerous relations the most important
of which are as follows.
1. The head of the pancreas lies within the C-shaped area
Fig. 26.4. Parts of the duodenum and their surface enclosed by different parts of the duodenum.
projection. S= superior part; D= descending part; 2. The horizontal part of the duodenum runs transversely
H= horizontal part; A= ascending part.

across the inferior vena cava and the aorta.
3. The descending part of the duodenum overlaps part of
the right kidney, along with the ureter and renal vessels.
retroperitoneal and, therefore, fixed to the posterior abdominal
4. The bile duct descends behind the first part of the
wall. It is continuous at its cranial end with the stomach. The
duodenum. Lower down it lies medial to the descending part
junction between the two is called the pyloroduodenal
before opening into it.
junction. At its caudal end, the duodenum becomes continuous
5. The portal vein lies between the first part of the duodenum
with the jejunum at the duodenojejunal flexure.
and the inferior vena cava.
Fig. 26.5. Posterior relations of the duodenum. The duodenum is drawn as if it was transparent.
6. The superior mesenteric vessels run vertically in front of the
horizontal part of the duodenum.
7. Anteriorly, parts of the duodenum are in contact with the liver, gall
bladder, and transverse colon.
Peritoneal relations:
Most of the duodenum is retroperitoneal and is covered by peritoneum
only on its anterior aspect. The proximal portion of the first half is
lined on both its anterior and posterior aspects by peritoneum
continuous with that on the stomach. The two layers meet above to
form the extreme right part of the lesser omentum; and below to form
the right part of the greater omentum. The part of the lesser omentum
attached to the duodenum passes upwards to the liver as the right free
margin. The free margin encloses the bile duct, the hepatic artery and
the portal vein.
Features on Interior of Duodenum
As in the rest of the small intestine the mucous membrane of the
duodenum is marked by transverse folds. In the posterolateral portion Fig. 26.6. Interior of the descending part of the
of the descending part the mucous membrane also shows a prominent duodenum showing the major and minor
vertical fold. the lower part of this fold is marked by a projection papillae. Note the transverse folds of the
mucous membrane.
called the major duodenal papilla. The papilla bears an opening of a
common channel, the hepatopancreatic ampulla, into which the bile
duct and the main pancreatic duct open. A short distance cranial to,
and in front of, the major duodenal papilla there is a smaller projection
called the minor duodenal papilla. The minor papilla has an opening
for the accessory pancreatic duct.
Vessels of Duodenum
The part of the duodenum cranial to the major duodenal papilla is
derived from the foregut. It is supplied by branches derived from the
coeliac trunk (hepatic, right gastric, supraduodenal, right gastroepiploic
and superior pancreatico-duodenal arteries). The remaining part of
the duodenum (caudal to the major duodenal papilla) is derived from
the midgut. It is supplied by the inferior pancreaticoduodenal branch
of the superior mesenteric artery.
The veins of the duodenum end in the splenic and superior mesenteric
veins. Fig. 26.7. Internal surface of part of ileum.
The lymphatic drainage of the duodenum. is described in Chapter 33.
THE JEJUNUM AND ILEUM
The jejunum and ileum are in the form of a long coiled tube suspended
from the posterior abdominal wall by the mesentery. The jejunum is
proximal to the ileum. It is about two meters long, whereas the ileum
is about three meters long.
The mucous membrane of the jejunum is marked by the presence of
numerous, large, transverse, folds. These are few or absent in the ileum.
The submucosa of the ileum contains large aggregations of lymphoid
tissue that can be seen with the naked eye and are called the aggregated
lymphatic follicles or Peyers patches. There are no such patches in
the proximal jejunum. The distal jejunum has some patches, but these
are smaller and fewer than those in the ileum.
The jejunum and ileum occupy the central and lower part of the Fig. 26.8. Attachment of root of mesentery
abdominal cavity, in the interval between the ascending colon (on the (M) to posterior abdominal wall.
right) and the descending colon (on the left). The terminal part of the
ileum lies in the true pelvis. It passes to the right to join the caecum.
253
254
The Mesentery peritoneum, while the anal canal does not
The attachment of the mesentery to the come in contact with peritoneum at all.
posterior abdominal wall is referred to as The following differences enable a
the root of the mesentery (Fig. 26.8). The segment of the colon to be easily
root is about 15 cm long. distinguished from a segment of small
The upper end of the root of the intestine.
mesentery corresponds in position to that (a) The colon is much wider than the
of the duodenojejunal flexure. It lies a little small intestine. That is why it is called
to the left of the median plane at the level the large intestine.
of the second lumber vertebra. In relation (b) The outer diameter of a segment of
to the anterior abdominal wall the upper small intestine is more or less uniform.
end lies about 3 cm below and medial to In contrast a segment of the colon shows
the tip of the left ninth costal cartilage. a series of sacculations (also called
The attachment of the mesentery runs haustrations).
downwards and to the right, its lower end (c) In the case of the small intestine the
lying to the right of the median plane in layer of longitudinal muscle is of uniform
front of the right sacroiliac joint. This thickness all round its circumference. In
point corresponds to the junction of the the caecum and colon, however, the
right lateral and intertubercular planes Fig. 26.9. A segment of the colon. longitudinal muscle layer shows
(Fig. 26.8). thickenings at three places on the
circumference. These thickenings of
Vessels of Jejunum and Ileum muscle form three prominent bands that
The jejunum and ileum are supplied by several branches arising run along the length of the colon, approximately equidistant
from the superior mesenteric artery. The veins from the jejunum from each other. These bands are called the taenia coli.
and ileum end in the superior mesenteric vein. (d) Attached to the outer wall of the colon there are numerous
The lymphatic drainage of the jejunum and ileum is described irregular projections called the appendices epiploicae. Each
in Chapter 33. of these consists of a small mass of fat enclosed by a covering
of peritoneum.
The Caecum
THE LARGE INTESTINE
The caecum lies in the right iliac fossa below the level of the
ileocaecal junction. Superiorly, the caecum is in open
Introductory Remarks about the Large Intestine communication with the ascending colon. The caecum is
The large intestine is about one and a half meters long. The about 6 cm in height, and about 7.5 cm in width. (The width
main subdivisions of the large intestine are shown in Figure is greater than the length). In relation to the anterior
26.10. These are the caecum, the ascending colon, the
transverse colon, the descending colon, the sigmoid (or pelvic)
colon, the rectum and the anal canal. The terminal part of the
ileum becomes continuous with the large intestine at the
ileocaecal junction. Near this junction the caecum is also
joined by a short, narrow, blind tube called the vermiform
appendix. The ascending colon meets the transverse colon at
the right colic flexure. The junction of the transverse colon
with the descending colon is called the left colic flexure.
The ascending colon, and the descending colon are
retroperitoneal; they are covered by peritoneum on the front
and sides, but posteriorly they are in direct contact with the
abdominal wall. The transverse colon is suspended from the
posterior abdominal wall by the transverse mesocolon; and
the sigmoid colon by the sigmoid mesocolon. The caecum is
usually surrounded all round by peritoneum and, therefore,
has considerable mobility. Its posterior aspect is separated from
the posterior abdominal wall by a recess of the peritoneal cavity
called the retrocaecal recess. The vermiform appendix often
lies in this recess. The rectum is partially covered by Fig. 26.10. Surface projection of the large intestine.
abdominal wall it lies in the triangle bounded above by the
transtubercular plane; medially by the right lateral line;
and below (and laterally) by the inguinal ligament (Fig.
26.10). It may be noted here that the ileocaecal junction
lies at the intersection of the right lateral and transtubercular
planes. The vermiform appendix opens into the caecum
about 2 cm below this point.
The Vermiform Appendix
The vermiform appendix looks very much like a round

worm: hence the name vermiform. It is a tube only a few
millimetres wide, and about 9 cm in length. The length is,
however, highly variable being anything between 2 to 20
cm. At one end, the apex, the appendix is blind; and at the
other end, the base, it opens into the (posteromedial part
of the) caecum. The opening into the caecum lies about
2 cm below the opening of the ileum. The appendix has a
Fig. 26.11. Some features in the interior of the caecum
short mesentery called the mesoappendix. The appendix seen after opening it.
is mobile and highly variable in position.
In about 60% of individuals it lies behind the caecum, in
the retrocaecal recess of the peritoneal cavity. In about The Ascending Colon
30% of individuals the appendix extends downwards and
medially into the true pelvis. Other positions that the appendix The ascending colon lies vertically in the right lateral region
may occupy are (a) subcaecal (inferior to the caecum); (b) of the abdomen. It is about 15 cm long. Its lower end is
preileal (in front of the terminal ileum); and (c) postileal (behind continuous with the caecum at the level of the intertubercular
the terminal ileum). plane. Its upper end meets the transverse colon at the right
colic flexure. This flexure lies about an inch below the
In relation to the abdominal wall
the position of the base of the
appendix is found as follows.
Draw a line joining the anterior
superior iliac spine to the
umbilicus and divide it into three
equal parts. The base lies at the
junction of the lateral and
middle-thirds of this line. This is
referred to as Mc Burneys
point. In operations for removal
of the appendix the usual
incision passes through this
point, at right angle to the line
mentioned above (Mc Burneys
incision).
Some other facts of importance
about the appendix are as
follows:
(a) The three taenia of the
caecum converge towards the
point at which the appendix is
attached. The taenia in front of
the caecum is, therefore, a useful
guide in locating the appendix.
(b) The appendix is supplied by
a branch of the ileocolic artery.
Fig. 26.12. Various positions of the vermiform appendix.
255
256
Fig. 26.13. Scheme to show the posterior relations of caecum, ascending colon, and descending colon.
transpyloric plane (to the right of the right lateral line). The flexures the transverse colon forms a downward loop of
ascending colon is covered by peritoneum in front and on varying size. Its lowest part frequently descends to a level
either side, but posteriorly it is in direct contact with structures below the umbilicus and may even descend into the pelvis.
on the posterior abdominal wall. Its lowermost part may be Its total length is about 50 cm.
separated from this wall by an upward extension of the
retrocaecal recess. Rarely, the descending colon may have a
short mesocolon. It is then covered all round by peritoneum. The Descending Colon
The posterior relations of the descending colon are shown in
figure 26.13). The descending colon begins at the left colic flexure. Its
upper end, therefore, lies in the left hypochondrium a little
above the transpyloric plane. From here the descending colon
The Transverse Colon descends through the left lateral region, and the left inguinal
region to reach the left side of the brim of the true pelvis
The transverse colon is the longest subdivision of the large (just above the inguinal ligament). It ends here by becoming
intestine. It begins at the right colic flexure (which we have continuous with the sigmoid colon. The descending colon is
seen lies in the right lateral region a short distance below the retroperitoneal. It is covered by peritoneum on the front and
transpyloric plane). It ends at the left colic flexure. sides, but posteriorly it rests directly on the abdominal wall.
This flexure is distinctly higher than the right flexure, and The descending colon is about 25 cm in length.
extends above the transpyloric plane into the left The posterior relations of the descending colon are shown
hypochondrium (Fig. 26.10). Between the right and left colic in Figure 26.13.
The Sigmoid Colon
The sigmoid, or pelvic, colon is highly

variable in length, but is usually about 40 cm
long. It is continuous at one end with the lower
end of the descending colon, and at the other
end with the rectum. The junction with the
descending colon lies over the pelvic brim
(left-half). The junction with the rectum is
more or less in the median plane. Between
these ends the sigmoid colon forms a
convoluted loop that is enclosed all round by
peritoneum and is attached to the posterior
abdominal wall by the sigmoid mesocolon.
The line of the attachment of the sigmoid
mesocolon to the posterior abdominal and
pelvic walls is shaped like an inverted V (Fig.
26.14). The apex of the V overlies the
bifurcation of the left common iliac artery. The
left ureter crosses the artery just deep to the
apex of the mesocolon. Fig. 26.14. Attachment of the transverse mesocolon.
Blood Vessels and Lymphatics of the Colon Vagus nerve in the abdomen
The caecum, ascending colon and the right two-thirds of the
transverse colon are supplied by the branches of the superior We have seen that in the thorax fibres of the right and left
mesenteric artery. These are the ileocolic branch (to the vagus nerves emerge from the posterior pulmonary plexuses
appendix, caecum, and lower one-third of the ascending colon); and descend on the oesophagus forming an anterior and a
the right colic branch (to the upper two-thirds of ascending posterior oesophageal plexus. The anterior plexus is formed
colon); and the middle colic branch (to the transverse colon). mainly by fibres from the left vagus; and the posterior plexus
The left one-third of the transverse colon, the descending colon mainly by fibres from the right vagus. Fibres emerging from
and the sigmoid colon are supplied by branches of the inferior the lower end of the anterior oesophageal plexus collect to
mesenteric artery (left colic, and sigmoid branches). form the anterior vagal trunk that is made up mainly of
The veins from the colon drain through the superior and inferior fibres from the left vagus. Similarly fibres arising from the
mesenteric veins. posterior oesophageal plexus (mainly right vagus) collect
The lymphatic drainage of the region is considered in Chapter to form the posterior vagal trunk. The anterior and posterior
33. vagal trunks enter the abdomen through the oesophageal
opening in the diaphragm. Some branches arising from these
trunks supply the stomach, the duodenum, the liver and the
Rectum and Anal Canal
pancreas. Other branches form plexuses around the coeliac
artery and its branches. Fibres passing through these plexuses
The rectum and anal canal will be considered along with other
provide parasympathetic innervation to the whole of the
pelvic viscera in Chapter 32.
small intestine, the large intestine up to the junction of the
right two-thirds and left one-third of the transverse colon,
the liver, the kidneys, and the spleen. It may be noted that
INNERVATION OF THE GUT all these plexuses also receive numerous sympathetic fibres
and that many fibres in them are afferent.
The gut is innervated by sympathetic and parasympathetic Autonomic Innervation of the gut
(vagal) nerve fibres. The distribution of the vagus nerve in the As stated above the parasympathetic nerve supply to the
abdomen is described below. The abdominal part of the greater part of the gastrointestinal tract (from pharynx to
sympathetic trunk is described in Chapter 48. the right two-thirds of the transverse colon) is through the
vagus.
257
258
The left one-third of the transverse colon, the descending colon, oesophagus, the stomach, and the duodenum up to the level
the sigmoid colon, the rectum and the upper part of the anal of the major duodenal papilla. A diverticulum from the
canal are supplied by the sacral part of the parasympathetic foregut forms the respiratory system. The abdominal part of
system. the foregut is supplied by branches of the coeliac artery.
As a rule, parasympathetic nerves stimulate intestinal The midgut gives origin to the distal part of the duodenum
movement and inhibit the sphincters. They are also the jejunum, the ileum, the caecum, the ascending colon and
secretomotor to the glands in the mucosa. Sympathetic fibres the right two-thirds of the transverse colon. The artery of
are distributed chiefly to blood vessels. the midgut is the superior mesenteric artery. Diverticula
arising from the junction of foregut and midgut give origin
Development of the gut
to the liver and the pancreas.
The primitive gut is divisible into foregut, midgut and hindgut.
The hindgut forms the left one-third of the colon, the
The foregut gives rise to part of the mouth, the pharynx, the
descending colon, the rectum and part of the anal canal. The
artery of the hindgut is the inferior mesenteric artery.
27 : The Liver, Pancreas and Spleen

THE LIVER
The liver lies in the upper, right part of the abdominal cavity behind in Figure 27.3. Areas not covered by peritoneum are
(Fig. 27.1). It lies mainly in the right hypochondrium and in shown in white. The edges of such areas are lines along
the epigastrium, but part of it extends into the left which peritoneum is reflected from the liver (mainly to the
hypochondrium and part of it into the right lateral region. When diaphragm). Double-layered folds of peritoneum are
seen from the front (Fig. 27.1) the liver is roughly triangular described as ligaments. Identify the following.
and appears to have upper, lower and right borders. In the 1. The falciform ligament (Fig. 27.2) is attached to the front
midline the upper border lies at the level of the xiphisternal of the liver near the median plane. The line of attachment
joint. To the right of the midline the upper border follows the divides the liver into right and left lobes.
upward convexity of the right dome of the diaphragm reaching 2. The left triangular ligament (Fig. 27.3) connects the
to a level just below the right nipple. To the left of the midline upper part of the left lobe to the diaphragm.
the upper border follows the curve of the medial part of the 3. Behind the right lobe of the liver there is a large triangular
left dome of the diaphragm, and ends a little below and medial area devoid of peritoneum. Hence it is called the bare area.
to the left nipple. The right border runs vertically, with an It is bounded above and below by the superior and inferior
outward convexity and ends at the level of the tip of the tenth layers of the coronary ligament. Near the right end the two
costal cartilage. The lower border runs layers meet. This part is called the right triangular ligament.
obliquely upwards and to the right. It To the left of the bare area the liver
crosses the midline at the level of the shows a deep vertical groove for the
transpyloric plane. From Figure 27.1 inferior vena cava. To the left of this
note that most of the liver is placed deep groove we see the caudate lobe of the
to the costal margin and comes into liver.
contact with the anterior abdominal wall The lower part of Figure 27.3 shows
in the epigastrium. the visceral surface that is also seen
The liver has two surfaces. Above it has in Figure 27.4. On this surface a deep
a convex diaphragmatic surface, and fissure separates the right and left
below it has an inferior or visceral lobes. This is the fissure for the
surface. The diaphragmatic and visceral ligamentum teres. A little to its right
surfaces meet in front at a sharp inferior we see the gall bladder (lying in a
border. Posteriorly, the junction of the fossa for it). The area of the liver
two surfaces is not sharply defined. Fig. 27.1. Surface projection of between the fissure for the
The liver is shown as seen from the the liver as seen from the front. ligamentum teres and the gall bladder
front in Figure 27.2 and as seen from is the quadrate lobe. It is bounded
LIVER, PANCREAS AND SPLEEN
posteriorly by a transverse depression called the
porta hepatis. The hepatic artery and the portal
vein enter the liver, and the hepatic ducts leave it,
through the porta hepatis. The left end of the porta
hepatis is continuous with the fissure for the
ligamentum venosum that lies along the left border
of the caudate lobe.
The porta hepatis and the fissure for the ligamentum
venosum give attachment to the two layers of the
lesser omentum. The attachment is L-shaped when
seen from behind. Note that the structures entering
or leaving the liver at the porta hepatis (portal vein,
hepatic artery, bile duct) are enclosed between the
two layers of peritoneum forming the lesser
omentum.
A narrow strip of liver tissue intervenes between
the posterior aspect of the porta hepatis and the
groove for the inferior vena cava. This strip projects
downwards and is called the caudate process. Fig. 27.2. Liver viewed from the front.
The most conspicuous feature on the visceral
surface of the liver is the gall bladder. It lies in a
depression on the liver surface called the fossa for the gall Lobes and Segments of the Liver
bladder. This fossa is not usually exposed to view as the gall
gladder is fixed to the liver by peritoneum. Starting near the The liver is drained by two hepatic ducts, right and left that
right end of the porta hepatis the gall bladder runs downwards join to form the common hepatic duct. It is rational to regard
and forwards across the visceral surface. Another conspicuous the territory drained by the right hepatic duct as the true
feature to be seen on the visceral surface is the fissure for the right lobe and that drained by the left hepatic duct as the
ligamentum teres. true left lobe. On the visceral surface the line of demarcation
The visceral surface of the liver comes into contact with several between these territories lies roughly along the fossa for
organs. These include the transverse colon, the stomach and the gall bladder. On the posterior part of the liver it lies along
duodenum, the right kidney and the right suprarenal gland. The the groove for the inferior vena cava. Each lobe, thus defined
areas in contact with them are shown in Figure 27.4. is divisible into a number of segments based on the branching
Fig. 27.3. Liver viewed from

behind.
259
260
pattern of the hepatic
ducts within the liver. A
simplified scheme of
these segments is
Further
Consideration of
Peritoneal Folds
Attached to the
Liver
In the course of the

description of the
surfaces of the liver
reference has been
made to a number of
peritoneal folds or
ligaments. Some of
these are considered

further below.
The lesser omentum: Fig. 27.4. Ventral surface
The lesser omentum of the liver seen from
behind and below.
consists of two layers of
peritoneum that are
continuous with the
peritoneum lining the anterior and posterior surfaces of the
stomach (Fig. 27.6). It is attached by its lower edge to the
lesser curvature of the stomach and to the proximal portion of
the first part of the duodenum. Its upper edge has an inverted
L shaped attachment to the liver.
We have seen that this attachment is to the fissure for the
ligamentum venosum and to the lips of the porta hepatis (Fig.
27.4). Extending between the duodenum and the right extremity
of the porta hepatis the lesser omentum has a free edge formed
by continuity of the anterior and posterior layers. The portal
vein, the bile duct and the hepatic artery lie between the two
layers of the omentum near its free edge. Along the lesser
curvature of the stomach the right and left gastric arteries and
veins lie within the omentum.
The falciform ligament:
The falciform ligament is attached on the anterior and superior Fig. 27.5. Scheme to show the
parts of the diaphragmatic surface of the liver. It is shaped like segments of the liver.
a sickle (falciform = sickle shaped). Its lower part is attached
anteriorly to the anterior abdominal wall, the attachment
extending up to the level of the umbilicus. is separated from the peritoneum lining the diaphragm, or
The ligamentum teres is enclosed within the falciform ligament adjoining viscera, only by a potential space. The spaces
(near its free edge). It passes from the umbilicus to the inferior lying between the diaphragm and the liver are referred to as
border of the liver within the ligament. subphrenic spaces. Spaces inferior to the liver are called
subhepatic spaces. The importance of the subphrenic and
subhepatic spaces is that they are sites where abnormal fluids
Peritoneal Spaces around the Liver (like pus) can collect. The spaces are:
1. The right subphrenic space.
Surrounding the liver there are a number of more or less isolated 2. The left subphrenic space.
regions where the peritoneum covering the surface of the liver
venosum (Fig. 27.7). The ligamentum teres, therefore,
begins at the umbilicus and ends by joining the left
branch of the portal vein; while the connections of
the ligamentum venosum are those of the ductus
venosus.
EXTRAHEPATIC BILIARY
APPARATUS
The passages through which bile, produced in the

liver, passes before entering the duodenum are seen
in Figure 27.8. The right and left hepatic ducts
emerge at the porta hepatis and join to form the
common hepatic duct. At its lower end the common
hepatic duct is joined by the cystic duct from the
gall bladder to form the bile duct. The bile duct
Fig. 27.6. Scheme to show the arrangement opens into the duodenum. The gall bladder and bile
of the lesser omentum. duct are considered in detail below.
3. The right subhepatic space, also called the hepatorenal or

Morrisons pouch.
4. The left subhepatic space is merely another name for the lesser
sac.
Blood Vessels of the Liver
The liver receives oxygenated blood through the hepatic artery. This
artery is a branch of the coeliac trunk, and is described in Chapter
43. Entering the liver at the porta hepatis it divides into two main
branches that are distributed to the true right and left lobes.
The liver receives blood from the gastrointestinal tract through the Fig. 27.7. Scheme to show the ligamentum
portal vein. This vein is described in Chapter 43. At the porta hepatis teres and the ligamentum venosum.
the portal vein divides into right and left branches that accompany
branches of the hepatic artery. Blood from the liver is drained by a
number of hepatic veins that open directly into the inferior vena cava.
Significance of Ligamentum Teres and Ligamentum Venosum
In fetal life oxygenation of blood takes places not in the lungs, but in
the placenta. Blood from the placenta is brought to the fetus initially
through right and left umbilical veins. The right vein is transitory
and soon disappears so that all blood now comes to the fetus through
the left umbilical vein. The left umbilical vein ends initially in the
left horn of the sinus venosus, but later in fetal life it ends by joining
the left branch of the portal vein. For some time during fetal life all
blood coming from the placenta has to filter through the liver before
reaching the heart.
However, at a later stage a new channel, the ductus venosus,
shortcircuits a large part of this blood to the inferior vena cava. The
ductus venosus is connected at one end to the left branch of the portal
vein, and at the other end to the inferior vena cava. After birth the left
umbilical vein and the ductus venosus are no longer functional. They
retrogress into fibrous structures. The left umbilical vein becomes Fig. 27.8. Scheme to show the parts of the
the ligamentum teres, and the ductus venosus becomes the ligamentum extrahepatic biliary apparatus.
261
262
THE GALL BLADDER THE BILE DUCT
The gall bladder is a small sac attached to the visceral surface The bile duct extends from just below the porta hepatis to
of the liver (Fig. 27.4). The gallbladder has a capacity of about the middle of the descending part of the duodenum. It is
40 ml. It is held in place by peritoneum that covers its inferior about 7 cm long. From above downwards it lies (a) in the
(or posterior) surface. Its superior (or anterior) aspect is in right margin of the lesser omentum (Fig. 27.6); (b) behind
direct contact with liver tissue. However, the lowest part of the first part of the duodenum; and (c) behind the head of
the gall bladder, that is called the fundus, projects beyond the the pancreas. Within the lesser omentum the duct lies to the
inferior border of the liver (Fig. 27.2) and is, therefore, right of the hepatic artery and in front of the portal vein (Fig.
surrounded all round by peritoneum. The central part of the 27.6).
gall bladder is called the body. The narrow part succeeding Just outside the duodenal wall the bile duct is joined by the
the body is called the neck. The neck is connected to the cystic pancreatic duct. The two ducts pierce the muscular wall of
duct through which the gall bladder drains into the bile duct. the duodenum; and then descend in the submucosa. The bile
and pancreatic ducts may open separately on the major
Some Relations of the gall bladder duodenal papilla, or may join (at a variable distance above
Anteriorly, the body and neck of the gall bladder are in contact the papilla) to form a common passage called the
with the liver. The fundus comes in contact with the anterior hepatopancreatic ampulla.
abdominal wall just below the ninth costal cartilage. The area
of contact corresponds to the point where the lateral margin of
the right rectus abdominis crosses the costal margin. SPHINCTERS RELATED TO THE BILE AND
PANCREATIC DUCTS
The posterior (or inferior) surface of the gall bladder comes

into contact with the transverse colon, and the duodenum.
The gall bladder is supplied by the cystic artery (branch of the The terminal part of the bile duct is surrounded by ring of
hepatic artery). It is drained by the cystic veins that drain into smooth muscle that forms the sphincter choledochus. It
the portal vein. normally keeps the lower end of the bile duct closed. As a
result, bile formed in the liver keeps accumulating in the
gall bladder (and also undergoes considerable concen-
tration). When the sphincter opens bile stored in the
gall bladder is poured into the duodenum. Another sphincter
Fig. 27.9. Parts of the pancreas and their

relationship to the stomach, the
duodenum and the spleen.
Some relations of the pancreas
1. The pancreas is placed in front of the
inferior vena cava, the abdominal aorta, and
the left kidney.
2. The superior mesenteric artery arises from
the aorta deep to the pancreas. Lower down
the artery lies in front of the uncinate process
that intervenes between the superior
mesenteric artery and the abdominal aorta.
3. The superior mesenteric and splenic veins
join to form the portal vein behind the
pancreas. The portal vein lies behind the neck
of the pancreas.
4. The posterior edge of the greater omentum
and the upper end of the transverse
mesocolon are attached to the anterior aspect
of the pancreas.
5. The stomach and the transverse colon lie
anterior to the pancreas.
6. The C-shaped loop of the duodenum
surrounds the head of the pancreas.
Fig. 27.10. Some posterior relations of the pancreas. The pancreas is
shown only in outline.
is usually present around the terminal part of the pancreatic Ducts of the Pancreas
duct. This is the sphincter pancreaticus. A third sphincter Secretions of the pancreas are poured into the duodenum
surrounds the hepatopancreatic ampulla and is called the through two ducts (Fig. 27.12).
sphincter ampullae. a. The main pancreatic duct begins in the tail of the pancreas,
and passes to the right through the body. It ends by joining
the bile duct.
b. The accessory pancreatic duct begins in the lower part of
THE PANCREAS the head of the pancreas. It opens into the duodenum at the
minor duodenal papilla (that lies a short distance above and
The pancreas lies obliquely on the posterior abdominal wall, in front of the major papilla).
partly to the right of the median plane, and partly to the left. Its
right end is enlarged and is called the head. Next to the head
there is a short, somewhat constricted part called the neck. The
neck is continuous with the main part of the gland that is called
the body. The left extremity of the pancreas is thin and is called
the tail.
The head lies in the C-shaped space bounded by the duodenum.
The neck is placed behind the pylorus, and the body of the
pancreas lies behind the body of the stomach.
The neck and body are separated from the stomach by the lesser
sac. The tail lies in the lienorenal ligament and its tip comes in
contact with the spleen. A projection arising from the lower
left part of the head is called the uncinate process of the
pancreas (Fig. 27.9). The head and neck of the pancreas have
anterior and posterior surfaces. The body has three surfaces.
The posterior surface faces backwards. The anterior and inferior
surfaces meet at the anterior border; the anterior and posterior
surfaces at the superior border; and the inferior and posterior
surfaces meet at the inferior border. A part of the body projects Fig. 27.11. Relationship of portal vein, superior
upwards beyond the lesser curvature of the stomach and comes mesenteric vein and splenic vein to the pancreas.
in contact with the lesser omentum. This projection is called
the tuber omentale (Fig. 27.9).
263
264
The region lying along the junction of these
three impressions of the visceral surface is
the hilum. The spleen is penetrated here
by branches of the splenic artery and vein.
The tail of the pancreas comes in contact
with the hilum of the spleen, near the colic
impression.
The spleen is attached to the greater
curvature of the stomach through the
gastrosplenic ligament. The lienorenal
ligament passes from the hilum to the front
of the left kidney.
Blood supply and innervation of the
spleen
The spleen is supplied by the splenic artery.
The splenic vein accompanies the artery
and ends in the portal vein.
Fig. 27.12. Schematic diagram of the ducts of the pancreas. Development
The biliary apparatus develops from a
hepatic bud that arises from the junction
Blood Supply, Lymphatic Drainage and Nerve of foregut and midgut. The bud divides into
Supply of the Pancreas the pars hepatica, that forms the liver, and the pars cystica
that forms the gall bladder. The part of the hepatic bud
The pancreas is supplied by branches from the splenic artery, proximal to the division forms the bile duct.
and from the superior and inferior pancreaticoduodenal arteries. The pancreas develops from two buds, ventral and dorsal,
The veins drain into the splenic, superior mesenteric and portal that arise from the junction of foregut and midgut.
veins. The spleen develops from mesoderm in the dorsal
mesogastrium.
THE SPLEEN
The spleen lies in the left hypochondrium, behind the stomach.

It is about 12 cm long and 7 cm broad. Posteriorly, the spleen
rests on the diaphragm opposite the ninth, tenth and eleventh
ribs (Fig. 27.13). Its long axis corresponds to that of the tenth
rib. The spleen has a medial end that is directed medially,
upwards and backwards; and a lateral end that is directed
laterally, forwards and downwards. The medial end lies about
4 cm from the midline at the level of the spine of the tenth
thoracic vertebra. The lateral end reaches up to the mid-axillary
line. The medial and lateral ends are joined by upper and lower
borders.
The spleen has a diaphragmatic surface and a visceral surface.
The diaphragmatic surface is convex and is separated from the
diaphragm only by peritoneum. The diaphragm separates this
surface from the lower parts of the left lung and pleura.
The visceral surface of the spleen is shown in Figure 27.13. It
is seen to be divided into three roughly triangular areas. The
largest of these areas comes into contact with the stomach and
is called the gastric impression.
The posteromedial part of the visceral surface comes into
contact with the left kidney. This part is therefore, called the
renal impression. Anteroinferiorly the spleen has a colic
impression that comes in contact with the left colic flexure.
Fig. 27.13. Spleen as seen from the front.
BLOOD VESSELS OF STOMACH, INTESTINES, LIVER, PANCREAS AND SPLEEN
28 : Blood Vessels of Stomach
Intestines, Liver, Pancreas and Spleen
The abdominal aorta gives off three large ventral branches.

These are the coeliac trunk, the superior mesenteric artery
and the inferior mesenteric artery. These three arteries are
responsible for blood supply to the entire abdominal part of
the alimentary tract (excepting the lower part of the rectum and
the anal canal). They are also responsible for supplying the
liver, the pancreas and the spleen. Although the abdominal aorta
itself will be considered in Chapter 30 we will consider its
ventral branches here as their course and relations are intimately
related to the structures considered in the preceding two
chapters.
We will also consider the related veins. The veins draining these
organs do not drain directly into the systemic circulation. Blood
in them first drains into the portal vein through which it reaches
the liver. After passing through the sinusoids of the liver the
blood reaches the inferior vena cava through hepatic veins. Fig. 28.1. Scheme to show course of the left
and right gastric arteries.
THE HEPATIC ARTERY

THE COELIAC TRUNK AND ITS BRANCHES
The hepatic artery arises from the celiac trunk. It first runs
to the right and somewhat downwards on the posterior
The coeliac trunk arises from the front of the uppermost part of
abdominal wall to reach the superior part of the duodenum.
the abdominal aorta just below the aortic opening in the
It then turns upwards to enter the free margin of the lesser
diaphragm. The trunk is only about one centimeter long. It
momentum. Ascending in the lesser omentum it reaches the
passes forwards and terminates by dividing into three branches,
porta hepatis where it divides into right and left branches
viz., the left gastric, hepatic and splenic arteries.
for the corresponding lobes of the liver. Within the free
margin of the lesser omentum the artery lies in front of the
portal vein with the bile duct to its right.
THE LEFT GASTRIC

ARTERY
This artery arises from the coeliac

trunk and passes upwards and to the
left (Fig. 28.1) on the posterior
abdominal wall. Reaching near the
cardiac end of the stomach the
artery turns forwards and passes
from the diaphragm to the lesser
curvature or the stomach. The
artery then runs to the right along
the lesser curvature of the stomach
between the two layers of the lesser
omentum. It ends by anastamosing
with the right gastric artery.
Fig. 28.2. Scheme to show the distribution of the hepatic and splenic arteries.
265
266
Branches of the hepatic artery:

These are the right gastric artery,
the gastroduodenal artery, the
supraduodenal artery (sometimes),
the cystic artery and terminal
hepatic branches (Fig. 28.2).
Right gastric artery
The right gastric artery arises as the
hepatic artery lies above the
duodenum. It passes to the left
along the lesser curvature of the
stomach to anastomose with the left
gastric artery.
Gastroduodenal artery
The gastroduodenal artery also
arises from the hepatic artery as the
latter lies above the duodenum. It
descends behind the superior part Fig. 28.3. Scheme to show parts of the gut supplied by the coeliac trunk,
the superior mesenteric and inferior mesenteric arteries.
of the duodenum. It ends by
dividing into the right gastro-

epiploic and superior pancreaticoduodenal arteries (anterior THE SPLENIC ARTERY
and posterior). The gastroduodenal artery also gives off small
branches to the stomach, the pancreas, and the duodenum. The splenic artery arises from the coeliac trunk. Its initial
part runs to the left on the posterior abdominal wall along
Supraduodenal artery
the upper border of the pancreas (Fig. 28.2). Reaching the
The supraduodenal artery may arise from the gastroduodenal
front of the left kidney the artery passes into the lienorenal
artery or directly from the hepatic artery. It supplies the superior
ligament to reach the hilum of the spleen where it divides
part of the duodenum.
into several branches. These are as follows (Fig. 28.2).
Right gastroepiploic artery 1. Several branches are given off to the pancreas.
The right gastroepiploic artery runs to the right along the greater 2. A number of short gastric arteries arise near the hilum of
curvature of the stomach (between the two layers of the greater the spleen. They supply the fundus of the stomach.
omentum). It ends by anastomosing with the left gastroepiploic 3. The left gastroepiploic artery arises near the hilum of the
artery (a branch of the splenic artery). The right gastroepiploic spleen. It passes downwards, forwards and to the right
artery gives branches to the stomach and to the greater through the gastrosplenic ligament to reach the greater
omentum. curvature of the stomach. It gives branches to the stomach
and ends by anastomosing with the right gastroepiploic
Superior pancreaticoduodenal arteries
artery.
There are two superior pancreaticoduodenal arteries, anterior
4. The splenic branches enter the hilum of the spleen to
and posterior. They descend respectively anterior and posterior
supply the organ.
to the junction of the second part of the duodenum with the
From the above account of the coeliac trunk and its branches
pancreas. They supply the pancreas, and the duodenum up to
it will be seen that, apart from the liver, pancreas and spleen,
the level of the major duodenal papilla.
the trunk supplies the infra-diaphragmatic part of the gut up
Cystic artery to the middle of the descending part of the duodenum (up to
The cystic artery usually arises from the right branch of the the major duodenal papilla). This part of the gut is derived
hepatic artery. It passes to the right to reach the gall bladder from the embryonic foregut. The coeliac trunk is, therefore,
which it supplies. It also gives branches to the hepatic ducts described as the artery of the foregut (Fig. 28.3).
and the upper part of the bile duct.
Hepatic branches
The right and left hepatic branches enter the corresponding
lobe of the liver and divide within them in a fairly constant
SUPERIOR MESENTERIC ARTERY
manner. As a result of this fact the liver can be divided into a
number of arterial segments. The superior mesenteric artery is the artery of the midgut.
Its area of supply extends cranially up to the middle of the
descending part of the duodenum, and caudally to the
BLOOD VESSELS OF STOMACH, INTESTINES, LIVER, PANCREAS AND SPLEEN
junction of the right two-thirds and left one-
third of the transverse colon. The artery arises
from the front of the abdominal aorta a little
below the coeliac trunk and runs downwards
and forwards. The artery then crosses in front
of the horizontal part of the duodenum to enter
the root of the mesentery. Passing through the
root of the mesentery it runs downwards and
to the right to reach the ileocaecal junction.
The artery gives off numerous branches to the
gut and these are described below.
The artery is accompanied by the superior
mesenteric vein which lies to its right side.
Branches of
Superior Mesenteric Artery
1. The inferior pancreaticoduodenal artery

is the first branch. It divides into anterior and
posterior branches. They supply the pancreas
and duodenum and anastomose with the
branches of the superior pancreaticoduodenal
arteries.
2. The branches to the jejunum and ileum are
many. They pass through the mesentery to Fig. 28.4. Distribution of superior mesenteric artery.
reach the gut. The branches anastomose with
each other to form a series of arches from which
numerous straight arteries arise to supply the gut (Fig. 28.4).
3. The ileocolic artery arises from the right side of the lower part
of the superior mesenteric artery. It ends by dividing into superior
and inferior branches. The inferior branch anastomoses with the
terminal part of the superior mesenteric artery. The superior branch
anastomoses with the right colic artery. The ileocolic artery gives
off various branches that supply the terminal part of the ileum, the
caecum, the appendix and the lower one-third of the ascending
colon (Figure 28.4).
4. The right colic artery arises from the right side of the superior
mesenteric artery at about its middle. It passes to the right (on the
posterior abdominal wall) to reach the ascending colon. It
terminates by dividing into descending and ascending branches
that anastomose with the ileocolic and middle colic arteries,
respectively. The artery supplies the upper two-thirds of the
ascending colon.
5. The middle colic artery arises from the right side of the superior
mesenteric artery just below the duodenum. It runs into the
transverse mesocolon to reach the transverse colon. Its branches
supply the right two-thirds of the transverse colon.
INFERIOR MESENTERIC ARTERY
The inferior mesenteric artery supplies the hindgut. Its area of

Fig. 28.5. Distribution of inferior mesenteric artery.
supply extends from the junction of the right two-thirds and left
one-third of the transverse colon to the rectum. The artery arises
267
268
THE HEPATIC
PORTAL SYSTEM
Normally the arteries supplying

an organ end in a set of capillaries
from which blood is collected by
veins that carry it to the heart. In
some cases, however, the veins
from an organ enter another
organ where they divide into
another set of capillaries (or
sinusoids). Such an arrangement
is called a portal system.
The best example of a portal
system is the hepatic portal
system. The arteries supplying
the abdominal part of the
gastrointestinal tract break up
into capillaries in its wall (first
set). Veins draining these

capillaries ultimately end in the
Fig. 28.6. Scheme to show the portal vein that enters the liver.
tributaries of the portal vein. Within the liver the portal vein
divides into sinusoids ( = 2nd set
of capillaries). This blood is
from the front of the aorta about 3 cm above its bifurcation. It

runs downwards (and slightly to the left) over the posterior
abdominal wall. It then crosses the left common iliac artery
below which its continuation is called the superior rectal artery.
The branches given off by the inferior mesenteric artery are
the left colic, sigmoid and superior rectal arteries.
The left colic artery divides into ascending and descending
branches.
The branches supply the left one-third of the transverse colon
and most of the descending colon.
The sigmoid branches enter the pelvic mesocolon to reach
the sigmoid colon. They anastomose with the lower branches
of the left colic artery and help to supply the lower part of the
descending colon.
Superior rectal artery
We have seen that the superior rectal artery is a continuation
of the inferior mesenteric artery into the true pelvis. It runs
across the left common iliac artery and vein to reach the rectum.
It divides into two main branches one of which descends on
either side of the rectum and supplies it. Their area of supply Fig. 28.7. Scheme to show some relations
extends up to the sphincter ani externus. of the portal vein.
KIDNEY, URETER AND SUPRARENAL GLAND
returned to the heart through the hepatic veins and the inferior PORTAL VEIN
vena cava.
The portal vein is formed, as stated above, by the union of
The main veins comprising the hepatic portal system are shown the superior mesenteric and splenic veins. The point of union
in Figure 28.6. Observe that the portal vein is formed by the lies at the level of the second lumbar vertebra, behind the
union of the superior mesenteric and splenic veins. The inferior neck of the pancreas. The vein passes upwards in the right
mesenteric vein joins the splenic vein. The right and left gastric free margin of the lesser omentum to reach the porta hepatis
veins drain directly into the portal vein. The left gastroepiploic where it ends by dividing into right and left branches. These
and short gastric veins drain into the splenic vein, while the branches enter the substance of the liver.
right gastroepiploic vein drains into the superior mesenteric Some important relations of the portal vein are shown in
vein. Figure 28.7.
Splenic vein HEPATIC VEINS

Emerging from the hilum of the spleen, the splenic vein runs
through the lienorenal ligament and then runs across the The hepatic veins are terminal parts of an elaborate venous
posterior abdominal wall, posterior to the body of the pancreas. tree that permeates the liver. The hepatic veins emerge from
It ends behind the neck of the pancreas by uniting with the liver tissue that is in close contact with the upper part of the
superior mesenteric vein to form the portal vein. vena cava, and immediately enter the vena cava. (The cut
ends of the veins are seen on the vena cava when the liver is
removed).
29 : Kidney, Ureter and Suprarenal Gland

.
Introduction to the Urinary System
The organs of the body that are concerned with the formation of urine and
its elimination from the body are referred to as urinary organs. They consist
(Fig. 44.1) of the right and left kidneys, in which urine is formed; the right
and left ureters; the urinary bladder, in which urine is stored temporarily
and is also concentrated; and the urethra that carries urine from the urinary
bladder to the exterior.
In this chapter we will consider the kidneys and the abdominal parts of the
ureters. The pelvic parts of the ureters, the urinary bladder, and the urethra
will be considered in Chapter 47. The suprarenal glands are endocrine
organs. It is convenient to consider them here because of their close
topographic relationship to the kidneys.
THE KIDNEYS
Each kidney has a characteristic bean-like shape (Fig. 44.2). It has a convex
lateral margin; and a concavity on the medial side that is called the hilum. It
has upper and lower ends and anterior and posterior surfaces. Terminal
branches of the renal artery enter the kidney at the hilum, and the veins
emerge from it. The hilum also gives attachment to the upper expanded end Fig. 29.1. Approximate dimensions of
of the ureter (called the renal pelvis). a kidney. The anteroposterior diameter
is about 3 cm.
269
270
The position of the kidneys relative to the anterior
abdominal wall is shown in figure. 44.3. Note the
following. Because of the presence of the liver on the
right side, the right kidney lies slightly lower than the left
kidney. The hilum of each kidney lies more or less in the
transpyloric plane, a little medial to the tip of the ninth
costal cartilage. The vertical axis of the kidney is placed
obliquely (Figs. 44.2 and 44.3) so that its upper end is
nearer the median plane than the lower end. The upper
end is about 2.5 cm (one inch) from the median plane,
while the lower end is about 7.5 cm (three inches) from
it.
In relation to the posterior surface of the body the hilum
of the kidney lies at the level of the first lumbar spine
(Fig. 44.4), the upper pole at the level of the 11th thoracic
spine, and the lower pole at the level of the third lumbar
spine. In figure 44.4 note that the area in which the kidney Fig. 29.2. Projection of the kidney to the
lies can be represented as a parallelogram (Morrisons front of the body.
parallelogram). The upper and lower boundaries of this
parallelogram are formed by transverse lines drawn
through the eleventh thoracic and third lumbar spines. Its
medial and lateral boundaries are formed by vertical lines

2.5 cm and 9 cm from the median plane.
Relations of the Kidneys
The posterior relations of the kidneys are shown in Figure
29.4, and the anterior relations in figure 29.5.
Structures in the hilum
The renal vein (or its tributaries), the renal artery (or its
branches), and the renal pelvis (see below) enter or leave
the kidney through the hilum. The vein is most anterior,
the artery is in the middle, and the pelvis is most posterior. Fig. 29.3. Surface projection of the kidney
Examination of the hilum therefore, enables one to on the back of the body.
distinguish between the anterior and posterior
aspects of the kidney. The direction of the
ureter enables the upper and lower ends of the
kidney to be distinguished. In this way it
becomes possible to distinguish between the
isolated right and left kidneys.
The hilum leads into a space called the renal
sinus (Fig. 44.9). The renal sinus is occupied
by the renal vessels and the renal pelvis. The
pelvis divides into two (or three) parts called
major calices (singular = calyx). Each major
calyx divides into a number of minor calices
(Fig. 44.10). The end of each minor calyx is
shaped like a cup. A projection of kidney tissue
called a papilla fits into the cup.
Gross internal structure
When we examine a coronal section through a
kidney we can make out some features of its
internal structure (Fig. 44.11).
Firstly it is seen that the papillae referred to
above are the apical parts of triangular areas
of renal tissue called the renal pyramids. As
seen in Figure 44.11 the pyramids occupy the Fig. 29.4. Posterior relations of kidneys.
KIDNEY, URETER AND SUPRARENAL GLAND
inner part of the kidney and are,
therefore, collectively referred to as
the medulla. The kidney tissue
lying between the bases of the
pyramids and the surface of the
kidney is referred to as the cortex.
Extensions of the cortex occupy the
intervals between adjacent
pyramids. These extensions are
called renal columns.
Renal Capsule
Kidney tissue is intimately covered
by a thin layer of fibrous tissue that
is called the capsule.
Renal Fascia
Fig. 29.5. Areas on anterior surfaces of right and left kidneys related to
Beyond the capsule the kidney is
various viscera. Peritoneum covered areas are shaded in black dots.
surrounded by a layer of perirenal
fat (also called perinephric fat).
Some of this fat extends into the
renal sinus.
The perinephric fat is surrounded
by a layer of fibrous tissue that
constitutes the renal fascia.
Renal Segments
The kidneys are supplied by the
renal arteries and are drained by the
renal veins (Chapter 45). Near the
hilum of the kidney the renal artery
divides into anterior and posterior
divisions. Within the renal sinus
Fig. 29.7. Scheme to show the segments of the kidney.
these divide further into primary branches each of which supplies a

specific region of renal tissue, there being no anastomoses between
arteries to adjoining regions. These primary branches are called
segmental arteries. Based on their distribution the kidney can be
divided into five segments as shown in Figure 44.14.
The lymphatic drainage of the kidneys is described in Chapter 48.

The kidneys are supplied by autonomic nerves that reach them along
the renal arteries.
Development of kidneys
The human kidney develops from the metanephros. The collecting
system is derived from the ureteric bud, that also forms the ureter.
Fig. 29.6. Some features to be seen in a coronal

section through the kidney.
271
272
Fig. 29.8. Relations of abdominal parts of right and left ureters
THE URETERS THE SUPRARENAL GLANDS
The ureter (right or left) is a long tube that connects the lower The right and left suprarenal glands lie in close relationship
end of the renal pelvis with the urinary bladder. It is about to the upper poles of the corresponding kidneys (Fig. 44.16).
25 cm long. The upper half of this length lies on the posterior They are enclosed with the kidney in the renal fascia, but lie
abdominal wall and the lower half in the true pelvis. outside the renal capsule (Fig. 44.13). Each suprarenal gland
The abdominal part of each ureter runs downwards (with a has an anterior and a posterior surface. When seen from the
slight medial inclination). At the brim of the pelvis the ureter front the right suprarenal gland is triangular; and has medial,
crosses the upper end of the external iliac artery (and vein), lateral and inferior borders. The left suprarenal gland is
and comes to lie on the lateral wall of the pelvis (Fig. 37.11). It semilunar. It has a convex medial margin and a concave
leaves the pelvic wall and turns medially and forwards to reach lateral margin.
the posterolateral part of the urinary bladder.
Some relations of the ureters are shown in Figure 29.8.
POSTERIOR ABDOMINAL WALL AND SOME RELATED STRUCTURES
A Brief Note on Structure and Functions of the A. Hormones of the suprarenal cortex
Suprarenal Glands a. The cells of the zona glomerulosa produce the hormone
The suprarenal gland is covered by a capsule from which septa aldosterone.
extend into the substance of the gland. The gland is made up of b. The cells of the zona fasciculata produce hydrocortisone.
a superficial layer the cortex, and a deeper part called the c. The cells of the zona reticularis produce sex hormones.
medulla. On the basis of the arrangement of its cells the cortex
B. Hormones of the suprarenal medulla
can be divided into the zona glomerulosa, the zona fasciculata,
Both functionally and embryologically the medulla of the
and the zona reticularis.
suprarenal gland is distinct from the cortex. Like typical
The medulla is made up of modified postganglionic sympathetic
postganglionic sympathetic neurons the cells of the medulla
neurons.
secrete noradrenalin and adrenalin.
The hormones produced by the suprarenal glands are as follows:
30 : Posterior Abdominal Wall

and Some Related structures
diaphragm are seen. The right crus descends to the level of

Preliminary Remarks
vertebra L3, and the left crus to level L2. In relation to the
diaphragm note the median arcuate ligament lying in front
The general layout of structures seen in relation to the posterior
of the aperture for the aorta, the medial arcuate ligament
abdominal wall is shown in Figure 30.1.
passing across the upper part of the psoas major, and the
The skeletal basis of the posterior abdominal wall is formed by
lateral arcuate ligament in relation to the upper end of the
the five lumbar vertebrae. Lower down the posterior wall
quadratus lumborum.
continues into the iliac fossae formed by the hip bones. In the
Many important viscera lie directly on the posterior
median plane the posterior abdominal wall continues into the
abdominal wall. These include the duodenum, the ascending
posterior wall of the true pelvis formed by the sacrum and
colon and the descending colon; the pancreas, the right and
coccyx. The twelth rib gives attachment to some structures seen
left kidneys and ureters, and the right and left suprarenal
in the posterior abdominal wall.
glands. The abdominal aorta and the inferior vena cava are
Lying just lateral to the bodies of these vertebrae body there is
intimately related to the posterior abdominal wall.
the psoas major muscle. Behind (and lateral to) the psoas major
Many structures relevant to the study of the posterior
we see the quadratus lumborum muscle. In relation to the
abdominal wall have already been described. These are:
quadratus lumborum and the erector spinae there is the
1. Lumbar vertebrae, sacrum, coccyx and sacroiliac joint.
thoracolumbar fascia made up of anterior, middle and posterior
2. Hip bone:
layers (Fig. 23.3). Traced laterally the three layers fuse along
3. Pelvis as a whole.
the lateral margin of the quadratus lumborum. These fused layers
4. Psoas major and iliacus muscles.
give attachment to the transversus abdominis and internal
Other structures are considered below.
oblique muscles which belong to the anterior abdominal wall.
It follows that at the lateral edge of the quadratus lumborum
the posterior abdominal wall becomes continuous with the Thoracolumbar Fascia
anterior abdominal wall.
When traced downwards the posterior abdominal wall extends The thoracolumbar fascia is intimately related to the muscles
into the iliac fossa. Over the fossa the wall is formed by the of the posterior abdominal wall. It has three layers (Fig.
psoas major (medially), and by the iliacus laterally. 23.3). The posterior layer covers the deep muscles of the
In the upper part of Figure 30.1 we see the diaphragm. Although back. It is attached medially to the lumbar and sacral spines.
the diaphragm is not described as a constituent of the posterior Laterally it blends with the anterior layer: the two layers
abdominal wall, many structures within the abdomen rest on form an aponeurosis which gives attachment to the internal
its posterior part. The diaphragm occupies the area above the oblique and transversus muscles. The middle layer separates
level of the twelfth ribs. Near the midline the crura of the the erector spinae from the quadratus lumborum. It is
273
274
Fig. 30.1. Posterior abdominal wall after removing most of the viscera.
attached medially to the tips of the transverse processes of below. Some structures lying over these muscles are seen in
the lumbar vertebrae. Laterally, it blends with the posterior Figure 30.2.
layer. The anterior layer covers the anterior surface of the
quadratus lumborum. It is attached medially to the anterior
surfaces of the transverse processes of the lumbar vertebrae
and merges laterally with the posterior layer as mentioned THE QUADRATUS LUMBORUM
above.
The quadratus lumborum is so called because of its
quadrilateral shape. It forms the posterior abdominal wall
between the psoas major medially, and the transversus
abdominis laterally. It is enclosed between the anterior and
MUSCLES OF middle layers of the thoracolumbar fascia.
POSTERIOR ABDOMINAL WALL
Origin:
The origin of the muscle lies inferiorly (Fig. 30.3). It arises
The muscles of the posterior abdominal wall are the psoas laterally, from the iliac crest (posterior one-third of inner lip
major and minor, the iliacus and the quadratus lumborum. The of ventral segment, behind the transversus abdominis); and
attachments of the psoas muscles and of the iliacus have been medially from the iliolumbar ligament. This ligament
described on page 107. The quadratus lumborum is described
Fig. 30.2. Posterior abdominal wall and some structures related to it.
stretches from the transverse process of the 5th lumbar

vertebra to the iliac crest .
Insertion:
The muscle is inserted chiefly into the lower border of the
twelfth rib (medial half). It also gives off small slips to the
tips of the transverse processes of the upper four lumbar
vertebrae.
Nerve Supply:
It is supplied by the ventral rami of the twelfth thoracic and
upper lumbar nerves.
Actions:
The muscle aids respiration by fixing the twelfth rib allowing
the diaphragm to act to better advantage. It can cause lateral
flexion of the vertebral column.
THE ABDOMINAL AORTA
The abdominal aorta is a continuation of the descending

thoracic aorta. Its upper end lies at the level of the lower
border of the twelfth thoracic vertebra, and behind the
Fig. 30.3. Attachments of the quadratus lumborum muscle.
median arcuate ligament. It descends in front of the upper
three lumbar vertebrae and terminates in front of the fourth
275
276
lumbar vertebra by dividing into the

right and left common iliac arteries.
Important organs lying anterior to the
abdominal aorta are parts of the liver
and pancreas and the horizontal part of
the duodenum. The inferior vena cava
lies to the right of the aorta.
BRANCHES OF
ABDOMINAL AORTA
The branches of the abdominal aorta

can be classified as follows (Fig. 30.4):
a. Ventral branches to the gut:

coeliac, superior mesenteric and
inferior mesenteric.
b. Lateral branches to the kidneys,

suprarenals, gonads and diaphragm:
Fig. 30.4. Diagram to show the branches of the abdominal aorta.
renal, middle suprarenal, gonadal and
inferior phrenic.
c. Dorsal branches to the body wall: lumbar and median sacral. The Renal Arteries
d. Terminal branches: common iliac.
The renal arteries arise from the lateral side of the abdominal
The ventral branches of the abdominal aorta have been aorta, a little below the origin of the superior mesenteric
considered in Chapter 28. The other branches are considered artery (Figs 30.1 and 30.5). The right artery is a little longer,
below. and a little lower, than the left renal artery. Each artery runs
laterally to reach the hilum of the corresponding kidney. Here
Lateral Branches of Aorta it divides into four or five branches that enter the kidney to
supply it. Each branch supplies a discrete area of the kidney,
The most important of these are the renal arteries, and the and the pattern of distribution is fairly constant. This allows
arteries to the testes or ovaries. In addition there are two the kidney to be divided into a number of arterial segments.
smaller pairs of arteries namely, the inferior phrenic and the Apart from branches to the kidney each renal artery gives
middle suprarenal arteries (Figs 30.4 and 30.5). off one or more inferior suprarenal arteries (Fig. 30.5) and
also supplies the upper part of the ureter.
Inferior Phrenic Arteries

The right and left inferior phrenic arteries (Fig. 30.2) arise from The Testicular Arteries
the uppermost part of the abdominal aorta. They pass laterally
and divide into a number of branches that ramify on the inferior The right and left testicular arteries arise from the abdominal
surface of the diaphragm and supply it. aorta a little below the renal arteries. Each artery runs
Each artery gives a superior suprarenal branch to the downwards and laterally over the posterior abdominal wall
corresponding suprarenal gland. to reach the external iliac artery. The artery runs downwards
along the external iliac artery to reach the internal inguinal
Middle Suprarenal Arteries ring. It passes through the inguinal canal as a constituent of
The middle suprarenal arteries (Figs 30.4 and 30.5) arise from the spermatic cord, and accompanies the cord into the
the aorta at the level of the origin of the superior mesenteric scrotum. Here it divides into branches that supply the testis
artery, and end in the corresponding suprarenal gland. (Fig. 30.5).
Fig. 30.6. Scheme to show the posterior branches of the
abdominal aorta. 1 to 4: lumbar arteries arising from aorta.
5: Fifth lumbar artery arising from median sacral artery.
The Lumbar Arteries

The lumbar arteries are intersegmental arteries that supply
the body wall, and are in series with the intercostal and
subcostal arteries (Fig. 30.6). Four pairs of lumbar arteries
arise from the back of the aorta: one pair opposite each of
Fig. 30.5. Lateral branches of the abdominal aorta. the upper four lumbar vertebrae. The course of the arteries
is variable, but typically each artery runs laterally and
backwards on the body of the vertebra. It passes deep to the
crus of the diaphragm (upper arteries only), the psoas major
The Ovarian Arteries and the quadratus lumborum. At the lateral border of the
quadratus lumborum the artery enters the interval between
Like the testicular arteries the ovarian arteries arise from the the internal oblique and the transversus abdominis. They
aorta a little below the renal arteries. The upper part of each end by supplying the anterior abdominal wall and
artery (right and left) runs downwards and laterally over the anastomose with arteries in the region.
posterior abdominal wall (formed here by the psoas
major) to reach the external iliac artery. This part of
the artery has relations similar to those of the
testicular artery. The ovarian artery then crosses
the external iliac vessels to enter the true pelvis.
(Although the course of the artery in the pelvis will
be understood when the pelvis is studied, it is given
here for sake of completeness.).
Leaving the lateral wall of the pelvis the ovarian
artery passes successively through the suspensory
ligament of the ovary, the broad ligament of uterus
and the mesovarium to reach the ovary.
Dorsal Branches of Abdominal Aorta
These are the lumbar arteries and the median sacral

artery.
Fig. 30.7. Scheme to show the course of a typical lumbar artery.
277
278
Median Sacral Artery External Iliac Arteries
The median sacral artery is small (Figs 30.1 and 30.6). It arises
from the back of the aorta just above its bifurcation. It descends The external iliac arteries begin at the bifurcation of the
in the midline over the lower two lumbar vertebrae, the sacrum common iliac. They run downwards and laterally and
and the coccyx. It often gives rise to a small pair of fifth lumbar terminate deep to the inguinal ligament. (Each artery is
arteries. It also gives off four pairs of small arteries that run continued into the corresponding thigh as the femoral artery).
over the sacrum to enter the anterior sacral foramina. The lower Near its termination the external iliac artery is crossed in
part of the median sacral artery lies behind the rectum to which the male by the ductus deferens; and in the female by the
it gives some branches. round ligament of the uterus. On the right side the artery is
crossed by the terminal ileum and frequently by the
vermiform appendix. On the left side it is crossed by the
Common Iliac Arteries
sigmoid colon (Fig. 30.9).
The right and left common iliac arteries are terminal branches
of the abdominal aorta (Figs 30.1 and 30.6). Branches of External Iliac Artery
Each of these arteries is about 4 cm long. The artery of the These are the inferior epigastric and the deep circumflex
right side is slightly longer than the left. iliac arteries. They are intimately related to the anterior
Each common iliac artery runs downwards and laterally and abdominal wall and have been described on page 239.
terminates by dividing into the external and internal iliac
arteries.
The Internal Iliac Arteries
Each artery is crossed by the ureter just near its termination.
The left artery is crossed by the superior rectal artery.

Each internal iliac artery (right or left) begins as a terminal
branch of the common iliac artery, in front of the sacroiliac
joint (Fig. 30.6). The artery is distributed mainly within the
pelvis and will be considered in Chapter 31.
THE INFERIOR VENA CAVA

AND ITS MAIN TRIBUTARIES
The structures in the abdomen and in the lower limb are

drained through the inferior vena cava. This is the largest
vein in the body. It lies on the posterior abdominal wall to
the right of the abdominal aorta. It is formed by the union of
the right and left common iliac veins (Fig. 30.10). It ends by
Fig. 30.8. Common iliac arteries and veins. piercing the diaphragm to open into the right atrium.
The common iliac veins are formed by the union of the
internal and external veins: these veins run along the
corresponding arteries. Each external iliac vein begins behind
the inguinal ligament as the continuation of the femoral vein.
The femoral vein drains the lower limb and lies alongside
the femoral artery.
The upper part of the vena cava rests on the right crus of the
diaphragm. The lower part of the vena cava lies on the third,
fourth and fifth lumbar vertebrae.
The vena cava is overlapped by the liver, part of the
duodenum and the head of the pancreas.
Direct Tributaries of Inferior Vena Cava
The largest tributaries of the inferior vena cava are the hepatic
veins from the liver and the renal veins from the kidneys.
Fig. 30.9. Scheme to show some relations of the right The hepatic veins are terminal parts of an elaborate venous
and left external iliac arteries. tree that permeates the liver. The hepatic veins emerge from
3. In the male the testicular vein travels
through the spermatic cord and the
inguinal canal in the form of a plexus
(called the pampiniform plexus). At
the deep inguinal ring two veins
emerge from this plexus and run over
the lower part of the posterior
abdominal wall along with the
testicular artery. Higher up they unite
to form a single trunk which opens on
the right side into the inferior vena
cava; and on the left side into the left
renal vein. In the female the testicular
veins are replaced by ovarian veins
which form a plexus in the broad
ligament. Two veins arising from the
plexus accompany the ovarian artery.
Higher up they unite to form one vein
that terminates like the testicular vein.
The lumbar veins accompany the
lumbar arteries. There are four of them
on either side. They drain blood from
the abdominal wall and from the
vertebral venous plexuses. In front of
the roots of the transverse processes
of the lumbar vertebrae the lumbar
veins are joined to each other by a
vertical venous channel called the
ascending lumbar vein.
Fig. 30.10. Scheme to show the inferior vena cava and its tributaries.
liver tissue which is in close contact with the upper part of the The Common Iliac Veins
vena cava, and immediately enter the vena cava.
The right or left renal vein runs horizontally from the hilum of Each common iliac vein (right and left) is formed by union of
the corresponding kidney to join the inferior vena cava. The the corresponding internal and external iliac veins. This union
right vein is about 2.5 cm long. It lies behind the descending takes place in front of the sacroiliac joint. From here the vein
part of the duodenum. The left renal vein is much longer (7.5 passes upwards and medially and ends by joining the vein
cm) than the right vein as it has to cross the midline to reach of the opposite side to form the inferior vena cava (in front
the vena cava. It crosses anterior to the aorta, and posterior to of the fifth lumbar vertebra).
the body of the pancreas and the splenic vein. As the lower end of the inferior vena cava lies to the right of
Some veins of the right side open into the inferior vena cava, the middle line the right common iliac vein has to follow a
but the corresponding veins of the left side end in the left renal shorter and more vertical course than the vein of the left
vein. These veins are as follows (Fig. 30.12): side.
1. The inferior phrenic veins accompany the corresponding
arteries. The vein of the right side ends in the inferior vena
External iliac veins
cava. The vein of the left side usually ends in the left renal
vein.
Each external iliac vein begins behind the corresponding
2. On either side the suprarenal vein emerges from the hilum of
inguinal ligament as a continuation of the femoral vein. It
the corresponding suprarenal gland. The vein of the right side
runs upwards and medially, along the brim of the pelvis. It
opens into the back of the inferior vena cava; and that of the
ends in front of the sacroiliac joint by joining the internal
left side into the left renal vein.
279
280
The Internal Iliac Veins
These will be considered when we

discuss the wall of the pelvis.
NERVES OF POSTERIOR
ABDOMINAL WALL
The main nerves present in relation to

the posterior abdominal wall are shown
in Figure 30.1. Just below the twelfth rib
we see the subcostal nerve. This nerve
is a continuation of the ventral ramus of
the twelfth thoracic spinal nerve, and has
been described on page 255.
Most of the other nerves are branches
of the lumbar plexus which is described
below.
LUMBAR NERVES AND

LUMBAR PLEXUS
There are five lumbar nerves. After

emerging from the intervertebral
Fig. 30.11. Scheme to show the anterior relations of the inferior vena cava. foramina they divide into dorsal and
ventral rami.
iliac vein to form the common iliac vein. The vein is medial to Dorsal Rami
the corresponding artery, but near its upper end it becomes Each dorsal ramus divides into a medial and lateral branch.
posterior to the artery and passes behind the internal iliac These branches supply deep muscles of the back (erector
artery. Along with the external iliac artery the vein rests on the
psoas major. The right and left veins
are crossed by the same structures
that cross the corresponding
arteries: on both sides the vein is
crossed (from above downwards) by
the internal iliac artery, the ureter
(Fig. 30.13), the testicular or ovarian
artery and the ductus deferens (or
in the female by the round ligament
of the uterus). On the right side it is
also crossed by the terminal part of
the ileum and sometimes by the
vermiform appendix. On the left side
the vein is crossed by the sigmoid
colon.
The tributaries of the external iliac
veins are the inferior epigastric, the
deep circumflex iliac and pubic
veins which run along the Fig. 30.12. Scheme to show some veins that open, on the right side into the
corresponding arteries. inferior vena cava, and on the left side into the left renal vein.
Fig. 30.13. Scheme to show
structures crossing the external
iliac veins. In the female the
ductus deferens is replaced by
the round ligament of the uterus,
and the testicular artery by the
ovarian artery.
Fig. 30.14. Lumbar plexus and its branches. Nerves arising

from dorsal divisions are shaded blue.
spinae). Some branches supply a strip of skin of the back near

the middle line.
Ventral Rami
The ventral rami enter the substance of the psoas major muscle.
Within the muscle the rami from the upper four lumbar nerves
join each other to form the lumbar plexus which is shown in
figure 30.14. Note that part of the fourth lumbar nerve joins Fig. 30.15. Some branches of the lumbar plexus
lying over the posterior abdominal wall.
the fifth lumbar to form the lumbosacral trunk which takes part
in forming the sacral plexus.
281
282
The greater part of the first lumbar nerve is continued into a often separate from the rest of the ganglion and is called the
nerve trunk that divides into the iliohypogastric and aorticorenal ganglion.
ilioinguinal nerves. The rest of the first lumbar nerve is joined The coeliac ganglion lies on the posterior abdominal wall, in
by a branch from the second lumbar to form the genitofemoral front of the corresponding crus of the diaphragm. Just medial
nerve. to it there is the abdominal aorta, and just lateral to the
The second, third and the greater part of the fourth lumbar ganglion there is the suprarenal gland.
nerve divide into anterior and posterior divisions. Fibres passing from one ganglion to the other (across the
The posterior divisions (which are large) from the femoral aorta and around the origin of the coeliac trunk) form the
nerve. The posterior divisions of L2 and L3 also give rise to coeliac plexus.
the lateral cutaneous nerve of the thigh. The anterior divisions
unite to form the obturator nerve.
Lymphatics of Abdomen
In addition to the above named branches others are given off
to the psoas major (L2, L3), the quadratus lumborum (T12,
Many groups of lymph nodes are present in the abdomen,
L1, L2, L3), the psoas minor (L1) and the iliacus (L2, L3).
and several of these are present in relation to the posterior
The iliohypogastric nerve has been described on page 237,
abdominal wall. A consolidated account of all the lymph
the ilioinguinal nerve on page 238, the lateral cutaneous nerve
nodes of the abdomen, and of the lymphatic drainage of
of the thigh on page 116, the femoral nerve on page 115, the
abdominal organs is presented in Chapter 33.
obturator nerve on page 116, and the genitofemoral nerves on
pages 116 and 238.
Cisterna Chyli
In Figure 30.1 we also seen the lumbar part of the sympathetic
The thoracic duct (which is the largest lymph vessel in the
trunk. The sympathetic trunk is involved in autonomic
body) begins within the abdomen as a continuation of a sac

innervation of abdominal and pelvic viscera along with
called the cisterna chyli. The cisterna chyli is seen in relation
parasympathetic nerves. Autonomic nerves of the abdomen will
to the posterior abdominal wall. It is an elongated lymphatic
be considered in Chapter 33.
sac about 6 cm long. Superiorly, the cisterna chyli becomes
Coeliac Ganglion continuous with the thoracic duct.
The coeliac ganglion (right or left) is the largest autonomic
ganglion in the body. It is irregular in shape. Its lower part is
31 : Walls of the Pelvis
In a study of the walls of the pelvis we have to consider the vertebra to form the lumbosacral joint. The structure of this
bones and joints, the muscles and fascia; and the blood vessels, joint is similar to that of intervertebral joints. Note that
nerves and lymphatics of the region. because of the large size of the body of the fifth lumbar
vertebra the lumbosacral joint is the largest intervertebral
Bones and Joints of Pelvis joint in the body. The intervertebral disc at this joint is the
thickest of the series. It is thicker anteriorly than posteriorly
The skeletal basis of the bony pelvis is formed by the right and thus contributes to the formation of the sharp angle
and left hip bones, the sacrum and the coccyx. The hip bones between the lumbar vertebral column and the sacrum
have been described in Chapter 9. The sacrum and coccyx (lumbosacral or sacro-vertebral angle). The sacrum is also
have been described in Chapter 23. united to the fifth lumbar vertebra through joints between
The bones of the pelvis are held together by a number of the articular processes, and by the strong iliolumbar
joints. In the middle line, in front, the right and left pubic bones ligaments.
articulate to form the pubic symphysis. Posteriorly the sacrum Inferiorly, the sacrum is united to the coccyx through a
articulates (on each side) with the corresponding hip bone to secondary cartilaginous joint. Individual pieces of the sacrum
form a sacroiliac joint. The pubic symphysis and the sacroiliac and coccyx are separate in the young, but fuse as age
joints have been described in Chapter 23. The sacrotuberous advances.
and sacrospinous ligaments are strong additional bonds of By its external surface the hip bone articulates with the head
union between the sacrum and the hip bone. Superiorly, the of the femur to form the hip joint.
body of the sacrum articulates with the body of the fifth lumbar
WALLS OF PELVIS
They merge with the internal and external
sphincters of the anal canal to form the anorectal
ring.
c. The most posterior fibres are attached to the
coccyx, and to a fibrous band called the
anococcygeal ligament.
The Coccygeus
The coccygeus has a narrow origin from the

ischial spine. It fans out to be inserted into the
lateral margin of the coccyx and the lowest part
of the sacrum (Fig. 31.1).
Nerve supply of levator ani and coccygeus
The levator ani is supplied by a branch from the
4th sacral nerve. It receives another branch from
the inferior rectal nerve or from the perineal
Fig. 31.1. Scheme to show the arrangement of the levator ani division of the pudendal nerve. The coccygeus
and coccygeus muscles. is supplied by the 4th and 5th sacral nerves.
Actions:
See under pelvic diaphragm, below.
MUSCLES AND FASCIAE OF PELVIC WALL
Pelvic Diaphragm
Preliminary remarks
The pelvic muscles arise from the inner wall of the bony pelvis. We have seen that the levator ani and the coccygeus form a
Two of them, the piriformis, and the obturator internus, have transverse partition across the pelvis that is called the pelvic
already been considered. diaphragm. This diaphragm separates the pelvic viscera
The other pelvic muscles are the levator ani and the coccygeus. (above) from structures in the perineum (Fig. 31.2) and the
These muscles of the two sides form the pelvic diaphragm. ischiorectal fossa. The pelvic diaphragm is pierced by the
Present in relation to pelvic muscles (and viscera) there are rectum, the urethra (Fig. 31.2) and in the female by the
layers of fascia that are collectively referred to as pelvic fascia. vagina. The diaphragm supports the pelvic viscera. It acts
as a sphincter for the rectum and the vagina.
Levator Ani (Fig. 31.1)
Origin:
The levator ani arises from the following (from front to back):
1. The pelvic surface of the body of the pubis .
2. The obturator fascia .
3. The spine of the ischium .
Insertion:
a. In the male the most anterior fibres pass across the sides of
the prostate to end in the perineal body. These fibres constitute
the levator prostate muscle. In the female the corresponding
fibres pass across the sides of the vagina to end in the perineal
body. They are then called the pubovaginalis.
b. The intermediate fibres pass across the sides of the rectum
and become continuous with those of the opposite side behind
the anorectal junction. These fibres constitute the puborectalis.
Fig. 31.2. Coronal section through the anterior part of
the pelvic diaphragm in the male.
283
284
The Pelvic Fascia rectum, where it anastomoses with the superior and inferior
rectal arteries. Apart from the rectum it supplies the seminal
The pelvic fascia consists of two main parts (Fig. 31.2). The vesicles and the prostate.
parietal layer lines the pelvic muscles. The visceral layer The uterine artery (present in the female only) runs medially
surrounds individual viscera. The parietal fascia covers the on the pelvic floor (formed by the levator ani) to reach the
piriformis and the obturator internus. Over the obturator lateral side of the upper end of the vagina (lateral vaginal
internus it is thick and forms the obturator fascia. fornix) (Fig. 31.4). Leaving the pelvic wall it runs along the
The pelvic diaphragm is covered by one layer of fascia that side of the uterus, within the two layers of the broad ligament
lies above it and another below it. The fascia below the pelvic to reach the junction of the uterus with the uterine tube.
diaphragm lines the medial wall of the ischiorectal fossa. Finally it turns laterally to reach the hilum of the ovary. Here
it anastomoses with the ovarian artery.
Apart from branches to the uterus, the uterine tube, and to
the ovary, it gives some branches to the vagina (Fig. 31.4).
The obturator artery runs forwards and downwards on the
BLOOD VESSELS OF TRUE PELVIS lateral pelvic wall. It is accompanied by the obturator nerve
(which lies above it), and the obturator vein (below it).
These are the internal iliac artery and its branches and the Reaching the obturator canal it passes through it to leave
corresponding veins. the pelvic cavity. The pubic branch runs over the pubis and
anastomoses with the pubic branch of the inferior epigastric
artery. Sometimes the anastomosis is large and then the
Internal iliac artery
obturator artery appears to be a branch of the inferior
epigastric. This is called the abnormal obturator artery.

Each internal iliac artery (right or left) begins as a terminal
The internal pudendal artery supplies the external genitalia.
branch of the common iliac artery, in front of the sacroiliac
It follows a complicated course. Starting within the pelvic
joint. It runs downwards to reach the upper margin of the greater
cavity the artery passes out of it through the greater sciatic
sciatic foramen. Here it divides into anterior and posterior
foramen to enter the gluteal region. After a short course in
trunks (Fig. 31.3).
this region the artery passes through the lesser sciatic foramen
to reach the lateral wall of the ischiorectal fossa.
Branches of internal iliac

artery
The branches arising from the
anterior trunk of the internal iliac
artery are as follows:
(Fig. 31.3):
The superior vesical artery
supplies the upper part of the
urinary bladder. The stem of the
artery represents the proximal part
of the umbilical artery of the fetus:
that is why it is continuous with
the medial umbilical ligament that
represents the distal obliterated
part of the umbilical artery.
The inferior vesical artery
(present only in the male) supplies
the urinary bladder, the prostate,
the seminal vesicle and the lower
end of the ureter. In the female,
the inferior vesical artery is
replaced by the vaginal artery
that supplies the vagina, the
urinary bladder and part of the
rectum.
The middle rectal artery (Fig.
31.3) runs medially to reach the Fig. 31.3. Scheme to show the branches of the internal iliac artery.
WALLS OF PELVIS
vein. These plexuses surround the urinary bladder (vesical
plexus), the prostate, the uterus, the vagina and the rectum.
The rectal venous plexus consists of two parts, internal and
external. The internal plexus lies in the submucosa, whereas
the external plexus lies outside the muscular coat (In other
words the two plexuses are separated by the muscle coat).
The internal plexus drains mainly into the superior rectal
vein. which is a tributary of the internal iliac. The external
plexus is drained by the superior, middle and inferior rectal
veins. As stated above, the superior rectal vein is a tributary
of the internal iliac. The inferior rectal vein is a tributary of
the internal pudendal vein. The portal and systemic
circulations communicate through the rectal venous
plexuses. The internal rectal plexus has a series of dilatations
that are placed immediately above the anal orifice. These
Fig. 31.4. Scheme to show the course and branches
sometimes get enlarged to form piles.
of the uterine artery.
The inferior gluteal artery begins within the pelvis where it

lies anterior to the piriformis. It passes through the greater sciatic NERVES OF THE PELVIS
foramen, below the piriformis to enter the gluteal region.
The nerves to be seen in relation to the pelvic wall are as

The branches arising from the posterior trunk of the internal follows:
iliac artery are as follows:
The superior gluteal artery is the main continuation of the 1. The genitofemoral nerve, already described.
posterior trunk of the internal iliac artery. It leaves the pelvic 2. The obturator nerve is a branch of the lumbar plexus. It
cavity by passing through the greater sciatic foramen. runs forwards over the lateral wall of the true pelvis just
The lateral sacral arteries, superior and inferior, pass medially above the obturator artery and leaves the pelvis through the
and divide into branches that pass through the anterior sacral obturator canal to reach the thigh.
foramina to supply the sacrum and related structures. 3. The lumbosacral trunk is derived from the fourth and
The iliolumbar artery arises from the fifth lumbar nerves. It descends into the true pelvis by passing
posterior trunk of the internal iliac
artery. It runs upwards and laterally
and passes deep to the psoas major.
Here it divides into a lumbar branch
that supplies the psoas major and an
iliac branch that supplies the iliacus.
The Internal Iliac Veins
Each internal iliac vein is formed by

the confluence of several veins that
accompany the branches of the internal
iliac artery (with the exception of the
iliolumbar veins that end in the
common iliac veins). The vein begins
near the upper part of the greater
sciatic foramen. It ends by joining the
external iliac vein to form the common
iliac vein.
The tributaries of the internal iliac vein
are shown in Figure 31.5. Fig. 31.5. Scheme to show the tributaries of the internal iliac vein in the male. In the
The pelvic organs are drained through female the prostatic plexus is replaced by a vaginal plexus; and in addition there is a
a number of venous plexuses that uterine plexus that gives origin to the uterine veins. The veins from the penis are
ultimately drain into the internal iliac replaced by veins from the clitoris.
285
286
The viscera of the pelvis are supplied by autonomic nerves,
sympathetic and parasympathetic. These nerves are
considered, along with those of the abdomen in Chapter 33.
SACRAL VENTRAL RAMI

AND SACRAL PLEXUS
The ventral rami of sacral nerves (referred to below simply

as sacral nerves) leave the vertebral canal by passing through
the anterior sacral foramina. They take part in forming the
sacral plexus and the coccygeal plexus. The sacral nerves
also have important connections with the autonomic nervous
system.
The sacral plexus is formed by the upper four sacral nerves
and the lumbosacral trunk (derived from L4 and L5). Nerves
L4, L5, S1 and S2 each divide into anterior and posterior
divisions. The posterior divisions of these nerves unite to
form the common peroneal part of the sciatic nerve. The
anterior divisions of these nerves, and S3 (that does not

divide into anterior and posterior divisions) unite to form
the tibial part of the sciatic nerve.
Part of nerve S4 joins branches from the ventral divisions of
Fig. 31.6. Sacral plexus and its branches. Branches arising S2 and S3 to form the pudendal nerve.
from posterior divisions are shown in blue.
Apart from the sciatic and pudendal nerves the sacral plexus
gives off several branches that are shown in Figure 31.6.
over the ala of the sacrum. to join the sacral plexus. The These are as follows:
lumbosacral trunk lies just behind the common iliac vessels. The branches arising from the posterior divisions are the
4. Sacral ventral rami and sacral plexus: Lying in front of the superior gluteal (L4, L5, S1), the inferior gluteal (L5, S1,
sacrum, just behind the lumbosacral trunk we see the ventral S2), the nerve to the piriformis (S1, S2), and the perforating
rami of sacral nerves. The roots S1, S2 and S3 are large and cutaneous nerve (S2, S3). The posterior cutaneous nerve of
that of S4 is much smaller. These roots take part in forming the thigh receives contributions from both the posterior
the sacral plexus that is described below. The main continuation divisions (S2, S3) and anterior divisions (S1, S2).
of the sacral plexus is the sciatic nerve which passes out of the The branches arising from the anterior divisions are the nerve
pelvis (into the gluteal region) through the greater sciatic to the quadratus femoris (L4, L5, S1); and the nerve to the
foramen. obturator internus (L5, S1, S2). Nerve S4 gives branches to
5. The pudendal nerve is a branch of the sacral plexus. It the levator ani, the coccygeus and the sphincter ani externus.
receives contributions from nerves S2, S3 and S4. Along with Branches to pelvic viscera (pelvic splanchnic nerves) arise
the internal pudendal artery the nerve passes through the greater from S2, S3 and S4.
sciatic foramen to enter the gluteal region. After a short course
in this region the nerve passes through the lesser sciatic foramen
to reach the lateral wall of the ischiorectal fossa. The nerve is LYMPHATICS OF PELVIS
distributed mainly to the perineum . Several groups of lymph nodes are present in relation to the
The lower sacral rami (S4, S5) join the coccygeal nerve to pelvic wall and viscera. These nodes, and the lymphatic
form the coccygeal plexus that lies over the pelvic surface of drainage of structures in the pelvis, are considered in Chapter
the coccygeus muscle. 33.
PELVIC VISCERA AND PERITONEUM
32 : Pelvic Viscera and Peritoneum
PELVIC VISCERA
The viscera to be seen in the true pelvis belong to the b. The rectum also has three lateral curves (Fig. 32.1).
gastrointestinal, urinary and reproductive systems. The c. The mucous membrane of the rectum shows a number of
viscera belonging to the alimentary system are the sigmoid transverse folds. Usually three folds are present (1, 2, 3 in
colon, the rectum and anal canal. In addition some coils of Figure 32.1).
small intestine are often present in the pelvis. The viscera
belonging to the urinary system are the pelvic parts of the Peritoneal relations:
ureters, the urinary bladder and the urethra (male or female). The upper one third of the rectum is covered by peritoneum
The main reproductive organs to be seen in the male pelvis in front and also on the sides. The middle one-third is covered
are the pelvic part of the right and left ductus deferens, the only in front. The lower one-third of the rectum is not
seminal vesicles, and the prostate gland. Reproductive organs covered by peritoneum.
present in the female pelvis are the uterus, the right and left In the male the peritoneum passes from the front of the
uterine tubes, and the vagina. rectum to the urinary bladder forming the rectovesical
pouch. In the female the peritoneum from the front of the
THE RECTUM
The rectum is a wide tube about 12 cm long. It lies in the true

pelvis, more or less in the middle line. Its upper end is
continuous with the sigmoid colon: the junction lies in front
of the third sacral vertebra. The lower end of the rectum lies
a little below and in front of the tip of the coccyx: this end
becomes continuous with the anal canal. The lower part of
the rectum is wider than the upper part and is called the
ampula.
Curves and Folds of the rectum:
a. The rectum has an anteroposterior curve corresponding Fig. 32.2. Transverse section through lower part
to that of the sacrum and coccyx (Fig. 32.8). of rectum in the male.
Fig. 32.1. Scheme to show lateral Fig. 32.3. Transverse section through the lower part of
curvatures and folds of the rectum. the rectum in the female.
287
288
rectum passes to the posterior wall of the vagina forming a (4) Lateral to the anal canal there is a triangular depression
pouch miscalled the recto-uterine pouch (or pouch of Douglas). called the ischiorectal fossa.
It is important to know that the bottom of the rectovesical
Interior of the Anal Canal
pouch (male) is 7.5 cm (3 inches) from the anus; and that of the
For convenience of description the interior of the anal canal
rectovaginal pouch is about 5 cm (2 inches) from the anus.
may be considered in three parts. The upper 15 cm or so are
Some Important Relations of The Rectum lined by mucous membrane. This mucous membrane shows
Posteriorly, the rectum rests on the sacrum and coccyx, and on six to ten longitudinal folds: these folds are called anal
some muscles. Anteriorly, the rectum is related in the male, to columns (Fig. 32.4). The lower ends of the anal columns
the urinary bladder and the prostate (Fig. 32.2). In the female are interconnected by short transverse folds of mucous
the rectum is related to the vagina and the lower part of the membrane: these folds are called the anal valves. Above
uterus (Fig. 37.10). The lateral walls of the rectum are each anal valve there is a depression in the mucosa that is
embraced by the right and left levator ani muscles (Figs 32.2, called an anal sinus. The anal valves together form a
32.3). transverse line that runs all round the anal canal: this is called
Clinically, a great deal of information about structures in the the pectinate line.
pelvis can be obtained by rectal examination (See Chapter The next 15 mm or so of the anal canal is also lined by
34). mucous membrane, but anal columns are not present here.
This region is referred to as the pecten or transitional zone.
The lower limit of the pecten often has a whitish appearance
because of which it is referred to as the white line (of Hilton).
The third, or lowest, subdivision of the anal canal is about 8
THE ANAL CANAL
to 10 cm long. It differs from the upper and middle parts in

that it is not lined by mucous membrane, but by skin.
The anal canal is the lowest part of the alimentary canal. Above
The Anal Musculature
it is continuous with the lower end of the rectum. Below it
The anal canal is surrounded by a number of sphincters that
opens to the exterior at the anus. The anal canal is about 4 cm
are as follows (Fig. 32.4B):
in length. It is distinctly narrower than the rectum. There is a
1. The internal anal sphincter represents a thickening of
sudden change in direction of the alimentary canal at the
the circular muscle coat of the gut. It extends from the upper
junction of the rectum with the anal canal. While the lower
end of the anal canal up to the white line.
part of the rectum is directed downwards and forwards, the
2. The external anal sphincter is made up of striated muscle.
anal canal is directed downwards and backwards. The anorectal
It is subdivided into subcutaneous, superficial and deep
junction lies at the level of the pelvic diaphragm (formed here
parts.
by the levator ani muscles): the rectum lies above the diaphragm
The anorectal junction is closely related to the puborectalis
in the true pelvis, whereas the anal canal lies below the
part of the levator ani muscle. The fibres of the puborectalis
diaphragm in the perineum.
form a sling that keeps the anorectal junction pulled forwards,
Relations of anal canal: thus maintaining the angle between the rectum and the anal
1. The lower aperture of the anal canal (or anus) is in the form canal.
of an antero-posterior slit, the right and left walls being in
apposition. The position is the
same in the interior of the anal
canal also.
2. Posteriorly, the anal canal
is separated from the coccyx
by a mass of fibromuscular
tissue that is called the
anococcygeal ligament (or
body).
3. In front of the anal canal
there is another similar mass
called the perineal body. The
perineal body separates the
anal canal from the
membranous urethra and the
bulb of the penis in the male,
and from the vagina in the
female (See Fig. 30.9). Fig. 32.4. Schemes to show: A. Some landmarks in the anal canal.
B. The anal musculature.
Blood Vessels, Lymphatics and Nerves of Rectum and
Anal Canal
The rectum and anal canal are supplied by the superior rectal
artery that is a continuation of the inferior mesenteric artery;
by the right and left middle rectal arteries; by the right and left
inferior rectal arteries; and by the median sacral artery.
The veins of the rectum and anal canal begin in two plexuses.
The internal rectal plexus lies in the submucosa, while the
external rectal plexus lies lateral to the muscle coat. The internal Fig. 32.5. The puborectalis sling.
rectal plexus is drained mainly by the superior rectal vein, which
is continued into the inferior mesenteric vein. The external rectal
plexus is drained mainly into the middle and inferior rectal veins.
The anal canal is one of the sites where systemic and portal THE URETERS
venous systems anastomose. When pressure in the portal system
rises the anstomoses enlarge and form piles (haemorrhoids).
The lymphatic drainage of the rectum and anal canal is described The abdominal part of the ureter has already been described.
in Chapter 33. We have seen that about half the length of the ureter lies in
The nerve supply of the rectum and the upper part of the anal the true pelvis. At the brim of the pelvis the ureter crosses
canal is through autonomic nerves. The internal anal sphincter the upper end of the external iliac artery (and vein), and
is also supplied by these nerves (sympathetic). The external comes to lie on the lateral wall of the pelvis. Here it runs
anal sphincter is supplied by the inferior rectal branch of the backwards and laterally. Finally it leaves the pelvic wall and
pudendal nerve and by the perineal branch of the fourth sacral turns medially and forwards to reach the posterolateral part
nerve. of the urinary bladder.
The terminal part of the ureter passes obliquely through the
Development of the Rectum and Anal Canal thickness of the wall of the urinary bladder to open into its
The rectum and upper part of the anal canal develop from the posterior wall. The openings lie at the lateral angles of a
hindgut (endoderm). The lower part of the anal canal is derived triangular area of the posterior wall of the urinary bladder
from the proctodaeum (ectoderm). called the trigone (Fig. 32.11).
Development
The ureters are derived from the ureteric diverticulum
(mesoderm).
THE URINARY BLADDER
The urinary bladder has four surfaces each of which is

triangular (Fig. 32.7). The posterior surface is also called
the base or fundus. It is broad above and pointed below.
Fig. 32.6. Scheme to show the course and relations of the pelvic Fig. 32.7. Scheme to show the surfaces of the
part of the ureter in the male. urinary bladder.
289
290
uterus (Fig. 32.10). The base
of the bladder is in contact
with the anterior wall of the
vagina.
The median umbilical
ligament connects the apex of
the urinary bladder to the
umbilicus.
Interior of the Urinary
Bladder
The interior of the bladder is
lined by mucous membrane.
In the empty bladder the
mucosa shows numerous
folds: these get stretched out
when the bladder distends. On
the posterior wall of the
bladder, however, there is a
triangular area where the
mucosa is relatively fixed.
This area is called the trigone

(Fig. 32.11). The ureters open
at the upper lateral corners of
the trigone while the upper
Fig. 32.8. Sagittal section through the male pelvis.
end of the urethra opens at the
lower angle. The urethral
The superior surface faces upwards. Its

posterior end is broad. Anteriorly it narrows
to form the apex of the bladder. The right and
left inferolateral surfaces face downwards,
laterally and forwards. They meet the superior
surface at the right and left lateral borders.
Posteriorly they meet the lateral margins of
the base.
The right and left ureters join the urinary
bladder at its posterolateral angles. The lowest
part of the bladder is called the neck. The
urethra emerges from the bladder here. The
apex of the bladder gives attachment to the
lower end of the median umbilical ligament.
Relations of Urinary Bladder in the Male
The base of the bladder lies in front of the
rectum, but is partly separated from it by the
right and left seminal vesicles and the right
and left ductus deferens (Fig. 32.9). The neck
of the bladder rests on the prostate (Fig. 32.8).
The peritoneum lined depression between the
urinary bladder and the rectum is called the
rectovesical pouch.
Relations of Urinary Bladder in the
Female
The greater part of the superior surface of the
Fig. 32.9. Male urinary bladder and some related structures seen from
bladder is in contact with the body of the behind. The parts covered by peritoneum are shaded in dots.
opening is called the internal
urethral orifice. The upper
margin of the trigone forms a
ridge stretching between the
openings of the two ureters. It is
called the interureteric crest.
Some additional features are
Vessels and Nerves of the
Urinary Bladder
The urinary bladder is supplied
(in the male) by the superior and
inferior vesical arteries. In the
female the inferior vesical artery
is replaced by the vaginal artery
and the uterine artery also gives
branches to the bladder.
Development
The urinary bladder is derived
from the vesicourethral canal Fig. 32.10. Sagittal section through female pelvis.
(endoderm). The trigone is
mesodermal and is derived from
absorbed mesonephric ducts.
THE URETHRA
The Male Urethra
The male urethra is divisible into three parts (Fig. 32.8).

1. The first part starts at the internal urethral orifice and
descends through the prostate to reach the urogenital diaphragm.
Fig. 32.11. Some features to be seen in the interior of
This part of the urethra is embedded within the prostate gland
the urinary bladder.
and is, therefore, called the prostatic part. It is about 3 cm
long. Some features to be seen in its interior are described below.
2. The next part passes through the deep perineal space. This
is the membranous part. It is about 1.5 cm long. The sphincter
urethrae externus surrounds this part of the urethra.
3. The third part of the urethra runs through the bulb and corpus
spongiosum of the penis (Fig. 32.8). It is, therefore, called the
penile part or the spongiose part. The glans penis is traversed
by the terminal part of the urethra. The total length of the penile
part of the urethra is about 15 cm.
4. The prostatic part of the male urethra shows the following
features (Fig. 32.13). On its posterior wall there is a median
ridge of mucous membrane that is called the urethral crest. On
either side of the crest there is a depression called the prostatic
sinus. Numerous prostatic ducts open into the prostatic sinuses.
Midway between its upper and lower ends the urethral crest
bears a rounded swelling called the colliculus seminalis. The
colliculus shows three openings. In the middle line there is the
opening of a small blind sac called the prostatic utricle. On Fig. 32.12. Diagram showing the sphincters of the
urethra, and the bulbourethral glands.
291
292
medial to the seminal vesicle. Here the deferent ducts of the
two sides approach the middle line. Just above the prostate
the ductus ends by joining the duct of the seminal vesicle to
form the ejaculatory duct.
The ductus deferens has a very narrow lumen, but has a thick
wall. The part lying behind the urinary bladder is dilated
and is called the ampulla; but the terminal part of the duct
again narrows down before joining the duct of the seminal
vesicle (Fig. 32.9).
The Seminal Vesicles
The right and left seminal vesicles lie posterior to the base
Fig. 32.13. Some features seen on the posterior wall of the urinary bladder, between it and the rectum (Fig. 32.9).
of the prostatic urethra. Each vesicle is about 5 cm long. The lower ends of the right
and left seminal vesicles lie close together near the median
plane. From here each vesicle passes upwards and laterally
either side of the opening of the utricle there are openings of so that the upper ends of the two vesicles are far apart, and
the right and left ejaculatory ducts. lie near the ureters.
When dissected out each seminal vesicle is seen to be a long
tube convoluted upon it self. One end of this tube is blind.

The Female Urethra The other end emerges at the lower end of the seminal vesicle
as its duct. This duct joins the corresponding ductus deferens
The female urethra corresponds (topographically) to the to form the ejaculatory duct.
prostatic and membranous parts of the male urethra, and is
about 4 cm long (Fig. 32.8). Throughout its length the urethra
is closely related to the anterior wall of the vagina. The Ejaculatory Ducts
Sphincters of the Urethra The ejaculatory ducts formed as described above pass
Both in the male and in the female the urethra is surrounded downwards and forwards through the substance of the
by an internal sphincter, the sphincter vesicae; and by an prostate (Figs 32.12 and 32.14) to open on the colliculus
external sphincter, the sphincter urethrae (Fig. 32.12). The seminalis (Fig. 32.13) just lateral to the aperture of the
sphincter vesicae is usually described as a ring of smooth prostatic utricle.
muscle surrounding the urethra at its junction with the bladder.
This sphincter is involuntary and is supplied by autonomic
nerves.
The sphincter urethrae surrounds the urethra as it passes
through the deep perineal space. It is made of striated muscle THE PROSTATE
fibres. It is voluntary and is supplied by the perineal branch of
the pudendal nerve. The prostate is a glandular structure. It lies in the space
Development of urethra between the lower end of the urinary bladder and the upper
The female urethra is derived partly from the distal part of the surface of the urogenital diaphragm. It lies behind the lower
vesicourethral canal, and partly from the pelvic part of the part of the symphysis pubis, and in front of the rectum. It is
urogenital sinus. In the male the origin of the prostatic urethra traversed by the prostatic part of the urethra, and the
is similar to that of the female urethra. The membranous part ejaculatory ducts. The prostatic utricle also extends into it.
is a derivative of the pelvis part of the urogenital sinus, and From Figure 32.9 it will be seen that the prostate is broadest
the penile part is a derivative of the phallic part of this sinus. above (base) and narrowest below (apex). Its width at the
base is about 4 cm. Its vertical diameter is about 3 cm, so
that its width is greater than its length. The anteroposterior
Pelvic part of Ductus Deferens diameter is about 2 cm.
The prostate has five surfaces. The superior surface, or
The ductus deferens enters the abdomen by passing through base, is in contact with the neck of the urinary bladder. The
the inguinal canal. At the deep inguinal ring the ductus deferens posterior surface is in contact with the rectum and can be
hooks around the lateral side of the inferior epigastric artery palpated through the latter. The anterior surface is connected
(Figs 24.20 and 25.4). The ductus then runs backwards over to the pubic bones by the right and left puboprostatic
the lateral wall of the true pelvis (Fig. 32.6). The terminal part of ligaments (Fig. 32.8). The right and left inferolateral
the ductus deferens lies behind the base of the urinary bladder, surfaces are in contact with the corresponding levatores ani
it has one surface directed forwards and downwards, and
another directed backwards and upwards.
The ovary is attached to the posterosuperior aspect of the
broad ligament by a fold of peritoneum called the
mesovarium. The part of the broad ligament between the
attachment of the mesovarium and the lateral wall of the
pelvis is called the suspensory ligament of the ovary.
The ovary has upper and lower ends, medial and lateral
surfaces, and anterior and posterior borders. The anterior
border gives attachment to the mesovarium and is, therefore,
also called the mesovarian border.
The posterior border is also called the free border. The
Fig. 32.14. Sagittal section through the prostate to lateral surface of the ovary lies in contact with the
show its lobes. peritoneum covering the lateral wall of the pelvis. It lies in
a depression called the ovarian fossa. The medial surface
is in contact with the terminal part of the uterine tube. The
muscles: these parts of the levatores ani muscles are often upper pole is in intimate contact with the uterine tube and
referred to as the levatores prostatae. is, therefore, also called the tubal end. The lower pole gives
The substance of the prostate is divided into five lobes. Two attachment to the ligament of the ovary: this ligament passes
right and left lateral lobes are separated in front by an anterior in the interval between the two layers of the broad ligament
lobe and posteriorly by a posterior lobe. to reach the uterus (near the attachment of the uterine tube
The prostate is surrounded by a fibrous capsule. Outside the to the latter) (Fig. 32.15).
capsule there is a fibrous sheath that is part of the pelvic fascia. The substance of the ovary is divisible into an outer cortex
Between the capsule and the sheath there is a dense venous and an inner medulla. In the cortex there are rounded
plexus. After the age of fifty years (or so) the prostate may structures called ovarian follicles (also called Graafian
undergo atrophy. In some persons it undergoes benign follicles). In relation to the wall of each follicle there is one
hypertrophy. developing ovum surrounded by supporting follicular cells.
In the reproductive period of a womans life one ovarian
follicle matures every month. It forms an elevation on the
Female Reproductive Organs
These consist of the female internal and

external genitalia and the mammary glands.
The female external genitalia have been
considered along with other structures in the
perineum. The mammary glands have
described earlier. The female internal genitalia
consist of the ovaries, the uterus and uterine
tubes, and the vagina. These are described
below.
THE OVARIES
The right and left ovaries are the female

gonads. Female gametes, called ova (singular
= Ovum), are produced in them. Each ovary is
shaped like an almond: it is approximately
3 cm in length; 1.5 cm in width; and 1 cm in
thickness. From Figure 32.15 it will be seen
that the uterus is attached, on either side, to a
fold of peritoneum called the broad ligament.
The broad ligament stretches from the side of
the uterus to the lateral wall and floor of the
Fig. 32.15. Scheme to show the female reproductive organs.
pelvis. The ligament is placed obliquely so that
293
294
surface of the ovary and with further enlargement, it ruptures THE UTERUS
shedding the ovum: this is called ovulation.
The region of the developing follicle is overlapped by the
The uterus is about 7.5 cm (3 inches) in length. Its maximum
fimbriated end of the uterine tube (see below) that receives
width (near its upper end) is about 5 cm (2 inches). Its
the ovum discharged from the ovary. After the ovum is
thickness (anteroposterior) is about 2.5 cm (1 inch). The
discharged the remaining part of the ovarian follicle is
exterior of the uterus shows a constriction at the junction of
converted into a yellowish body called the corpus luteum.
its upper two-thirds with the lower one-third. The part above
Development the constriction is called the body: it is broad above and
The ovary develops from coelomic epithelium. Oocytes narrow below. The part below the constriction is called the
develop from primordial germ cells that are formed near the cervix: this part is more or less cylindrical.
yolk sac. The uterus has a thick wall, and a relatively narrow lumen.
The wall is made up of a thick layer of muscle (called the
Blood vessels,Lymphatics, and Nerves of the Ovary:
myometrium) and of an inner lining of mucosa (called the
The ovary is supplied by the ovarian artery; and by some
endometrium). When seen from the front the lumen of the
branches of the uterine artery. A number of veins arise from
uterus is triangular (Fig. 32.15). The lumina of the uterine
the ovary and form a pampiniform plexus (as in the testis).
tubes join the lateral angles of this triangle. The part of the
The ovarian veins arise from this plexus. The right vein
body of the uterus that lies above the level of the openings
terminates in the inferior vena cava, but the left vein ends in
of the uterine tubes is called the fundus. The cavity of the
the left renal vein.
cervix (or canal of the cervix) is roughly cylindrical.
Lymph vessels from the ovary reach the lateral aortic lymph
However, its upper and lower ends are somewhat narrower
nodes.
than the central part. The upper narrow end is called the
internal os and the narrow lower end is called the external
os. The cavity of the uterus communicates with that of the
THE UTERINE TUBES vagina through the external os.
The uterus lies in the true pelvis. Its orientation is best
appreciated in a sagittal section through the pelvis (Fig.
Each uterine tube (right or left) lies in the free margin of the
32.10). In the erect posture the long axis of the uterus is
corresponding broad ligament. It has medial and lateral ends
oblique. The long axis of the uterus is more or less at right
(Fig. 32.15). The medial end is attached to the corresponding
angles to the long axis of the vagina. The forward bending
side of the uterus. Here its lumen communicates with the cavity
of the uterus relative to the vagina is referred to as
of the uterus. The lateral end of the tube lies near the ovary.
anteversion of the uterus. The uterus is also slightly bent
At this end it has an opening through which its lumen is in
forwards on itself: this is referred to as anteflexion. The
communication with the peritoneal cavity: this opening is called
caudal part of the cervix projects into the upper part of vagina
abdominal ostium (Fig. 32.15).
through the anterior wall of the latter: it is separated from
The uterine tube is about 10 cm long. About 1 cm of the tube,
the vaginal wall by recesses called the anterior, lateral, and
near the medial end, is embedded in the muscle wall of the
posterior fornices (singular = fornix) of the vagina. The
uterus: this is the uterine part of the tube. The next 3 cm or so
posterior fornix is deepest.
is thick-walled and has a narrow lumen so that it is cord like:
this part is called the isthmus. The next 5 cm or so is thin Peritoneum Related to the Uterus
walled and has a much larger lumen than the rest of the tube. The peritoneum from the anterior abdominal wall passes on
This dilated part is called the ampulla. The lateral end of the to the superior surface of the urinary bladder. From the
uterine tube is funnel shaped and is called the infundibulum. posterior part of this surface the peritoneum is reflected on
The walls of the infundibulum are prolonged into a number of to the anterior surface of the uterus at the junction of the
irregular processes called fimbria. One of these fimbria is larger body with the cervix. It lines the anterior surface of the
than the others and is in close contact with the ovary. It is body, passes over fundus and runs over the posterior aspect
called the ovarian fimbria. of the uterus reaching the upper part of the vagina from where
it is reflected on to the front of the rectum. The peritoneum
Blood vessels,Lymphatics and Nerves of the Uterine Tubes:
lined space between the front of the body of the uterus and
Each uterine tube is supplied by the uterine artery and by the
the superior surface of the urinary bladder is called the
ovarian artery (See Fig. 31.4). This blood drains through the
vesico-uterine pouch. The space between the uterus (and
corresponding veins. Lymph vessels travel along the ovarian
the uppermost part of the vagina) in front, and the rectum
vessels to the lateral aortic nodes.
behind is called the recto-uterine pouch (or pouch of
Douglas). The bottom of the pouch is only about 5 cm
(2 inches) from the anal orifice.
When traced laterally the layers of peritoneum lining the
front and back of the uterus meet along its lateral margins to
form the broad ligament.
Relations of the Uterus b. the urogenital diaphragm and the perineal body;
The anterior surface of the uterus is related to the superior c. some peritoneal folds and ligaments.
surface of the urinary bladder. The posterior surface of the
uterus is in contact with the sigmoid colon and with coils of
small intestine.
THE VAGINA
On either side the corresponding uterine artery reaches the
lateral side of the cervix and then ascends along the lateral
margin of the body of the uterus, lying between the two layers The vagina is a tubular structure with a muscular wall. Its
of peritoneum forming the broad ligament (See Fig. 31.4). The lower end opens to the exterior through the vestibule (Fig.
ureters run downward and forward a short distance (about 32.15). At its upper end it is attached to the cervix of the
2 cm) lateral to the cervix. uterus. The cervix projects into the upper part of the vagina
through the uppermost part of its anterior wall (Fig. 32.10).
Upper and Lower Uterine Segments
The space between the cervix and the adjoining part of the
The uterus can be divided into an upper part, consisting of the
vaginal wall is divided (for descriptive purposes) into the
fundus and the greater part of the body; and a lower part
anterior, posterior, and lateral fornices.
consisting of the lower part of the body, and of the cervix. These
From Figure 32.10 it will be seen that the long axis of the
are called the upper uterine segment, and the lower uterine
vagina runs upwards and backwards: we have seen that this
segment respectively. Enlargement of the uterus in pregnancy
axis is approximately at right angles to that of the uterus.
involves mainly the upper uterine segment.
The vagina has anterior and posterior walls. As seen in Figure
Blood Vessels, Lymphatics and Nerves of the Uterus 32.10 the anterior wall is shorter than the posterior. The
The uterus is supplied by the uterine arteries. The uterine veins anterior wall is about 7.5 cm (3 inches) long, while the
follow the arteries. posterior wall is about 9 cm long. The anterior wall of the
The lymphatic drainage of the uterus is described in Chapter vagina is related above to the base of the urinary bladder,
33. and below to the urethra. The posterior wall of the vagina is
related from above downwards to the rectouterine pouch,
Round Ligament of Uterus
the rectum, and the perineal body. Laterally, the vagina is
The round ligament of the uterus is connected at one end to the
related to the levator ani muscles. At its upper end the vagina
upper lateral part of the body of the uterus. The initial part of
is related laterally to the right and left ureters, and the right
the ligament lies within the broad ligament. The next part runs
and left uterine arteries.
forwards across the lateral wall of the pelvis. Crossing the
The vagina is supplied mainly by the vaginal branch of the
external iliac vessels it hooks round the lateral side of the inferior
internal iliac artery. It also receives branches from the uterine,
epigastric artery, and enters the deep inguinal ring. It then passes
internal pudendal and middle rectal arteries.The vaginal
through the inguinal canal and after emerging from the
veins end in the internal iliac veins.
superficial inguinal ring it ends in the labium majus.
Lymph vessels from the upper part of the vagina travel along
Supports of the Uterus the uterine artery to the internal and external lymph nodes.
The uterus is maintained in position by various factors. The Those from the middle of the vagina run along the vaginal
most important of these are: artery to reach the internal iliac nodes. The lower part of the
a. the pelvic diaphragm including the levator ani muscles and vagina drains into the superficial inguinal nodes.
the pelvic fascia lining them;
THE PERITONEUM
The abdominal cavity and most of the viscera within it are lined each other. Notice carefully the distinction between the terms
by a serous membrane called the peritoneum. The peritoneum abdominal cavity and peritoneal cavity. The abdominal
is a closed sac that is invaginated by viscera. It, therefore, comes cavity contains all the contents of the abdomen, while the
to have a parietal layer lining the abdominal wall; and a visceral peritoneal cavity is only a potential space.
layer that is in intimate relationship to the viscera. The parietal The basic arrangement of the peritoneum relative to the
and visceral layers of peritoneum are separated only by a viscera is shown in Figure 32.16. Viscus X and Y project
potential space called the peritoneal cavity. only partially into the peritoneal cavity. As a result they are
This space contains a thin film of fluid that allows free in contact with the posterior abdominal wall, and are only
movement of the viscera against the abdominal wall and against partly lined by peritoneum. Such viscera (and other
295
296
We will briefly consider some peritoneal folds and parts of
the peritoneal cavity.
The Greater Omentum
The greater omentum has four layers. The first layer is a
downward continuation of the peritoneum lining the anterior
surface of the stomach. The second layer is a continuation
of the peritoneum lining the posterior surface of the stomach.
These two layers meet at the greater curvature. They extend
downwards and then get folded on themselves to form the
third and fourth layers. These extend upwards to reach the
anterior border of the pancreas where they gain attachment
to the posterior abdominal wall.
The space enclosed between the first and second layers (in
Fig. 32.16. Scheme to show two basic types of front) and the third and fourth layers (behind) is the lower
relationship between viscera and peritoneum. part of the lesser sac. On the right and left sides also, the
space is closed by continuity of the anterior two layers with
the posterior two.
structures) are described as being retroperitoneal. They have
very limited mobility. Examples of retroperitoneal viscera are The Lesser Omentum
the duodenum, the ascending colon, the descending colon and This fold is attached below to the lesser curvature of the
the kidneys. In contrast to such viscera others (Z in figure) stomach (and to a small part of the duodenum). Its upper
are suspended from the abdominal wall by double layered end has an L-shaped attachment to the liver (porta hepatis
folds of peritoneum passing
from the abdominal wall to
the viscera. The best
example of such a viscus is
the small intestine. We have
already noted that the fold of
peritoneum by which it is
attached to the posterior
abdominal wall is called the
mesentery.
Similar folds of peritoneum
are sometimes called
ligaments. Finally note that
a peritoneal fold may pass
from one organ to another.
For example the gastro-
splenic ligament connects the
stomach to the spleen.
Subdivisions of
Peritoneal Cavity
The main part of the
peritoneal cavity is the
greater sac. An isolated part
of the cavity lying behind the
stomach is called the lesser
sac. The lesser sac opens into
the greater sac through the
foramen epiploicum. Some
times a relatively isolated
part of the peritoneal cavity
is referred to as a pouch or
recess.
Fig. 32.17. Schematic sagittal section through the abdomen and pelvis to
show reflections of peritoneum.
and the fissure for the ligamentum
venosum). Just above the duodenum
the lesser omentum has a right free
margin (formed by continuity of
anterior and posterior layers). The bile
duct, the hepatic artery and the portal
vein lie within the free margin that lies
just in front of the foramen
epiploicum.
Folds connecting the liver to the
abdominal wall
These are the falciform ligament, the
coronary ligament and the right and
left triangular ligaments.
Gastrosplenic and Lienorenal
ligaments
Two layers of peritoneum attached to
the uppermost part of the greater Fig. 32.18. Transverse section across abdomen at the level of the
curvature of the stomach pass to the foramen epiploicum to show peritoneal reflections.
hilum of the spleen forming the
gastrosplenic ligament. At the hilum one layer goes right round A good idea of the constitution of the anterior and posterior
the spleen to again reach the hilum where it rejoins the second walls of the sac can be had from Figure 32.17. It is seen that
layer. From here both layers pass to the front of the left kidney the anterior wall is formed (from above downwards) by the
as the lienorenal ligament. The gastrosplenic and lienorenal lesser omentum (posterior layer), the peritoneum lining the
ligaments are continuous inferiorly with the greater omentum. posterior surface of the stomach, and the anterior two layers
They help to form the left margin of the lesser sac. of the greater omentum. Some facts about the lesser sac that
Gastrophrenic ligament are easily appreciated are as follows:
This is formed by peritoneum reflected from the back of the 1. The upper part of the posterior wall of the lesser sac is
stomach (fundus) to the diaphragm. It forms the superior formed by the peritoneum lining several structures on the
boundary of the lesser sac. posterior abdominal wall.
2. The lower part of the posterior wall of the lesser sac is
The Mesentery
formed by the posterior two layers of the greater omentum.
The jejunum and ileum are suspended from the posterior
abdominal wall by the mesentery. 3. The lower border of the lesser sac is formed by continuity
of the anterior two layers of the greater omentum with its
Transverse Mesocolon posterior two layers (Fig. 32.17).
The transverse mesocolon attaches the transverse colon to the The constitution of the right, left and upper borders of the
posterior abdominal wall. It is attached to the anterior aspect sac is complex and will not be considered in detail. Some
of the pancreas (head and body). The transverse mesocolon facts are as follows:
lies just behind the most posterior layer of the greater omentum 1. The upper border of the lesser sac is formed partly by the
and is usually fused to it. gastrophrenic ligament, and by peritoneum passing from
Sigmoid Mesocolon the liver (caudate lobe) to the diaphragm.
The sigmoid mesocolon has an inverted V-shaped attached to 2. The left border of the lesser sac is formed, in the greater
the posterior abdominal and pelvic walls. The apex of the V part of its extent, in the same way as the lower border i.e., by
overlies the bifurcation of the left common iliac artery. The left continuity of the anterior two layers of the greater omentum
ureter crosses the artery just deep to the apex of the mesocolon. with its posterior two layers Higher up the left border is
formed by the gastrosplenic and lienorenal ligaments (Fig.
32.18). These ligaments are continuous, below, with the
The Lesser Sac (or Omental Bursa) greater omentum.
3. The right border of the lesser sac is formed as follows
The lesser sac is a fairly large recess of the peritoneal cavity, (from below upwards):
that communicates with the main cavity (or greater sac) only a. by continuity of the anterior two layers with the posterior
through the foramen epiploicum. The sac has anterior and two layers of the greater omentum .
posterior walls that meet each other at right, left, upper and b. reflection of peritoneum on the back of the first part of the
lower borders. duodenum on to the front of the neck of the pancreas.
297
298
c. Immediately above the duodenum there is a gap in the surface of the uppermost part of the vagina forming the
right border of the sac because of the presence here of the recto-uterine pouch. From the vagina it passes on to the
foramen epiploicum (Fig. 32.18). posterior surface of the uterus, and winds over the fundus
d. Above the foramen epiploicum the right margin is formed to reach the anterior surface. It leaves the anterior surface of
by reflection of peritoneum from the liver (caudate lobe) to the uterus and passes on to the superior surface of the urinary
the diaphragm. bladder forming the vesicouterine pouch.
In the male the peritoneum on the front of the rectum passes
Boundaries of Foramen Epiploicum to the upper part of the base of the urinary bladder forming
The foramen is bounded: the rectovesical pouch.
Anteriorly, by right free margin of lesser omentum
(containing the bile duct, hepatic artery, and portal vein). Peritoneal Recesses
Posteriorly, by peritoneum covering the inferior vena cava. At many sites in the abdomen there are relatively isolated
Below, by the superior part of the duodenum. areas of the peritoneal cavity. These are of importance in
Above, by the caudate process of the liver. that they can become sites of infection and fluid can collect
in them. These spaces include the various pouches mentioned
Peritoneum related to pelvic organs in relation to pelvic organs. Subphrenic spaces present
Peritoneum lining the posterior abdominal wall continues around the liver have been mentioned. Small recesses in
into the pelvis. At the level of the third piece of the sacrum which pieces of intestine can get caught are present in relation
it passes on to the front of the middle-third of the rectum. to the duodenum, the ileocaecal junction, and at the apex of
From the rectum it passes, in the female, on to posterior the transverse mesocolon.
33 : Lymphatics and Autonomic

Nerves of Abdomen and Pelvis
LYMPHATICS OF ABDOMEN AND PELVIS
We have seen that the largest lymph vessel in the body is the either side of the aorta there are the right and left lateral
thoracic duct. This duct begins in the abdomen as an upward aortic nodes (Fig. 33.1). Some outlying members of these
continuation of a sac-like structure called the cisterna chyli . groups lying behind the aorta constitute the retroaortic
Most of the lymph from the abdomen drains into the cisterna nodes. In front of the aorta there are the preaortic nodes.
chyli and from there into the thoracic duct (through which it is These are divided into the coeliac, the superior mesenteric
poured into the venous system). and the inferior mesenteric nodes (Fig. 33.2) lying around
the origins of the corresponding arteries.
On each side the efferents from the lateral aortic nodes form
the corresponding lumbar trunk that ends by joining the
CHIEF LYMPH NODES OF cisterna chyli (Fig. 33.1). Efferents from the preaortic nodes
ABDOMEN AND PELVIS form the intestinal trunk that also ends in the cisterna chyli.
The area of drainage of the preaortic nodes is shown in
Figure 33.2. The coeliac lymph nodes receive lymph from
The entire lymph from the abdomen (and from the lower limbs) the stomach, most of the duodenum, the liver, the extrahepatic
ultimately ends in terminal groups of lymph nodes present in biliary apparatus, the pancreas and the spleen. The superior
relation to the abdominal aorta. These nodes are arranged in mesenteric lymph nodes receive lymph from part of the
three main groups, each having a specific area of drainage. On duodenum, the whole of the jejunum, ileum, caecum,
LYMPHATICS AND AUTONOMIC NERVES
Fig. 33.1. Scheme to show the terminal lymph
nodes of the abdomen.
Fig. 33.3. The lateral aortic

Fig. 33.2. Subgroups of the preaortic lymph nodes, and areas lymph nodes.
drained by them.
appendix, ascending colon and transverse colon. The inferior

mesenteric lymph nodes receive lymph from the descending
colon, the sigmoid colon, and the upper part of the rectum.
The internal iliac nodes (Fig. 33.3) lie along the
Numerous groups of outlying nodes are associated with the
corresponding blood vessels. They receive most of the
lymphatic drainage of the organs mentioned above. These
nodes are referred to while discussing lymphatic drainage of lymph of the pelvic organs and from the deeper tissues of
the organs concerned. the perineum. They also receive some vessels of the lower
The lateral aortic nodes (Fig. 33.3) receive all the lymph draining limbs that travel along the superior and inferior gluteal blood
through the common iliac nodes. They also receive lymph vessels.
directly from the (a) posterior abdominal wall, (b) the kidneys The external iliac lymph nodes (Fig. 33.3) lie along the
and upper part of the ureters, (c) the testes or ovaries and (d) external iliac blood vessels. They receive lymph from the
the uterine tubes and part of the uterus. lower limb through the inguinal nodes. They also receive
The common iliac nodes (Fig. 33.3) lie along the corresponding direct lymph vessels from the deeper tissues of the
blood vessels. They receive lymph from the external and internal infraumbilical part of the anterior abdominal wall and from
iliac nodes and send it to the lateral aortic nodes. some pelvic organs.
299
300
LYMPHATIC DRAINAGE OF
ABDOMINAL AND PELVIC VISCERA
Lymphatic Drainage of the Stomach

For purposes of lymphatic drainage the stomach may be divided
into four areas as follows (Fig. 33.4).
1. Draw a vertical line immediately to the left of the cardio-
oesophageal junction: the part to the left of this line is area
A.
2. Draw another vertical line separating the pyloric part of the
stomach (Area D) from the body.
3. Divide the area between these two vertical lines into two
unequal parts by a curved line drawn parallel to the greater
Fig. 33.4. Areas of stomach having separate
curvature so that the area above it (Area B) is larger (2/3) than
lymphatic drainage.
the area (C) below it. The lymphatic drainage of these areas is
shown in Figure 33.5 and is described below.
Area A drains into the pancreatico-splenic nodes lying along in the wall of the gut and from there to vessels in the
the splenic artery (i.e. on the back of the stomach). Lymph mesentery. It ultimately reaches lymph nodes present in front
vessels from these nodes reach the coeliac nodes. of the aorta at the origin of the superior mesenteric artery.
Area B drains into the left gastric nodes lying along the artery Before reaching these nodes the lymph from the intestines
of the same name. These nodes also drain the abdominal part passes through hundreds of lymph nodes located in the
of the oesophagus. Lymph from these nodes drains into the mesentery.
coeliac nodes.
Area C drains into the right gastro-epiploic nodes that lie along Lymphatic Drainage of Caecum and Appendix
the artery of the same name. Lymph vessels arising in these The lymph from the caecum and appendix drains into the
nodes drain into the pyloric nodes that lie in the angle between superior mesenteric lymph nodes after passing through
the first and second parts of the duodenum. From here the lymph outlying groups of nodes.
is drained further into the hepatic nodes that lie along the Lymphatic Drainage of Colon
hepatic artery; and finally into coeliac nodes. The ascending colon and the transverse colon drain into the
Lymph from area D drains in different directions into the superior mesenteric group of preaortic nodes. The
pyloric, hepatic and left gastric nodes, and passes from all these descending colon and sigmoid colon drain into the inferior
nodes to the coeliac nodes. mesenteric group of preaortic nodes. On its way to these
Note that lymph from all areas of the stomach groups the lymph passes through various groups of outlying
ultimately reaches the coeliac nodes. From here it nodes.
passes through the intestinal lymph trunk to reach
the cisterna chyli.
Lymphatic Drainage of the Duodenum
Most of the lymph vessels from the duodenum
end in the pancreatico-duodenal nodes present
along the inside of the curve of the duodenum
(i.e. at the junction of the pancreas and the
duodenum). From here the lymph passes partly to
the hepatic nodes, and through them to the coeliac
nodes; and partly to the superior mesenteric nodes.
All the lymph reaching the hepatic nodes drains
into the coeliac nodes.
Lymphatic Drainage of the
Jejunum and Ileum
The small intestine has a very rich lymphatic
drainage. Some food substances, chiefly fats, are
absorbed through them. Mucous membrane of the
region is studded with finger like processes called
villi. Each villus has a central lymph vessel called Fig. 33.5. Scheme to show the lymphatic drainage
a lacteal. Lymph from lacteals drains into plexuses of the stomach.
Lymphatic Drainage of Rectum and Anal Canal
The upper part of the rectum drains to the inferior mesenteric
nodes through vessels passing along the inferior mesenteric
artery (1 in Figure 33.6).
The lower part of the rectum and the upper part of the anal
canal drain into the internal iliac nodes through vessels running Fig. 33.6.
along the middle rectal artery (2). Lymphatic
The lower part of the anal canal drains into the superficial drainage of rectum
inguinal nodes (3). and anal canal.
Lymphatic Drainage of the Liver
Lymph from the liver drains into the coeliac lymph nodes after
passing through hepatic nodes lying in the porta hepatis. Some
lymph drains into nodes present around the upper end of the
inferior vena cava.
Lymphatic Drainage of Gall Bladder and Bile Duct
The gallbladder and bile duct drain to the hepatic nodes (lying
along the hepatic artery), and through them to the coeliac nodes.
Vessels from the lower end of the bile duct drain into the
pancreaticoduodenal nodes.
Lymphatic Drainage of Urinary Bladder

The urinary bladder drains into the external iliac
lymph nodes .
Lymphatic Drainage of Urethra
The prostatic (a) and membranous (b) parts of
the urethra drain into the internal iliac lymph
nodes. The penile part of the male urethra drains
to the superficial inguinal nodes.
Fig. 33.7. Lymphatic drainage

of pancreas.
Lymphatic Drainage of the Pancreas

The pancreas drains into (1) the pancreaticosplenic nodes lying
along the splenic artery; and (2) the pancreatico-duodenal nodes
lying at the junction of pancreas and duodenum (Fig. 33.7).
From these nodes most of the lymph drains into the coeliac
nodes, but some of it drains into the superior mesenteric nodes.
Lymphatic Drainage of Kidney
All lymph vessels from the kidneys drain directly into the lateral
aortic nodes.
Lymphatic Drainage of the Ureter
The upper abdominal part of the ureter drains directly to the
lateral aortic nodes. The lower abdominal part drains into the
common iliac nodes. The pelvic part of the ureter drains into
the external iliac and internal iliac nodes.
Fig. 33.8. Lymphatic drainage of uterus.
301
302
Lymphatic Drainage of the Prostate (3) posteriorly to the sacral nodes . The sacral nodes lie in
and of the Seminal Vesicles front of the sacrum along the median sacral artery.
The prostate and seminal vesicles drain to both the internal
and external iliac nodes .
Lymphatic Drainage of Testes and Ovaries
Lymph from the testis or ovary passes along the testicular or LYMPHATIC DRAINAGE
ovarian vessels directly to the lateral aortic lymph nodes . OF ABDOMINAL WALL
Lymphatic Drainage of the Perineum
Superficial structures in the perineum including the lower part
of the anal canal, the scrotum and penis in the male, and the A. The Skin
lower part of the vagina in the female, drain into the upper a. The skin above the level of the umbilicus (in front, Figure
medial group of superficial inguinal lymph nodes. The glans 24.21) and above the iliac crest drains into the axillary lymph
(penis or clitoris), however, drains into the deep inguinal nodes. nodes.
Some vessels from the glans reach the external iliac nodes. b. The skin of the anterior abdominal wall below the umbilicus
Deeper tissues of the perineum drain into the internal iliac drains into the superficial inguinal lymph nodes (Fig. 24.21).
lymph nodes.
Lymphatic Drainage of Uterus and Uterine Tube B. Deeper Tissues
Lymph from the uterine tube (a) and from the upper part of the (a) Lymph vessels from the posterior abdominal wall travel
uterus (b) travels along the ovarian vessels to reach the lateral along the lumbar vessels to the lateral aortic nodes, including
the retroaortic nodes. (b) The vessels from the upper part of
aortic nodes (Fig. 33.8).

Lymph from the lower part of the body of the uterus (c) travels the anterior and lateral part of the abdominal wall drain into
to the external iliac nodes. the parasternal nodes (Fig. 24.22). The vessels from the lower
Lymph from the cervix travels (1) laterally to the external iliac part of the anterolateral abdominal wall reach the external
nodes; (2) posterolaterally to the internal iliac nodes ; and iliac nodes (Fig. 24.22).
AUTONOMIC NERVES
OF ABDOMEN AND PELVIS
Autonomic Ganglia and Plexuses related to the corresponding internal iliac arteries. Some other
in Abdomen and Pelvis plexuses are present in close relation to viscera, or even
within their walls. The vesical plexus surrounds the urinary
Many autonomic nerve fibres, both sympathetic and bladder. In the gut there is a myenteric plexus (of Auerbach)
parasympathetic, reach viscera after passing through a number between the muscle coats, and a submucous plexus (of
of plexuses (Fig. 33.9). Although they are called plexuses they Meissner).
contain numerous neurons and are, in fact, equivalent to
ganglia. The plexuses /ganglia to be seen in the abdomen and
pelvis are as follows:
The coeliac ganglion and coeliac plexus lie in relation to the PARASYMPATHETIC NERVES
abdominal aorta at the level of the origin of the coeliac trunk. IN ABDOMEN AND PELVIS
The coeliac plexus is the uppermost part of an extensive aortic
plexus surrounding the abdominal aorta. This is continued into
subsidiary plexuses around the branches arising from the vessel. Parasympathetic nerve fibres are derived from a cranial
The part of the aortic plexus between the origins of the superior outflow and a sacral outflow. In the thorax and abdomen the
and inferior mesenteric arteries is called the intermesenteric cranial outflow is represented by the vagus nerve. We have
plexus. The part overlying the bifurcation of the aorta is called seen that fibres of the vagus form an anterior and a posterior
the superior hypogastric plexus. When traced downwards it oesophageal plexus. Fibres emerging from the lower end of
divides into the right and left inferior hypogastric plexuses the anterior oesophageal plexus collect to form the anterior
Sympathetic Nerves in Abdomen and Pelvis
Branches of Thoracic Part of Sympathetic Trunk

entering the abdomen
The lower thoracic sympathetic ganglia give origin to
prominent medial branches called the greater, lesser and
lowest splanchnic nerves. All these nerves pass through the
diaphragm and enter the abdomen. Here the greater
splanchnic nerve ends mainly in the coeliac ganglion. Some
fibres of the greater splanchnic nerve end in the aorticorenal
ganglion. The lesser splanchnic nerve ends in the aorticorenal
ganglion. The lowest splanchnic nerve ends in the renal
plexus.
Lumbar Part of Sympathetic Trunk
The sympathetic trunk passes from the thorax to the abdomen
by passing posterior to the medial arcuate ligament.
Sometimes it may pass through the crus of the diaphragm.
There are usually four ganglia on the lumbar part of the
trunk. Their branches and communications are as follows:
1. The ganglia give off grey rami communicantes to the
lumbar nerves.
2. The first two ganglia (sometimes three) receive white rami
from the corresponding spinal nerves. These white rami are
part of the thoracolumbar outflow carrying preganglionic
fibres to the sympathetic trunk.
3. Each ganglion gives off splanchnic and vascular
branches. The ramifications of the vascular branches reach
Fig. 33.9. Schematic presentation of the location of up to the femoral artery.
important autonomic plexuses in the thorax and abdomen.
Pelvic Part of Sympathetic Trunk
This part of the trunk bears four or five sacral ganglia. In
front of the coccyx the right and left sympathetic trunks both
vagal trunk that is made up mainly of fibres of the left vagus end in a median ganglion, the ganglion impar. Grey rami
nerve. Similarly, fibres arising from the posterior oesophageal are given off to the sacral and coccygeal nerves. Other
plexus (derived mainly from the right vagus) collect to form branches travel along plexuses over the aorta and iliac
the posterior vagal trunk. These two trunks enter the abdomen arteries to reach arteries of the lower limb.
through the oesophageal opening in the diaphragm. They are
responsible for the parasympathetic supply to the greater part Afferent Autonomic Pathways
of the gastrointestinal tract and to some other organs. Both sympathetic and parasympathetic nerves carry
Preganglionic neurons that constitute the sacral numerous afferent fibres. They carry impulses arising in
parasympathetic outflow are located in the intermediolateral viscera and in blood vessels to the central nervous system.
grey column in spinal segments S2, S3 and S4 (Fig. 21.10). Some important points that may be noted about autonomic
They emerge from the spinal cord through the ventral nerve afferent are as follows:
roots of the corresponding spinal nerves. They soon leave the a. Autonomic afferents are necessary for various visceral
spinal nerves through their pelvic splanchnic branches. The reflexes. Most of these impulses are not consciously
preganglionic fibres end in relation to postganglionic neurons perceived.
that are located either in the walls of the viscera supplied or in b. Some normal visceral sensations that reach consciousness
plexuses related to them. The organs supplied directly by the include those of hunger, nausea, rectal distension and sexual
pelvic splanchnic nerves are the urinary bladder, the rectum, sensations.
the testes or ovaries, the uterus, the uterine tubes and the penis c. Under pathological conditions visceral pain is perceived.
or clitoris. Some fibres of these nerves pass through the This is produced by distension, by spasm of smooth muscle,
hypogastric plexuses to supply the pelvic colon, the descending or by anoxia.
colon and the left one-third of the transverse colon. (Note that
the parts of the gut supplied are hind gut derivatives).
303
304
Nerve Supply of some Abdominal Viscera
to the detrusor muscle and inhibitory to the sphincters.
According to classical teaching sympathetic stimulation has
General remarks
an effect opposite to that of the parasympathetic. However,
As a rule, viscera are innervated by both sympathetic and
it is believed that normal bladder function is controlled only
parasympathetic nerves that travel to them along arteries that
by the parasympathetic nerves and that sympathetic nerves
supply them. Parasympathetic supply to the greater part of the
are purely vasomotor in function.
gut, and other organs in the upper abdomen (liver, pancreas,
Sensory fibres carry impulses of distension and pain. They
spleen, kidneys) is through vagal fibres. Pelvic viscera (urinary
run through both sympathetic and parasympathetic pathways.
bladder, rectum, gonads, uterus, uterine tubes) receive
parasympathetic supply through the sacral outflow. Some pelvic Ureter
viscera receive direct branches from pelvic splanchnic nerves. Autonomic nerves to the ureter are predominantly sensory
in function. Distension of the ureter by a stone causes severe
Gastrointestinal tract
pain (renal colic). This is referred to regions of skin
See page 276.
innervated by segments T10 to L2. It, therefore, commences
Urinary Bladder in the back over the lower ribs and shoots downwards and
The parasympathetic nerves to the urinary bladder are derived forwards to the inguinal region, scrotum and sometimes into
from the sacral outflow. Parasympathetic stimulation is motor the front of the thigh.

Correlations of Abdomen and Pelvis
SURFACE MARKING
In drawing projections of various structures of the abdomen it cardiac orifice. The right margin of the orifice lies 1 cm to
is necessary to refer to a number of artificial planes or lines. the right of this point, and the left margin is 1 cm to the left
These lines also enable us to demarcate several regions of the of it.
abdomen. The lines and regions are shown in Figure 23.4. The pyloric orifice is also about 2 cm broad. Its middle lies
on the transpyloric plane about 1.2 cm (half inch) to the right
Relationship of Inguinal Canal to the surface of
of the median plane.
the Abdominal Wall
The lesser curvature can be marked by joining the right
To mark the superficial inguinal ring draw a triangle just above
border of the cardiac orifice with the left border of the pyloric
the pubic tubercle. For the shape of the triangle see Figure
orifice. The line should be concave upwards, and the lowest
24.4. To mark the deep inguinal ring draw a roughly circular
part of its curve should reach slightly below the transpyloric
area 1 cm above the midinguinal point. The inguinal canal can
plane.
be marked by joining the upper and lower edges of the deep
The fundus and greater curvature can be marked by a much
and superficial inguinal rings.
longer line joining the left border of the cardiac orifice with
Surface marking of Stomach the right border of the pyloric orifice. The first part of the
To draw the outline of the stomach first define the cardiac and line is drawn with an upward convexity that reaches the fifth
pyloric ends and then draw the lesser and greater curvatures left intercostal space just below the nipple. It then continues
by joining these ends with curved lines (Fig. 26.2). to the left and downwards to return to the level of the cardiac
The cardiac end of the stomach lies over the left 7th costal orifice. (The line up to this point represents the outline of
cartilage. Mark a point on this costal cartilage 2.5 cm to the the fundus of the stomach). The second part of the line
left of the median plane. This point marks the middle of the (representing the margin of the body of the stomach) forms
a convexity to the left and downwards, cutting the costal margin of the 9th right costal cartilage. It can be marked by two
between the tips of the 9th and 10th costal cartilages, and vertical lines, the first drawn along the right lateral line; and
extending down to the level of the subcostal plane. the second drawn 5 cm to the right of the first line.
Surface marking of Duodenum (Fig. 26.4) Transverse colon
The projection of the duodenum is represented by two parallel The transverse colon begins at the right colic flexure (i.e. at
lines 2.5 cm apart that are drawn as follows. the level of the upper part of the 9th costal cartilage) (Fig.
The first part of the duodenum begins at the pyloric end of the 26.10). It runs to the left, with a marked downward curve,
stomach (transpyloric plane half an inch to the right of the to reach the left colic flexure. This flexure lies to the left of
median plane). It is 2.5 cm (one inch) long. It can be marked the left lateral line, at the level of the left 8th costal cartilage.
by two lines 2.5 cm apart that pass upwards and to the right Between the two colic flexures the transverse colon hangs
from the pyloric end of the stomach. downwards to a varying degree and can reach the level of
The upper end of the second part of the duodenum is continuous the transtubercular plane or even lower. Using this
with the termination of the first part. The junction lies just below information the transverse colon can be marked using two
the right costal margin. From here the second part descends parallel lines that are about 5 cm apart.
almost vertically (with a slight curve to the right) for a distance
Descending colon
of 7.5 cm. The right margin of this part of the duodenum lies
It is marked by drawing two lines, 2.5 cm apart that begin at
along the right lateral line. The lower end of the second part
the left colic flexure (i.e. over the left eighth costal cartilage)
reaches the subcostal plane.
and running downwards a little to the left of the left lateral
The third part of the duodenum lies transversely at the level of
line. Its lower end lies just above the inguinal ligament.
the subcostal plane. It is about 10 cm long, and slightly convex
downwards. Its right end is continuous with the lower end of Sigmoid colon
the second part. Traced to the left the third part of the duodenum The sigmoid colon is in the form of coils that lie
crosses the median plane, lying above the level of the umbilicus. predominantly in the true pelvis. No useful purpose is served
The fourth part of the duodenum is only 2.5 cm long. It is by trying to mark it on the surface. It begins, as a continuation
marked by two lines running upwards and to the left from the of the descending colon, just above the left inguinal ligament
end of the third part. and descends into the true pelvis. It terminates near the
middle line of the pelvis by becoming continuous with the
Surface projection of Root of Mesentery
upper end of the rectum.
The root of the mesentery can be represented by a broad
obliquely placed line 15 cm long (Fig. 26.8). Its upper end lies Surface marking of the Liver
to the left of the median plane, about 3 cm below and medial to The projection of the liver can be drawn both on the anterior
the tip of the ninth costal cartilage. (This point corresponds to and posterior aspects of the trunk. A projection on the
the position of the duodenojejunal junction). The lower end anterior surface is illustrated in Figure 27.1.
of the root of the mesentery lies to the right of the median plane, When seen from the front the liver has a triangular outline.
at the junction of the right lateral and intertubercular planes. The triangle is bounded by upper, lower and right lateral
This point also marks the position of the ileocaecal junction borders.
(Fig. 26.10). The left end of the upper border lies just below the left nipple,
in the left fifth intercostal space 9 cm from the median plane.
Surface marking of Caecum and Appendix Draw a line joining this point to the xiphisternal joint. Carry
The caecum lies in the right iliac fossa. For guidance on how the line to the right of the middle line (with a slight upward
to mark it see Figure 26.10. First draw the right lateral and convexity) till it reaches the place where the upper border
transtubercular planes. Next note that the caecum is 6 cm long of the right fifth costal cartilage is crossed by the right lateral
and 7.5 cm broad. Draw a vertical line starting at the intersection line. Carry the line further to the right, more or less
of the right lateral and intertubercular planes and carry it down horizontally, and note that on reaching the midaxillary line
for about 6 cm. (This line marks the left margin of the caecum). the projection of the upper border lies over the sixth rib.
Draw a second line parallel to the first and 7.5 cm to its right. Continue the line across the side of the thorax to the back
(This line marks the right margin). Join the lower ends of the and continue it to the inferior angle of the scapula. Finally
two lines by a line convex downwards to complete the outline extend the line so that it reaches the middle line at the back,
of the caecum. at the level of the 8th thoracic spine.
A point 2 cm below the ileocaecal junction lies over the root of To mark the lower border of the liver return to the front of
the appendix. the trunk and go back to the left end of the superior border
Surface marking of Large Intestine (Fig. 26.10) (i.e. left fifth intercostal space 9 cm from the median plane).
This is also the starting point for marking the lower border
Ascending colon of the liver. From here draw a line running downwards and
The ascending colon begins at the level of the transtubercular to the right so that it cuts the left costal margin over the tip
plane (as an upward continuation of the caecum). It ascends to of the left eighth costal cartilage. Carry the line downwards
a level just below the transpyloric plane, and ends at the level and to the right to the intersection of the transpyloric plane
305
306
with the median plane. Crossing the median plane carry the Surface marking of Ureter (abdominal part)
line to the right costal margin which it should cut at the level To mark the ureter on the front of the abdomen locate
of the tip of the ninth costal cartilage. Continue the line to the (a) the tip of the 9th costal cartilage, and (b) the pubic
midaxillary line where it should lie over the tip of the tenth tubercle. A line joining these two points marks the position
costal cartilage. Finally carry the line across the back of the of the abdominal part of the ureter.
trunk to reach the median plane (at the back) at the level of the To mark the ureter on the back, locate the second lumbar
11th thoracic spine. spine. Take a point about 4 cm lateral to the spine. From
here draw a line downwards to reach the posterior superior
Fundus of Gall Bladder
iliac spine.
Draw the lower border of the liver as described above and
mark the gall bladder as a small convex area just below the Abdominal Aorta
border, over the place where the right linea semilunaris meets On the front of the abdomen the level of the upper end lies
the costal margin. 2.5 cm above the transpyloric plane. The lower end lies over
a point about 1 cm below and to the left of the umbilicus.
Surface marking of Pancreas
The aorta can be marked by drawing two vertical lines 2 cm
To mark the projection of the head of the pancreas, first mark
apart between these levels.
the duodenum as described above. Also mark the transpyloric
and subcostal planes. Common Iliac and External Iliac Arteries
The inner border of the C-shaped curve of the duodenum We have seen that the projection of the lower end of the
demarcates the head of the pancreas. Draw two lines about abdominal aorta lies about 1 cm below and to the left of the
3 cm apart that pass upwards and to the left from the head. umbilicus. Draw a broad line from here to the midinguinal
The initial 1 cm of these lines should lie over the transpyloric point (i.e. midway between the anterior superior iliac spine
plane. This part represents the neck of the pancreas. Continue and the pubic symphysis). The upper one third of this line
the two lines upwards and to the left till they reach the subcostal gives the surface marking of the common iliac artery, while
plane. This continuation of the lines, that should be about its lower two thirds give the marking of the external iliac
10 cm long, represents the body of the pancreas. The terminal artery.
part of the same lines represents the tail.
Inferior Vena Cava
Surface marking of the Spleen The inferior vena cava lies to the right of the abdominal
The long axis of the spleen lies along the long axis of the 10th aorta, and so its marking has to be to the right of the median
rib. The medial end lies over the 10th rib, about 5 cm from the plane. Its left edge should be about 1 cm to the right of the
median plane. The lateral end lies over the 10th rib in the median plane and its right edge 2.5 cm further to the right. It
midaxillary line. The upper border of the spleen is drawn by begins just below the transtubercular plane and ends opposite
joining the medial and lateral ends by a line convex upwards the sternal end of the right sixth costal cartilage.
so that its uppermost part reaches the upper border of the 9th
Common and External Iliac Veins
rib. The lower border of the spleen is drawn by joining its
Draw a line from the lower end of the inferior vena cava to
medial and lateral ends by a line convex downwards and
a point a little medial to the midinguinal point. The upper
reaching the lower border of the 11th rib.
one third of this line represents the common iliac vein, while
Surface marking of Kidneys its lower two thirds represent the external iliac vein.
See page 270.
Vertebral Column
When neural elements are also present in the swelling the
1. The two halves of the neural arch may fail to fuse in the condition is called meningomyelocoele.
midline. This condition is called spina bifida. If the gap 3. Abnormality in ossification of a vertebra may result in a
between the neural arches is small no obvious deformity may condition in which the spine, laminae and inferior articular
be apparent on the surface (spina bifida occulta: occult = processes are not fused to the rest of the vertebra. When this
hidden). abnormality is present, body weight can cause the body of the
2. When the gap is large, meninges and nerves may bulge out 5th lumbar vertebra to slips forwards over the sacrum. This
through the gap forming a visible swelling. When the swelling condition is called spondylolisthesis. Spondylolisthesis can
contains only meninges and CSF it is called a meningocoele. be a cause of persistent low back pain.
Lumbar puncture A better estimate of pelvic dimensions can be made by trying
The term lumbar puncture is applied to a procedure in which a to palpate some features of the pelvis by fingers introduced
long needle is passed into the subarachnoid space through the into the vagina (vaginal examination). This is called internal
interval between the 3rd and 4th lumbar vertebrae, or sometimes pelvimetry.
through the interval between the 4th and 5th vertebrae. In this The most reliable estimates of pelvic dimensions can be
connection it is important to note that the lower end of the spinal made by taking skiagrams of the pelvis (X-ray pelvimetry).
cord lies at the level of the lower border of the first lumbar An added advantage is that the dimension of the fetal head
vertebra. The subarachnoid space (containing cerebro-spinal can also be determined at the same time.
fluid) extends down to the level of the lower border of the second
sacral vertebra. Hence a needle passed into the lower lumbar Pelvic Diaphragm
part of the vertebral canal does not injure the spinal cord. The pelvic diaphragm is subject to great stretching during
Lumbar puncture is used for various purposes. childbirth and injury to it can occur. The resulting weakness
1. Samples of cerebrospinal fluid (CSF) can be obtained for can lead to prolapse of the uterus or prolapse of the rectum.
examination. Herniation of the urinary bladder into the vagina (cystocele)
2. The pressure of CSF can be estimated. can lead to incontinence of urine when intra-abdominal
3. Air or radio-opaque dyes can be introduced into the pressure is raised. Damage to the pelvic diaphragm is more
subarachnoid space for certain investigative procedures. A serious if the perineal body is torn during labour.
skiagram taken after injecting iodinized oil into the
subarachnoid space outlines the space.
4. Anaesthetic agents injected into the subarachnoid space act The Umbilicus
on the lower spinal nerve roots and render the lower part of the
body insensitive to pain. This procedure, called spinal a. The umbilicus is one of the sites at which tributaries of
anaesthesia, is frequently used for operations on the lower the portal vein communicate with systemic veins. In case of
abdomen and on the lower extremities. obstruction to the portal vein these communications become
very prominent and are seen as veins that radiate from the
Prolapse of Intervertebral disc
umbilicus. This appearance is given the name caput
The intervertebral discs are very strong in the young. With
medusae.
advancing age, however, the annulus fibrosus becomes weak
b. The vitello-intestinal duct connects the embryonic gut to
and it then becomes possible for the nucleus pulposus to burst
the yolk sac. In the normal course of development this duct
through it. This is called prolapse of the intervertebral disc. A
prolapsed nucleus pulposus may press upon nerve roots attached disappears. If the duct remains patent there is a channel
to the spinal cord resulting in local pain in the back. When through which intestinal contents flow out at the umbilicus
nerves are pressed upon there is shooting pain along the course (faecal fistula). Sometimes the vitellointestinal duct may
of the nerve involved. Disc prolapse occurs most frequently in not communicate with the exterior but part of it may remain
the lumbosacral region and results in pain shooting down the patent as a diverticulum communicating with the gut. This
back of the leg and thigh. This is called sciata. is called Meckels diverticulum.
c. The allantoic diverticulum is a tube like structure that is
connected, at one end, to the distal part of the embryonic
Pelvic wall
gut (the part called the cloaca). The other end of the allantoic
diverticulum is blind. This end passes through the umbilical
Dimensions of the female pelvis and their importance in opening. Normally the allantoic diverticulum is occluded
obstetrics and forms a fibrous band called the urachus. This band
During childbirth the fetus has to pass through the true pelvis. connects the apex of the urinary bladder to the umbilicus.
The largest part of the fetus is the head and for smooth passage Occasionally, however the urachus remains patent resulting
of the fetus the dimensions of the true pelvis have to be large in a communication between the urinary bladder and the
enough for the fetal head to be able to pass through it. In cases umbilicus (urinary fistula).
where the passage is not large enough serious difficulties can d. In the early embryo the abdominal cavity is small.
arise during childbirth, and in the absence of adequate medical Meanwhile the gut undergoes rapid growth and the abdomen
facilities this can be a cause of death both of the mother and the is unable to accommodate it. As a result some coils of
fetus. Because of these facts one of the important aspects of intestine pass out of the abdomen through the umbilical
antenatal care is to examine the expectant mother to make sure
opening (This is referred to as physiological hernia). Later,
that the pelvis is of normal size. Various methods have been
as the abdomen becomes larger in size, the coils return into
used for this purpose as follows.
the abdominal cavity. In some cases the coils of gut fail to
In external pelvimetry an attempt is made to judge to size of
return, and the infant is born with coils of gut protruding
the birth canal by making measurements between bony
landmarks of the pelvis that can be felt on the surface of the out of the abdomen in the region of the umbilicus. This is
body. referred to as congenital umbilical hernia or exomphalos.
307
308
Herniae Through Abdominal Wall The coverings of an indirect inguinal hernia are the same as
the coverings of the testis. From deep to superficial these
The term hernia is applied to a condition in which the contents are extraperitoneal tissue, internal spermatic fascia,
of a cavity protrude out of it through a weak area in its wall. cremasteric fascia, external spermatic fascia, and skin.
Most hernias are seen in relation to the abdomen. Direct Inguinal Hernia
Abdominal viscera exert pressure on the abdominal wall, and In this type of hernia the sac does not pass through the deep
this pressure is increased considerably during acts like inguinal ring, but enters the inguinal canal by pushing through
coughing or defecation. If there is a gap (or weakened area) in the posterior wall of the canal.
the abdominal wall repeated pressure against it can cause a The coverings of a direct inguinal hernia (from deep to
process of peritoneum to pass out through the gap into superficial) are extraperitoneal tissue, fascia transversalis,
subcutaneous tissues. Further pressure gradually increases the cremasteric fascia, external spermatic fascia and skin.
size of the peritoneal process that gradually becomes sac like.
As the sac enlarges coils of intestine (or other abdominal
contents) may enter it. Such a hernial sac can become very Scrotum and Testis
large, but the site of the original protrusion remains narrow
and is referred to as the neck of the hernial sac. Skin and Two common causes of scrotal swelling are inguinal hernia
other tissues that cover the sac are called coverings of the (discussed above) and hydrocele (see below).
hernia. Abdominal contents that enter the sac are the contents Hydrocele
of the hernia. In the section on inguinal hernia we have seen that the
Usually pressure over a hernia can push its contents back into processus vaginalis is a prolongation of peritoneum that
the abdominal cavity. Such a hernia is said to be reducible. passes through the inguinal canal into the scrotum. Its distal
Some times sudden increase in intraabdominal pressure may part forms the tunica vaginalis that surrounds the testis, while
push contents into the hernia, but thereafter they may be unable the proximal part normally disappears. We have also seen
to return. Pressure exerted by the margins of the narrow neck that abnormally various parts of the processus vaginalis may
of the hernia may cut off vascular supply of the contents. This persist.
is then called a strangulated hernia ( that is an emergency The tunica vaginalis, or any persisting part of the processus
requiring urgent surgery). vaginalis, may become filled with a collection of fluid. This
condition is called hydrocele.
Inguinal Hernia Varicocele
The pampiniform plexus of veins drains the testis. When
these veins become tortuous and dilated (varicose) and form
Preliminary remarks
a palpable mass (that feels like a mass of worms) the
The inguinal canal is a passage through the entire thickness of
condition is called varicocele.
the abdominal wall. It represents a site of weakness through
which hernia may occur. Descent of the testes:
In fetal life the inguinal canal serves as a passage through which The testes develop in relation to the lumbar region of the
the testis passes through the abdominal wall to descend into posterior abdominal wall. During fetal life they gradually
the scrotum. A tubular process of peritoneum called the descend to the scrotum, reaching the iliac fossa in the third
processus vaginalis passes through the canal and facilitates month. They lie at the deep inguinal ring up to the seventh
the descent of the testis. Normally, the greater part of the month of intrauterine life, and pass through the inguinal canal
processus vaginalis is obliterated, but the part around the testis during the seventh month. Normally the testes reach the
becomes the tunica vaginalis. Sometimes the processus scrotum by the end of the eighth month.
vaginalis (or parts of it) may persist as a patent channel into 1. Descent of the testis may fail to occur or may be incomplete
which herniation of abdominal contents may occur. In such a (cryptorchidism, literally hidden testis). The organ may lie
hernia the contents pass through the deep inguinal ring, the anywhere along the path of descent.
inguinal canal, and the superficial ring and can pass into the 2. Instead of descending into the scrotum the testis may get
scrotum. This type of hernia is called an indirect inguinal lodged at an abnormal site (ectopic testis). It may come to
hernia. lie under the skin of the front of the abdomen, under the skin
The second reason for occurrence of inguinal hernia can be of the thigh, in the femoral canal, under the skin of the penis,
weakening of muscles with age. This results in a direct inguinal or in the perineum behind scrotum.
hernia. 3. A number of small vestigial elements are present in relation
to the testis and epididymis and can lead to formation of
Indirect Inguinal Hernia cysts. The vestigial structures include the appendix of the
Indirect inguinal hernias are much more common in the male testis (or hydatid or Morgagni), the appendix of the
than in the female (the inguinal canal being much narrower in epididymis, the superior or inferior aberrant ductules and
the female as the ovary does not pass through it). the paradidymis.
Vasectomy appendicitis pain is first felt round the umbilicus. When the
This operation is very frequently performed in India as a family parietal peritoneum gets involved pain shifts to the right
limiting measure. The operation can be done using local iliac fossa.
anaesthesia. The right and left ductus deferens are approached We have seen that the peritoneal cavity is divided into various
through small incisions in the upper part of the scrotal wall, parts as a result of the presence of many folds. Because of
and are cut. The cut ends are ligated. The operation is called this infection can occur in localized pockets of peritoneum
vasectomy as an old name for the ductus deferens is vas as follows.
deferens. Following the operation spermatozoa do not reach a. Infection may occur in the subphrenic spaces that
the exterior. Normal ejaculation takes place, the ejaculate surround the liver. The right posterior space (or right
consisting of prostatic and other secretions. In case of need the subhepatic space) is the most dependent part of the peritoneal
two ends of the ductus deferens can be reanatomosed in many cavity (in a supine position). It is closely related to the right
cases. This is easier if a segment of the ductus deferens has not kidney and is therefore also called the hepatorenal pouch
been removed during vasectomy. (also called Morisons pouch). This is the commonest site
of a subphrenic abscess. Infection may spread to this space
from the gall bladder, the vermiform appendix or from any
other organ in the region.
The Peritoneum
b. Rectouterine pouch: The peritoneum on the front of the
rectum is reflected on to the upper most part of the vagina
1. The smoothness of the peritoneal surface, and the presence forming the so called rectouterine pouch. Clinicians often
of a thin film of fluid between adjacent layers of peritoneum, refer to this pouch as the pouch of Doughlas. In a sitting or
greatly facilitates movements of viscera over one another. Such standing person this pouch is the most dependent part of the
movements take place as a result of respiration, of peristaltic peritoneal cavity and fluid or pus tends to collect here when
movements of the intestines, and because of alternate distension there is infection. It is important to know that the floor of
and emptying of organs like the stomach, and the urinary pouch lies only 5.5 cm from the anus. It can be palpated,
bladder. and drained, either through the posterior fornix of the vagina
2. Under certain conditions there may be great increase in the or through the rectum.
quantity of peritoneal fluid. This condition is called ascites.
Laparotomy and laparoscopy
Fluid that has accumulated in the peritoneal cavity can be
An operation that opens the peritoneal cavity is called
removed through a canula introduced through the abdominal
laparotomy. The procedure may be preliminary to surgery
wall. The procedure is called paracentesis. It may be done
on any organ, or may be used to inspect the interior of the
through the linea alba or on one flank.
abdominal cavity in cases where diagnosis is otherwise
3. The large absorptive area of the peritoneum poses a serious
difficult. However, it is now possible to inspect the interior
danger when infection develops in the peritoneal cavity
of the peritoneal cavity by introducing an instrument called
(peritonitis). Toxins are rapidly absorbed into blood leading to
a laparoscope through a small opening in the abdominal
toxaemia. Because of this reason generalised peritonitis can be
wall. The procedure is called laparoscopy. Several
a life threatening condition. However, the peritoneum itself tries
abdominal surgical procedures are now being carried out
to combat the spread of infection in various ways. When
through such instruments.
infection develops in an area (usually by spread from an
inflamed viscus like the appendix) the peritoneum tries to
localise the infection by formation of adhesions. The greater Portosystemic Anastomosis and
omentum plays a special role in this regard. It has the ability to Associated Conditions
move to a site of infection and tries to wrap itself around the
infected region. It is for this reason that the greater omentum The portal vein and its tributaries form a system separate
has been termed the policeman of the abdomen. from the systemic (or caval) veins. However, at certain sites
4. Abdominal infections are accompanied by pain. The visceral veins of the portal system anastomose with systemic veins.
peritoneum, supplied by autonomic nerves, is much less Normally, the flow through these communications is
sensitive to pain than the parietal peritoneum that is innervated insignificant, but when there is obstruction to flow of blood
by somatic nerves. Pain arising in the visceral peritoneum is in the portal circulation (e.g. by cirrhosis of the liver) these
stimulated mainly by stretching, and tends to poorly localized. communications enlarge and serve as alternative channels
In contrast pain caused by inflammation of an area of parietal of flow. It is important to know the sites of such
peritoneum can be accurately localized. Embryologically, the communications as these enlarged veins are of clinical
gut is a midline structure. Because of this, visceral pain arising significance. The sites of communication (portosystemic or
in the gut is at first felt over the midline. Pain arising in the portocaval anastomoses) are as follows.
stomach and duodenum is referred to the epigastrium, that from a. The region of the umbilicus is drained by systemic veins
the rest of the small intestine, the appendix and the ascending of the anterior abdominal wall. Some small paraumbilical
colon to the area around the umbilicus; and from the rest of the veins pass from the umbilicus through the falciform ligament
gut to the hypogastrium. For example in a case of acute to reach the liver where they anastomose with the left branch
309
310
of the portal vein. In portal obstruction blood flows through bleeding that can at times be serious. Cases of gastric ulcer
paraumbilical veins into systemic veins at the umbilicus. The are treated by drugs that block acid secretion.
superficial veins of the abdominal wall enlarge and are seen
radiating from the umbilicus (caput medusae). The Intestine
b. The lower end of the oesophagus drains partly into the left
gastric vein (portal) and partly into the accessory hemiazygos
vein (systemic). In portal obstruction the communications Infections of the intestines
between these two sets of veins enlarge to form swellings called Numerous infections can affect the intestine as they can enter
oesophageal varices. Rupture of these varices can cause them through ingested food. Infection of the small intestine
serious bleeding. (enteritis) or of the colon (colitis) can be acute or chronic. It
c. Veins from the wall of the anal canal drain partly into the can be produced by bacteria, by viruses, and by parasites
superior rectal vein (portal), and partly into the middle and like entamoeba histolytica (amoebiasis). A bacterial infection
inferior rectal veins (systemic). Enlargement of the can be tubercular. Another serious bacterial infection is
communications between these veins can be an important factor typhoid that is accompanied by typhoid fever (or enteric
predisposing to formation of haemorrhoids or piles. fever). In such infection ulcers form and these can lead to
intestinal perforation.
d. Other sites of communication between systemic and portal
veins are seen in relation to the bare area of the liver (where Diverticulosis
hepatic veins anastomose with phrenic and intercostal veins); Diverticuli can occur in any part of the gut as a congenital
and the posterior abdominal wall where veins draining the anomaly and that these are most common in the duodenum.
parts of the gut that are retroperitoneal (i.e., the duodenum, Diverticuli can be sites of infection, and, occasionally, of
the ascending colon and descending colon) anastomose with perforation.
systemic veins of the posterior abdominal wall (renal, lumbar Sigmoidoscopy

and phrenic veins). The interior of the sigmoid colon can be viewed directly
through a sigmoidoscope.
Meckels diverticulum Intussusception
This term is used for a condition in which one part of gut
The embryonic gut is connected to the yolk sac through the invaginates into another part leading to obstruction.
vitello intestinal duct. This duct passes through the embryonic
umbilical opening. Later in fetal life this duct undergoes Volvulus
complete obliteration and disappearance. However, in some This condition results if a loop of gut rotates on itself. Such
persons its proximal part (near the gut) persists and forms a rotation may take place around a fibrous band. Volvulus may
occur in the ileum, the caecum, or the pelvic colon.
diverticulum arising from the terminal part of the ileum. This
is diverticulum ilei or Meckels diverticulum. The diverticulum
is of surgical importance as it may undergo inflammation giving The Vermiform Appendix
rise to symptoms similar to those of appendicitis.
Some facts of interest about the diverticulum are as follows. It Inflammation of the appendix is appendicitis. Pain of
is attached to the ileum about 2 feet proximal to the ileocaecal appendicitis is first felt around the umbilicus. This is referred
junction. It length is variable and is usually 2 inches. It is seen pain. When inflammation reaches the parietal peritoneum
in about 2% of the population. pain shifts to the right iliac fossa. Here the pain is precisely
localized and severe.
Variations in position of the appendix can influence
The Stomach symptoms observed in appendicitis. If the appendix is
retrocaecal (as it very often is) tenderness may be difficult
1. The Greek word for stomach is gaster. From this we have to elicit over the right iliac fossa. Such an appendix comes
the adjectives gastric and gastro- that are used in relation to into contact with the psoas major muscle. Because of this,
the stomach. Inflammation of the stomach is gastritis. An pain may be felt on extending the right hip joint (the muscle
instrument that is used to visualise the interior of the stomach being stretched in this position). So the patient tends to keep
is a gastroscope, and the procedure is called gastroscopy. the right thigh flexed. When the appendix is in the pelvic
2. The condition called congenital pyloric stenosis is a position tenderness may be present in the hypogastrium
developmental anomaly in which there is great thickening of instead of the right iliac fossa. Tenderness may also be
muscle at the pyloric end of the stomach. The condition appears elicited by rectal or vaginal examination. A pelvic appendix
to be genetically determined and is much more common in may irritate the obturator internus muscle, and the patient
male infants. It can be successfully treated by surgically incising may find relief in keeping the hip laterally rotated. Flexion
the thickened mass of muscle longitudinally. and internal rotation of the right hip joint ( that causes the
3. The term peptic ulcer is applied to ulcers in the stomach, obturator internus to be stretched) may produce pain in the
and in the duodenum. An ulcer can be a source of pain, and of hypogastrium.
The Rectum Ischiorectal Fossa
The ischiorectal fossa can be the site of an abscess. Infections

Rectal Examination
can reach the fossa from the anal canal. Bursting of an
Considerable information about the structures surrounding the
ischiorectal abscess on to the perineal skin results in a sinus.
rectum and anal canal can be obtained, in the living, by palpation
If the abscess also bursts into the anal canal an anal fistula
with a finger inserted through the anus. This is referred to as
(ischiorectal type) is produced.
rectal examination. It is often referred to by doctors as PR
that is an abbreviation for examination per rectum). The
structures that can be felt through the anterior wall of rectum The Liver
and anal canal in the male are (from below upwards) the bulb
of the penis and membranous urethra, the prostate, the seminal 1. A small piece of liver tissue can be obtained for
vesicles, and the base of the urinary bladder. In the female the examination by introducing a needed into the organ. The
main structures in front of the anal canal are the vagina and needle is usually introduced through the right 8th or 9th
uterus, but as these are directly accessible for examination intercostal space and pierces through the diaphragm. Biopsy
(through the vagina) a rectal examination is needed for them can also be obtained through the epigastrium.
only when for some reason a vaginal examination is not 2. Inflammation of the liver is called hepatitis (hepar = liver).
desirable. Posteriorly, in both the male and female, the coccyx Hepatitis is often viral. The infection can reach the liver
and the lower part of the sacrum can be felt; and laterally, the through contaminated drinking water. Hepatitis can also be
ischial spine and ischial tuberosity can be palpated. In addition spread through needles used for injection. Severe viral
an experienced surgeon can recognise abnormalities in infections can lead to serious liver damage. They can also
surrounding viscera (ovary, uterine tube, ureters, a pelvic predispose to cancer.
appendix) such as inflammation or enlargement. Enlarged Infection with amoeba histolytica leads to amoebic hepatitis.
internal iliac lymph nodes, abnormalities in the rectovesical or This is usually secondary to intestinal infection. Amoebic
rectouterine pouches, or in the ischiorectal fossae can also be hepatitis can lead to the formation of an amoebic abscess.
detected. Various other infections may occur.
3. All substances absorbed into the blood stream from the
gut pass, through the portal vein, into the liver. Apart from
The Anal Canal
nutrients these include alcohol and drugs. The liver tries to
detoxify harmful substances before they are passed into the
Haemorrhoids (or Piles) systemic circulation, but in the process liver tissue can itself
This term is used to describe swellings in the anal canal produced undergo damage. In persons who consume excessive
by dilated veins. Haemorrhoids may be internal or external. amounts of alcohol over long periods, the liver tissue
undergoes fibrosis (cirrhosis of liver).
Internal or true haemorrhoids
Internal or true haemorrhoids are located in the part of the anal
canal lined by mucosa. They are therefore painless. They are Gall Bladder and Biliary Ducts
located in relation to anal columns above the level of anal valves,
and are formed by dilatation of radicles of the superior rectal Inflammation of the gall bladder is called cholecystitis.
vein. Chronic cholecystitis is often associated with the formation
There is one tributary of the superior rectal vein in each anal of stones in the gall bladder (cholelithiasis). Surgical
column. However, the tributaries located in the left lateral, right removal of the gall bladder is called cholecystectomy.
posterior, and right anterior positions are largest and the first to Pain arising in the gall bladder is felt over the right
enlarge. These enlargements are called primary piles. When hypochondrium. The pain may radiate to the right scapula
the anal canal is viewed with the patient lying supine with the or right shoulder specially if the subdiaphragmatic parietal
thighs raised (lithotomy position) the position of primary piles peritoneum is involved.
is often described with reference to a clock. They are said to be When a gall stone tries to pass through the bile duct it causes
located at the 3 oclock, 7 oclock and 11 oclock positions. severe pain called biliary colic that is felt in the epigastrium.
Secondary piles may form later at other positions. Obstruction to the biliary duct system from any cause leads
The most important clinical feature of piles is painless bleeding to the development of jaundice. Such obstruction is often
that may take place every time the patient passes stools. associated with a tumour of the pancreas.
External haemorrhoids The Pancreas

In contrast to internal haemorrhoids external haemorrhoids are
formed by dilatation of tributaries of the inferior rectal veins. 1. The beta cells of pancreatic islets produce insulin,
They are placed below the anal valves and are covered by skin. deficiency of which causes diabetes mellitus.
They are highly painful.
311
312
2. Inflammation of the pancreas is called pancreatitis. It is projection on the interior of the urinary bladder just behind
often associated with collection of fluid in the lesser sac the internal urethral orifice: this projection is called the uvula.
(pseudopancreatic cyst). The uvula may form a flap that covers the internal urethral
meatus and obstructs it.
Obstruction to flow of urine is also caused by distortion of
The Spleen
the prostatic urethra produced by enlargement of the prostate.
Traditionally an enlarged prostate has been treated by
1. Enlargement of the spleen (splenomegaly) occurs in many
surgical removal (prostatectomy). The organ can be
diseases. In India the most important of these is malaria.
approached through the urinary bladder (transvesical
Enlargement also takes place in portal hypertension.
prostatectomy), through the retropubic region without
A normal spleen does not extend anteriorly beyond the
entering the bladder (retropubic prostatectomy), or through
midaxillary line. When enlarged considerably (to almost twice
the perineum (perineal prostatectomy). However, at present
its normal size) the spleen projects from under the costal margin
the operation of choice is removal through an instrument
and can be felt on palpation of the abdomen.
passed through the urethra. This is called transurethral
2. Surgical removal of the spleen is called splenectomy.
resection (TUR).
3. Radio-opaque dyes can be introduced into the portal venous
system through a needle introduced into the spleen
(splenovenography or splenoportography). The technique has Uterine Tubes
now been largely replaced by coeliac angiography.
1. Inflammation of the uterine tubes is salpingitis. This can
lead to blockage of the tubes, and this can become a cause
The Kidneys and Ureters
of infertility. Patency of the tubes can be tested by injecting

a radio-opaque dye into them (hysterosalpingography).
The classical surgical approach to the kidney is through an
Spillage of dye into the peritoneal cavity (through the lateral
incision that starts just below and lateral to the renal angle
end) is an indication of patency.
(point where the 12th rib cuts the lateral margin of the erector
2. As a family planning measure (to prevent pregnancy) the
spinae). The incision is carried downwards and forwards
uterine tubes may be purposely cut and ligated (tubectomy).
towards the anterior superior iliac spine.
3. If a fertilised ovum gets stuck in the uterine tube (thus
In making this incision the relationship of the 12th rib to (the
failing the reach the uterus) it may start developing there
line of costodiaphragmatic reflection of) the pleura has to be
resulting in a tubal pregnancy. Such a pregnancy seldom
remembered.
goes on to full term. Rupture can lead to serious haemorrhage
In many cases surgeons approach the kidney from the front
into the peritoneal cavity.
using a paramedian or transverse incision.
The Uterus
The Prostate
1. The uterus undergoes great enlargement (and many other
The two most important clinical conditions affecting the
changes) during pregnancy. The uterine mucosa undergoes
prostate are enlargement in old age (benign hypertrophy, or
cyclic alterations as a part of the menstrual cycle.
benign enlargement), and carcinoma.
2. We have seen that the normal uterus is anteverted and
Benign enlargement of prostate anteflexed. The uterus can become retroverted.
Benign hypertrophy of the prostate is due to the formation of 3. Weakening of the pelvic diaphragm can lead to prolapse
an adenoma. This condition occurs most frequently in the of the uterus. Retroversion predisposes to prolapse (as the
median lobe; and somewhat less frequently in the inner parts uterus comes into line with the vagina).
of the lateral lobes. The region corresponds to the inner 4. Neoplasms may take place. The most common growth is
glandular zone, which is therefore also called the adenomatous a fibroma (fibroid) that can be multiple. Carcinoma is
zone. (In contrast, the outer glandular zone is frequently the common in the cervix.
site of carcinoma and is, therefore, called the carcinomatous 5. Surgical procedures are commonly performed on the
zone). Some facts concerning benign enlargement of the uterus. In cases in which normal birth of a baby is not possible
prostate are as follows. delivery may be done by opening the uterus (Caesarean
One of the important symptoms of prostatic enlargement is section). Any operation requiring opening of the uterus is
repeated desire to pass urine but with difficulty in doing so. called hysterotomy, and removal of the uterus is called
The condition can also lead to urinary retention. The reasons hysterectomy.
for these symptoms are as follows. 6. Intrauterine contraceptive devices (IUCD) made of metal
We have seen that benign hypertrophy most frequently affects or plastic may be inserted into the uterus to prevent
the median lobe of the prostate. The median lobe produces a implantation of a fertilised ovum.
Vagina Oral cholecystography
A suitable radio-opaque dye is given by mouth. It is absorbed
by the gut and reaches the liver through the portal circulation.
1. Vaginal examination
It is then secreted into bile which is concentrated in the gall
Most of the structures related to the vagina can be palpated
bladder making it visible in a skiagram.
through fingers introduced into the vagina. On the anterior side
we can feel the pubic symphysis, the urinary bladder, and the Intravenous cholangiography
urethra. Posteriorly we can feel the rectum, and any structure A suitable radio-opaque dye is injected intravenously reaches
lying in the rectouterine pouch. The perineal body can also be the liver and is secreted into bile. It permits visualisation of
felt. On either side the structures that can be felt through the the bile ducts.
vaginal wall are the ovary, the uterine tube, the ureter, and the
Excretory Pyelography
urogenital diaphragm. The position and size of the uterus can
This procedure is also referred to as intravenous or
be determined.
descending pyelography. A suitable preparation (e.g. conray
2. Trauma during childbirth can lead to the formation of a fistula
280) is injected intravenously. The dye is excreted by the
between the vagina and the rectum. The urinary bladder may
kidneys. Skiagrams taken at suitable intervals after injection
bulge into the vagina through the weakened anterior wall
show the renal pelvis and ureter. The dye also outlines the
(cystocele); and the rectum may bulge through the posterior
urinary bladder.
wall (rectocele).
3. Surgical procedures on the vagina include cutting of its wall Retrograde pyelography
(colpotomy), or repair of the wall (colporraphy). This is also called ascending pyelography. A ureteric catheter
4. Collections of pus in the rectouterine fossa can be drained is passed into the ureter through the urinary bladder. A
through the posterior fornix of the vagina. suitable radio-opaque solution (of sodium iodide) is injected
into the ureter and reaches the renal pelvis. These are outlined
much more clearly than with excretory pyelography.
SOME COMMON RADIOLOGICAL Angiography
PROCEDURES USED FOR THE ABDOMEN There have been many advances in techniques for visualising
blood vessels of different organs. A suitable radio-opaque
dye injected into the femoral artery under high pressure
Any radiological procedure in the abdomen should be preceded
enters the aorta (against the direction of blood flow) and
by careful preparation of the patient. The objective of
outlines the aorta. A more sophisticated method is to
preparation is to remove gas and faecal matter from the
introduce a catheter into the femoral artery and pass it up
intestines as they cast shadows that may obscure significant
into the aorta. The tip of the catheter can be guided into a
findings. This is achieved by restricting feeding for some hours,
large branch e.g., the coeliac trunk and dye can be injected
and by the use of laxatives and substances that absorb gas (e.g.
directly into the artery and its branches. After a short interval
charcoal tablets).
the dye passes into venous blood (venous filling phase) and
Plain skiagram the veins are then seen.
A plain skiagram shows shadows of bones in the region. Some
soft tissues also cast faint shadows. The domes of the diaphragm
can be made out. The psoas major muscle, the kidneys the liver
NEWER IMAGING TECHNIQUES
and the spleen may cast light shadows. Swallowed air present
in the fundus of the stomach is usually seen under the left dome
Investigation of the abdomen (and other parts of the body)
of the diaphragm.
has been revolutionised in recent years by the introduction
Barium meal of several new techniques. The following are now in common
Skiagrams taken after administering a barium meal (barium use.
sulphate suspension) can reveal many details about the mucosa
Ultrasonography
of the stomach, the duodenum and the small intestine. The
The principle of the method is that ultrasound waves applied
pattern of mucosal folds in the stomach can be seen. Barium
to any part of the body are reflected back by various
filling the first part of the duodenum casts a characteristic
structures. The reflected waves can be picked up and
shadow that is referred to as the duodenal cap. Mucosal folds
visualised on a screen. Images of internal organs can be
in the distal part of the duodenum and in the jejunum producing
obtained in this way.
a feathery appearance. The large intestine show characteristic
haustrations. Computed Tomography
The term tomography has been applied to radiological
Barium enema
methods in which tissues lying in a particular plane are
A barium sulphate suspension can be introduced into the large
visualised.
intestine through the anus. The large intestine is much better
visualised than with a barium meal.
313
314
In recent years a technique has been developed in which images resonance in different tissues. These differences can be
at a series of levels are analysed using computers. Such analysis recorded using sophisticated machines and result in images
provides images giving a remarkable degree of detail. of outstanding clarity. The degree of detail seen in a good
MRI is just like seeing the actual structures in an anatomical
Magnetic Resonance Imaging
cross section.
It has been observed that if some radioactive materials are
injected into the body, they induce a specific magnetic
BONES OF THE HEAD AND NECK
PART 5:HEAD AND NECK
35 : Bones of the Head and Neck
VERTEBRAL COLUMN b. The vertebral bodies are small in the cervical vertebrae. In
shape the body is oval. The upper surface of the body is
concave from side to side: the posterolateral parts of its edge
The structure of a typical vertebra has been considered earlier.
are raised to form distinct lips. As a result of this the superior
Here we will consider some additional features of typical
vertebral notch is prominent.
cervical vertebrae, and also some atypical cervical vertebrae.
c. The pedicles are long and directed backwards and laterally.
d. The laminae of cervical vertebrae are long (transversely)
and narrow (vertically).
Typical Cervical Vertebrae (Fig. 35.1) e. The spinous processes are short and bifid.
f. In the cervical region the articular facets are flat. The
a. The transverse processes of a typical cervical vertebra is superior facets are directed equally backwards and upwards.
pierced by a foramen transversarium. It is relatively short. The inferior facets are directed forwards and downwards.
The part of the process in front of the foramen is called the The superior and inferior articular processes form a solid
anterior root; and the part behind it is called the posterior root articular pillar that helps to transmit some weight from one
(Fig. 35.2). The part lateral to the foramen is usually called the vertebra to the next lower one.
costo-transverse bar, but it is more correct to call it the
intertubercular bar. The anterior and posterior roots end in
thickenings called the anterior and posterior tubercles ATYPICAL CERVICAL VERTEBRAE
respectively. When viewed from the lateral side the transverse
process is seen to be grooved. The cervical nerves lie in these
grooves after they pass out of the intervertebral foramina. In The Atlas (First Cervical) Vertebra
the cervical region the costal element forms the anterior root,
the costotransverse bar, and both the anterior and posterior The first cervical vertebra is called the atlas. It looks very
tubercles. different from a typical cervical vertebra as it has no body,
Fig. 35.2. Cervical transverse processes showing the

Fig. 35.1. Typical cervical vertebra seen from above. parts derived from the costal elements (red shading).
315
316
Fig. 35. 3. The atlas (first cervical vertebra) seen Fig. 35.4. The atlas (first cervical vertebra) seen
from above from below.
and no spine (Figs 35.3 and 35.4). It consists of two lateral masses and the arches) into anterior and posterior parts.
masses joined anteriorly by a short anterior arch, and The posterior part corresponds to the vertebral foramen of a
posteriorly by a much longer posterior arch. The arches give typical vertebra: the spinal cord passes through it. The
the atlas a ring like appearance. A large transverse process, anterior part is occupied by the dens (which is an upward
ESSENTIALS OF ANATOMY : HEAD AND NECK
pierced by a foramen transversarium, projects laterally from projection from the body of the axis). The dens articulates
the lateral mass. The superior aspect of each lateral mass shows with the posterior aspect of the anterior arch, that bears a
an elongated concave facet that articulates with the circular facet for it. The dens also articulates with the
corresponding condyle of the occipital bone (to form an transverse ligament, these two articulations collectively
atlanto-occipital joint). Nodding and lateral movements of forming the median atlanto-occipital joint. In side to side
the head take place at the two (right and left) atlanto-occipital movements of the head the atlas moves with the skull around
joints. The inferior aspect of each lateral mass (Fig. 35.4) shows the pivot formed by the dens.
a large oval facet for articulation with the corresponding The anterior arch bears a small midline projection called the
superior articular facet of the axis (second cervical vertebra) to anterior tubercle. The posterior arch bears a similar projection,
form a lateral atlanto-axial joint. The medial side of the lateral the posterior tubercle, which may be regarded as a
mass shows a tubercle that gives attachment to the transverse rudimentary spine. The upper surface of the posterior arch
ligament of the atlas (shown in dotted line in Figure 35.3). This has a groove for the vertebral artery. The groove is
ligament divides the large foramen (bounded by the lateral continuous laterally with the foramen transversarium.
Some Relations of the Atlas
1. The vertebral artery passes upwards through the foramen
transversarium and then runs medially on the groove over
the posterior arch.
2. The first cervical nerve crosses the posterior arch deep to
the vertebral artery and divides here into anterior and
posterior primary rami.
3. Structures passing through the vertebral canal include the
spinal cord, the meninges, the spinal part of the accessory
nerve, and the anterior and posterior spinal arteries.
The Axis (Second Cervical) Vertebra
The most conspicuous feature of the axis, that distinguishes

it from all other vertebrae, is the presence of a thick finger
like projection arising from the upper part of the body. This
Fig. 35.5. The second cervical vertebra (axis) seen from the
posterosuperior aspect.
projection is called the dens, or odontoid process (Fig. 35.5).
We have already seen that the dens fits into the space between
arch. Its posterior aspect shows a transverse groove for the
transverse ligament.
On either side of the dens the axis vertebra bears a large
oval facet for articulation with the corresponding facet on
the inferior aspect of the atlas. The transverse process of
the axis lies lateral to this facet. It is small and ends in a
single tubercle corresponding to the posterior tubercle of a
typical cervical vertebra. The transverse process is pierced
by a foramen transversarium.
The Seventh Cervical Vertebra
The seventh cervical vertebra differs from a typical vertebra

in having a long thick spinous process that ends in a single
tubercle (Fig. 35.6). The tip of the process forms a prominent
surface landmark. Because of this fact this vertebra is
Fig. 35.6. Seventh cervical vertebra seen from above.
referred to as the vertebra prominens. The transverse
processes are also large and have prominent posterior
the anterior arch of the atlas and its transverse ligament to form tubercles.
the median atlanto-occipital joint. The anterior aspect of the Note that the vertebral artery and vein do not traverse the
dens bears a convex oval facet for articulation with the anterior foramen transversarium of this vertebra.
THE SKULL
The skull forms the skeleton of the head. It is a difficult part of The cranium consists of two main parts. Its upper and
the skeleton to study as there are a very large number of named posterior part contains a large cranial cavity in which the
features on it, and many of these are difficult to identify. Here brain lies. Anteriorly, and inferiorly, the cranium forms the
we will confine ourselves only to the most important features. skeleton of the face including the walls of the orbits (in which
As the skull is rounded we have to examine it from all sides. the eyeballs lie), the cavity of the nose, and the upper part of
For the same reason many features are seen from more than the cavity of the mouth. The upper dome-like part of the
one side. skull is called the vault or skull cap. It forms the upper,
The bone forming the lower jaw is called the mandible. The lateral, anterior and posterior walls of the cranial cavity. Note
other bones of the skull are firmly united to one another at joints that its anterior wall forms the forehead. The part of the skull
called sutures: these bones collectively form the cranium. forming the floor of the cranial cavity is called the base.
(Cranium = skull minus mandible).
317
318
Skull seen from above
Looking at the skull from above (Fig. 35.7) we see

four bones. The bone forming the anterior part of the
vault is the frontal bone. The greater part of the roof
and side walls of the cranial cavity are formed by the
right and left parietal bones. The two parietal bones
meet in the midline at the sagittal suture. Their
anterior margins join the frontal bone at the coronal
suture that runs transversely across the vault. The
posterior part of the vault is formed by the occipital
bone. The suture joining the occipital bone to the
parietal bones is shaped like the Greek letter lambda
(that is like an inverted Y). It is, therefore, called
the lambdoid suture.
The point where the coronal and sagittal sutures meet
is called the bregma, while the point where the sagittal
suture meets the lambdoid suture is called the lambda.
In the fetal skull (and for a few months after birth)
there are gaps in the bones of the skull in these
situations, these being filled by membranes. These
gaps are called the anterior and posterior fontanelles.
Examination of the parietal bone shows that in one
area it is more convex than at other places: this area
is called the parietal tuber (or parietal eminence). Fig. 35.7. Skull viewed from above.
Skull seen from behind Inferior to the orbit there is the maxilla (upper jaw) bearing
the upper teeth. Near the middle line we see the nasal
When we view the skull from behind we see many features aperture that leads into the nasal cavity. Just above the nasal
seen from the top (Fig. 35.8). Now we see more of the occipital aperture we see the right and left nasal bones. Some other
bone, and lateral to it we see a small part of the temporal bone. features to be seen are as follows.
Near the middle of the occipital bone we see a median 1. A little above the orbit the frontal bone is more convex
projection called the external occipital protuberance. than elsewhere. This area is the frontal eminence.
Extending laterally from the protuberance we see a curved ridge 2. The upper margin of the orbit is formed by the frontal
called the superior nuchal line. Extending downwards (and bone. Near its medial end the margin shows the supraorbital
forwards) from the protuberance we see
a median ridge called the external
occipital crest. Extending laterally
from the crest we see the inferior
nuchal line. A little above the superior
nuchal lines we see the highest nuchal
lines (running parallel to the former).
Skull seen from the front
The skull is viewed from the front in

Figure 35.9A. (The mandible is not
included). The region of the forehead
is formed by the anterior part of the
frontal bone. A small part of the parietal
bone can be seen. Just below the frontal
bone we see the opening into the orbit
(shown in white). Lateral to the orbit
we see a part of the temporal bone
(purple) and the zygomatic bone (blue). Fig. 35.8. Features seen on the skull when viewed from behind.
notch. Medial to it there is a smaller frontal notch (or foramen). The Orbit
3. The lateral margin of the orbit is formed by the zygomatic
process of the frontal bone, above; and by the frontal process The interior of the orbit is shown in Figure 35.9. Confirm the
of the zygomatic bone, below. facts already mentioned about the orbital margin.
4. The medial margin of the orbit is formed by the nasal process
Walls of the Orbit
of the frontal bone, above; and by the frontal process of the
Each orbit is shaped like a pyramid. The orbital opening
maxilla, inferiorly.
represents the base of the pyramid, while the apex lies at
5. The inferior margin of the orbit is formed by the zygomatic
the posterior end. The orbit has a roof, a floor, a medial wall
bone that is joined by the zygomatic process of the maxilla.
and a lateral wall; but these are not sharply marked off from
6. A little below the orbital margin the anterior surface of the
one another.
maxilla shows the infraorbital foramen. On the lateral surface
The roof is formed mainly by the orbital plate of the frontal
of the zygomatic bone we see a zygomatico-facial foramen.
bone. Posteriorly, a small part of it is formed by the lesser
7. Through the nasal aperture we can see some bones that lie
wing of the sphenoid. The anterolateral part of the roof has
within the nasal cavity. In the midline note the ethmoid bone
a depression called the lacrimal fossa. Close to the orbital
and the vomer. These form part of the nasal septum. Laterally
margin, at the junction of the roof and medial wall, there is
we see two curved plates, the middle and inferior nasal conchae
a small depression called the trochlear fossa.
projecting into the nasal cavity.
The floor is formed mainly by the maxilla. (This part of the
8. Each maxilla bears eight teeth. Beginning from the midline
maxilla is its orbital surface). The anterolateral part of the
there are two incisors, one canine, two premolars, and three
floor is formed by the zygomatic bone.
molars. The part of the maxilla that bears the teeth is called the
The lateral wall is formed, in its anterior part by the
alveolar process.
zygomatic bone, and in its posterior part by the greater wing
of the sphenoid.
Fig. 35.9A. Skull seen from the front.
319
320
Fig. 35.9B. Orbit and surrounding structures.
The medial wall is formed mainly by the orbital plate of the Skull seen from lateral side (Fig. 35.10)
ethmoid. Anterior to the ethmoid the medial wall is formed by
the lacrimal bone, and by the frontal process of the maxilla. First identify the various bones seen. Most of them have
The region of the medial wall formed by the lacrimal bone and already been seen from other aspects. Identify the frontal
by the maxilla shows a deep lacrimal groove (for the lacrimal bone forming the region of the forehead; the parietal bone
sac). The groove is continuous, inferiorly, with the nasolacrimal forming the vault behind the frontal bone; the occipital bone
canal, the lower end of which opens into the nasal cavity. at the posterior end of the skull; and the maxilla bearing the
Apertures in the Orbit upper teeth.
The superior orbital fissure is a prominent cleft that separates Below the parietal bone we see the temporal bone. Just in
the posterior parts of the roof and lateral wall. It is bounded front of the temporal bone we see the greater wing of the
above and medially by the lesser wing of the sphenoid; and sphenoid bone, and further anteriorly we see the zygomatic
below and laterally by the greater wing. Medial to it, at the bone.
apex of the orbit, there is the opening of the optic canal. Additional features to be identified are as follows:
The inferior orbital fissure intervenes between the posterior 1. Running across the frontal, parietal and temporal bones
parts of the floor and the lateral wall of the orbit. It is bounded we see two C-shaped temporal lines. Anteriorly, there is
above and laterally by the greater wing of the sphenoid, and only one line, but over the parietal bone superior and inferior
below and medially by the orbital surface of the maxilla. The lines can be distinguished. At its anterior end the line
fissure is continuous anteriorly with the infraorbital groove becomes continuous with the sharp lateral edge of the
on the maxilla. Anteriorly, the groove ends in a canal that passes zygomatic process of the frontal bone. The superior temporal
through the bony substance of the maxilla to open on the surface line fades away over the posterior part of the parietal bone.
through the infraorbital foramen. The inferior line curves forwards and reaches the zygomatic
arch (see below).
Fig. 35.10. Skull seen from lateral side.
2. The oval area enclosed by the temporal line is called the 5. A little in front of the external acoustic meatus there is a
temporal fossa. Note that its floor is formed by the temporal, depression, the mandibular fossa, into which the head of
parietal, and frontal bones and by the greater wing of the the mandible fits, to form the temporo-mandibular joint.
sphenoid. These four bones meet within a small area (shown as 6. The shape of the zygomatic bone is best appreciated from
a circle) that is called the pterion. the lateral side. Note its articulations with the frontal bone,
3. The zygomatic arch is a bar of bone lying horizontally over the temporal bone and the maxilla. The bone also has a
the lateral aspect of the skull. There is a gap between it and the temporal surface directed towards the temporal fossa.
floor of the temporal fossa. The posterior part of the arch is 7. When we view the skull from the lateral side we see some
formed by the zygomatic process of the temporal bone, and parts of the sphenoid bone. The greater part of the bone lies
the anterior part by the temporal process of the zygomatic bone. in the base of the skull. Here we see the greater wing forming
4. Just below the posterior end of the zygomatic arch there is a part of the floor of the temporal fossa. (We have already
large oval aperture. This is the external acoustic meatus. It seen that the greater wing takes part in forming the lateral
leads into the ear. The meatus is surrounded by a plate of bone wall of the orbit).
with an irregular surface. This plate belongs to the tympanic Another part of the sphenoid bone that is seen from the lateral
part of the temporal bone. side is the pterygoid process, which is made up of medial
Just behind the external acoustic meatus there is a thick and lateral pterygoid plates. The pterygoid process comes
downward projection called the mastoid process. This process into contact with the posterior aspect of the maxilla.
forms the mastoid part of the temporal bone. A little below The infratemporal fossa is a space that lies lateral to the
the external acoustic meatus there is a pin-like process directed pterygoid process. Its roof is formed by the infratemporal
downwards and forwards. This is the styloid process, which is surface of the greater wing of the sphenoid. The
also a part of the temporal bone. Running medially into the infratemporal fossa communicates with the temporal fossa
base of the skull (seen from below) we see yet another part of through the gap between the zygomatic arch and the side of
the temporal bone. This is the called the petrous part, as it is the skull. The anterior wall of the infratemporal fossa is
stone like. The greater part of the ear lies within the petrous formed by the posterior surface of the maxilla.
part of the temporal bone.
321
322
Skull seen from below
(Base of skull)
When the skull is viewed from

below (Fig. 35.11) we see parts of
several bones already identified.
These are the maxilla (pink), the
sphenoid (purple), the temporal
(green) and the occipital bone (blue).
We also see parts of the zygomatic
bone, of the vomer; and the palatine
bone (yellow) that is seen for the
first time.
The maxillae bear the upper teeth.
Lateral to the teeth a part of the
maxilla is seen articulating with the
zygomatic bone. Medial to the teeth
the maxilla forms the anterior part
of the bony palate. The posterior
part of the palate is formed by the
right and left palatine bones. Above
the posterior edge of the palate we
see the posterior openings of the
right and left nasal cavities that are
separated by the vomer.
Behind the vomer we see the

sphenoid, which is an unpaired
bone. It has a median part, the body.
On either side of the body there is a
greater wing (that is seen partly on
the base of the skull and partly on
the lateral wall). Posteriorly, the
body of the sphenoid is continuous
with the basilar part of the occipital
bone. Just behind the basilar part the
occipital bone has a large foramen,
the foramen magnum through
which the cranial cavity
communicates with the vertebral
canal. Posterior to the foramen
magnum the occipital bone forms a Fig. 35.11. Skull as seen from below.
large part of the base of the skull.
The lateral part of the base of the skull is formed by the temporal separates the nasal cavities (above) from the cavity of the
bone that is wedged in between the sphenoid and occipital mouth (below). The anterior part of the palate is formed by
bones. Portions of the petrous part, the squamous part and the the palatal processes of the right and left maxillae. The
mastoid part are seen on the base of the skull. The zygomatic part of the alveolar process bearing the incisor teeth, and
arch is seen from below. Note the gap between it and the side including the adjoining part of the palate is called the
of the skull. premaxilla.
We shall now examine the features to be seen on each of these Lateral to the alveolar arch we see the inferior aspect of the
bones when the skull is viewed from below. zygomatic process of the maxilla as it passes laterally to
A. Note the following in Figure 35.12. meet the zygomatic bone. We also see the posterior surface
1. The alveolar process of the maxilla projects downwards of the maxilla which is separated (posterolaterally) from the
and provides attachment to the upper teeth. The posterior end greater wing of the sphenoid by the inferior orbital fissure.
of each alveolar process forms a backward projection called The posterior part of the palate is formed by the palatine
the maxillary tuberosity. Within the concavity of the arch bones. This part of each palatine bone is called the horizontal
formed by the alveolar process we see the bony palate that plate. The posterior borders of the horizontal plates of the
Fig. 35.12. Anterior part of skull seen from below.
palatine bones are free and form the posterior margin of the When viewed from below the body of the sphenoid is seen
hard palate. A little in front of the posterior border we see a in the roof of the posterior part of the nasal cavity and of the
curved ridge called the palatine crest. adjoining nasopharynx. Posteriorly, the body of the sphenoid
The part of the palate formed by the palatine bone shows the is directly continuous with the basilar part (or body) of the
greater and lesser palatine foramina. The greater palatine occipital bone.
foramen lies on the most lateral part of the horizontal plate, The pterygoid process projects downwards from the junction
just medial to the last molar tooth. It is the lower opening of the of the body of the sphenoid with the greater wing. It consists
canal of the same name. The lesser palatine foramina, usually of medial and lateral pterygoid plates. These plates meet
two, are present just behind the greater palatine foramen. anteriorly, but posteriorly they are free. The space between
Just above the posterior margin of the hard palate there are two them is called the pterygoid fossa. Anteriorly, the pterygoid
posterior nasal apertures. Each aperture is bounded, below, process is fused to the posterior aspect of the maxilla in its
by the posterior edge of the horizontal plate of the palatine
bone. The lateral wall of the aperture is formed by another part
of the palatine bone that is called the perpendicular plate. The
perpendicular plate and the medial pterygoid plate of the
sphenoid bone together form the lateral wall of the region where
the nose and pharynx meet.
The vomer is a flat plate of bone that forms part of the nasal
septum. It has been seen through the anterior nasal aperture
(Fig. 35.9A).
B. Note the following features to be seen on the sphenoid bone
in Figures 35.12 to 35.14.
The sphenoid bone is large, extending across the entire width
of the base of the skull and extending also onto the lateral wall
of the vault. It is made up of several parts that have already
been encountered. These are the body (that is median in
position), the right and left greater and lesser wings, and the Fig. 35.13. Schematic coronal section to show
right and left pterygoid processes. relationship of pterygoid process to the rest of the
sphenoid bone.
323
324
Fig. 35.14. Part of base of skull formed by temporal and sphenoid bones.
middle part. Higher up it is separated from the maxilla by the bone. Two important foramina are seen near the posterior
pterygomaxillary fissure. border of the greater wing. The foramen ovale lies
The medial pterygoid plate is directed backwards so that it posterolateral to the upper end of the lateral pterygoid plate.
has medial and lateral surfaces, and a free posterior border. Posterolateral to the foramen ovale there is a smaller round
The lower end of the posterior border is prolonged downwards foramen called the foramen spinosum. It is so called because
and laterally to form the pterygoid hamulus. it lies just in front of a downward projection called the spine
The lateral pterygoid plate projects backwards and laterally. of the sphenoid. Posteromedial to these foramina, and to
It has medial and lateral surfaces. At its upper end its lateral the spine of the sphenoid, the posterior margin of the greater
surface becomes continuous with the infratemporal surface of wing forms the anterior wall of a prominent groove. The
the greater wing (Figs 35.13 and 35.14). posterior wall of this groove is formed by the petrous
The greater wing of the sphenoid (Fig. 35.14) has temporal bone. The two bones meet in the floor of the groove
infratemporal and temporal surfaces that can be seen from that is meant for the cartilaginous part of the auditory tube.
below; and an orbital surface that has been seen in the lateral Traced laterally, the groove ends in relation to the opening
wall of the orbit (Fig. 35.9B). The anterior margin of the of the bony part of the auditory tube.
infratemporal surface is separated from the maxilla by the
inferior orbital fissure. Laterally, the infratemporal surface is
C. Additional features on the temporal and occipital bones
separated from the temporal surface by the infratemporal crest.
The posterior margin of the lateral part of the infratemporal (Figs 35.14 and 35.15).
surface articulates with the infratemporal surface of the The squamous part of the temporal bone has a temporal
squamous part of the temporal bone. surface that has been seen from the lateral aspect: part of it
Medially, the infratemporal surface of the greater wing is can be seen from below. Inferior and medial to the temporal
continuous with the body of the sphenoid. Posteriorly, the surface the squamous part has an infratemporal surface that
greater wing meets the anterior margin of the petrous temporal takes part in forming the roof of the infratemporal fossa (along
Fig. 35.15. Posterior part of the base of the skull formed by the
temporal and occipital bones.
with the infratemporal surface of the greater wing of the the petrous temporal bone and opens into the posterior wall
sphenoid). Behind its infratemporal surface, the squamous part of the foramen lacerum. Behind the opening of the carotid
bears the mandibular fossa. This fossa is bounded anteriorly canal there is another large depression, the jugular fossa.
by a rounded eminence called the articular tubercle. The This fossa leads posteriorly into the jugular foramen that
articular area for the mandible extends on to the tubercle. is bounded posteriorly and below by the occipital bone,
The tympanic plate separates the mandibular fossa from the and opens into the posterior cranial fossa.
external acoustic meatus. (The arrow in Figure 35.14 points to In the mastoid part of the temporal bone we have already
the opening of the meatus that cannot be seen from below). noted the presence of the mastoid process. Medial to the
The junction of the fossa (squamous part) with the tympanic mastoid process there is a deep mastoid notch. Near the
plate is marked by the squamotympanic fissure. anterior end of the notch, and just behind the styloid process
Projecting through the fissure we sometimes see the lower edge we see the stylomastoid foramen.
of a plate of bone called the tegmen tympani. The posterior
The greater part of the occipital bone is seen when the skull
part of the tympanic plate partially surrounds the base of the
is viewed from below. The most conspicuous feature on it is
styloid process.
the large foramen magnum through which the cranial cavity
The petrous part of the temporal bone runs forwards and
communicates with the vertebral canal. The part of the bone
medially between the greater wing of the sphenoid
(anterolaterally), and the occipital bone (posteromedially). Its anterior to the foramen magnum is the basilar part.
apex is separated from the body of the sphenoid, the root of the Anteriorly, the basilar part of the occipital bone is directly
pterygoid process, and the basilar part of the occipital bone by continuous with the body of the sphenoid bone. These two
a very irregular aperture called the foramen lacerum. The bones are separated by a plate of cartilage in the young, but
inferior surface of the petrous temporal bone is marked by a fuse with each other in the adult.
large round aperture. This is the lower opening of the carotid The parts of the occipital bone lateral to each side of the
canal through which the internal carotid artery enters the cranial foramen magnum are its lateral (or condylar) parts. Here
cavity. The canal passes medially, through the substance of we see the prominent occipital condyles.
325
326
Each condyle (right or left) articulates with the corresponding divided into three depressions called the cranial fossae:
superior articular facet on the atlas vertebra to form an atlanto- anterior, middle, and posterior.
occipital joint. There are two canals closely related to the The floor of the anterior cranial fossa (Fig. 35.16) is formed
occipital condyles. The hypoglossal (or anterior condylar) mainly by the orbital plates (right and left) of the frontal
canal opens on the surface of the skull just above the lateral bone. Anteriorly, the right and left halves of the frontal bone
border of the anterior part of the condyle, and is hidden from are separated by a median projection called the frontal crest.
view by the condyle. The canal runs backwards to open into Just behind the crest there is a depression called the foramen
the posterior cranial fossa. Behind the condyle there is a caecum.
depression, the condylar fossa in which the opening of the Between the right and left orbital plates of the frontal bone
posterior condylar canal is sometimes seen. there is a notch occupied by the cribriform plate of the
The part of the occipital bone lateral to the condyle is called ethmoid bone. This plate has numerous foramina. It also
the jugular process. It forms the posterior (and inferior) wall bears a median vertical projection called the crista galli that
of the jugular fossa and foramen. The jugular foramen passes lies immediately behind the foramen caecum. The posterior
backwards and medially from the fossa. It is often partially part of the floor of the anterior cranial fossa is formed by the
divided into anterior, middle and posterior parts. sphenoid bone. In the median part it is formed by the anterior
The part of the occipital bone behind the foramen magnum is part of the superior surface of the body of the sphenoid.
the squamous part. Posteriorly, the squamous part forms the Laterally, the floor is formed by the lesser wing of the
posterior part of the vault of the skull. Its external surface is sphenoid. The lesser wing also forms the sharp posterior
marked by the external occipital protuberance; the external edge of the floor of the anterior cranial fossa. The medial
occipital crest; the inferior, superior and highest nuchal lines; edge of each lesser wing projects backwards as the anterior
and by numerous unnamed ridges that give it a rough surface clinoid process.
for muscular attachments. The middle cranial fossa (Figs 35.16 and 35.17) has a raised
median part formed by the body of the sphenoid bone, and
two large deep hollow areas on either side. The features to
The Cranial Fossae be seen in relation to the body of the sphenoid are as follows.
Immediately behind the jugum sphenoidale the body of the

When the top of the skull (skull cap) is removed by a transverse sphenoid is crossed by a transverse shallow groove that
cut we can view the floor of the cranial cavity. It is seen to be connects the two optic canals. It is called the sulcus
Fig. 35.16. Parts of the anterior and middle cranial fossae seen from above.
Fig. 35. 17. Floor of.middle and posterior cranial fossae.
chiasmaticus (even though the optic chiasma does not lie over optic canal passes forwards and laterally between the body
the sulcus). Behind the sulcus the superior surface of the body of the sphenoid and the two roots of the lesser wing. The
of the sphenoid shows a median elevation, the tuberculum greater and lesser wings are separated by the superior orbital
sellae; and behind the tuberculum there is a depression called fissure that leads into the orbit. Just below the medial end
the hypophyseal fossa. Posterior to the fossa there is a vertical of the fissure, and just lateral to the carotid groove we see
plate of bone called the dorsum sellae. The deep hollow the foramen rotundum. This foramen opens anteriorly into
bounded anteriorly by the tuberculum sellae, and posteriorly the pterygopalatine fossa.
by the dorsum sellae is called the sella turcica. The superolateral The posterior wall of the middle cranial fossa is formed, on
angles of the dorsum sellae are called the posterior clinoid either side, by the anterior sloping surface of the petrous
processes. On each side the body of the sphenoid slopes temporal bone. The apex of the bone is separated from the
downwards into the floor of the deep lateral part of the middle body of the sphenoid by the foramen lacerum already seen
cranial fossa. In this situation each side of the body of the from below. A little above and lateral to the foramen the
sphenoid is marked by a shallow carotid groove. Posteriorly, surface of the petrous temporal bone shows a shallow
the groove becomes continuous with the foramen lacerum. depression called the trigeminal impression. The anterior
Anteriorly, it turns upwards medial to the anterior clinoid surface of the petrous temporal bone is formed by a thin
process. plate of bone that separates the middle cranial fossa from
On either side, the anterior wall of the middle cranial fossa is the cavities of the middle ear, the auditory tube and the
formed by the greater and lesser wings of the sphenoid. The mastoid antrum. This plate is called the tegmen tympani.
lesser wings are attached to the sides of the body of the sphenoid The floor of the deep lateral part of the middle cranial fossa
by two roots: anterior (or upper), and posterior (or lower). The is formed by the greater wing of the sphenoid, medially, and
327
328
by the squamous part of the temporal bone, laterally. Near the structures like cranial nerves, large blood vessels etc. These
posterior margin of the greater wing we see the foramen ovale, are listed below.
and the foramen spinosum that have already been seen from 1. The lower end of the medulla oblongata passes through
below. The lateral wall of the middle cranial fossa is formed, the foramen magnum to become continuous with the spinal
anteriorly, by the greater wing of the sphenoid, and posteriorly cord. Other important structures passing through the
by the squamous temporal bone. foramen magnum are the vertebral arteries and the spinal
The most prominent landmark in the posterior cranial fossa part of the accessory nerve.
(Fig. 35.17) is the foramen magnum already seen from below. 2. The internal carotid artery enters the skull by passing
Anterior to the foramen magnum the wall of the fossa is formed through the carotid canal.
by the basilar part of the occipital bone that is continuous 3. The junction of the upper end of the internal jugular vein
above with the posterior surface of the body of the sphenoid. with the sigmoid sinus lies in the jugular foramen.
The lateral margin of the basilar part of the occipital bone is 4. Bundles of nerve fibres that constitute the olfactory nerve
separated from the petrous temporal bone by a fissure that pass through minute apertures in the cribriform plate of the
ends below in the jugular foramen. ethmoid bone. This plate intervenes between the nasal cavity
Between the jugular foramen, laterally, and the anterior part and the anterior cranial fossa.
of the foramen magnum, medially, there is a rounded elevation 5, The optic nerve passes from the middle cranial fossa into
called the jugular tubercle. In the interval between the jugular the orbit through the optic canal.
tubercle and the foramen magnum there is a fossa. The
6. The oculomotor, trochlear and abducent nerves enter the
hypoglossal canal opens into this fossa. When present, the
orbit through the superior orbital fissure.
posterior condylar canal opens just lateral to the jugular
7. The trigeminal nerve has three divisions each of which
tubercle immediately behind the jugular foramen. The lateral
leaves the middle cranial fossa through a different foramen.
part of the anterior wall of the posterior cranial fossa is formed
The ophthalmic division enters the orbit through the superior
by the posterior surface of the petrous temporal bone. A little
orbital fissure. The maxillary division passes into the
above the jugular foramen this surface presents the opening of
the internal acoustic meatus. The floor and lateral walls of foramen rotundum, while the mandibular division passes
the posterior cranial fossa are formed, posteriorly, by the through the foramen ovale to reach the infratemporal region.
squamous part of the occipital bone; and in the anterolateral 8. The facial nerve leaves the posterior cranial fossa by
part by the mastoid part of the temporal bone. Behind the passing into the internal acoustic meatus. After a
foramen magnum the two halves of the fossa are separated by complicated course through the petrous part of the temporal
a ridge called the internal occipital crest. Posteriorly, the crest bone, it emerges on the external surface of the skull through
ends in an elevation called the internal occipital protuberance. the stylomastoid foramen.
Running laterally from the protuberance, in the transverse 9. The vestibulocochlear nerve leaves the posterior cranial
plane, we see a prominent wide groove (transverse sulcus) in fossa by passing through the internal acoustic meatus, to
which the transverse sinus is
lodged. The groove first lies
on the occipital bone, and
near its lateral (or anterior) end
it crosses the posteroinferior
angle of the parietal bone. It
then runs downwards and
medially with an S-shaped
curve to reach the jugular
foramen. This S-shaped part
of the groove is called the
sigmoid sulcus. The terminal
part of the groove lies on the
occipital bone just behind the
jugular foramen.
Foramina of the Skull
The bones of the skull show

numerous foramina, small and
large. The most important
foramina are those that give
passage to very important Fig. 35.18. Lateral wall of nasal cavity.
reach the internal ear. The internal ear lies within
the substance of the petrous part of the
temporal bone.
10. The glossopharyngeal, vagus and
accessory nerves leave the posterior cranial
fossa through the jugular foramen, to enter
the neck.
11. The hypoglossal nerve leaves the posterior
cranial fossa through the hypoglossal canal.
The Nasal Cavity
The nasal cavity consists of right and left

halves that are separated by a nasal septum
(Figs 35.18 and 35.19). The cavity opens,
anteriorly, on the front of the skull through the
anterior nasal aperture; and, posteriorly, on the
base of the skull just above the posterior edge
of the bony palate, through the right and left Fig. 35.19. Main bones taking part in forming the nasal septum.
posterior nasal apertures. Each half of the
cavity has a lateral wall, a medial wall formed by the septum, a the junction of the medial one-third with the lateral two-
floor formed by the upper surface of the palate, and a roof. thirds.
The formation of the lateral wall is complicated and we will not The sinus extends for some distance into the orbital plate of
go into details. The bones taking part in forming it are (a) the the frontal bone between the roof of the orbit and the floor
medial surface of the maxilla, (b) the palatine bone (perpendicular of the anterior cranial fossa. Each frontal sinus usually opens
plate); (c) the lacrimal bone; (d) the inferior nasal concha; and into the middle meatus through a funnel like space, the
(e) the ethmoid bone. ethmoidal infundibulum (Fig. 35.20) that is continuous with
The floor of the nasal cavity is formed by the upper surface of the upper end of the hiatus semilunaris.
the bony palate. Each half of the palate is formed anteriorly by The right and left sphenoidal sinuses are present in the body
the palatine process of the maxilla, and posteriorly by the of the sphenoid bone. Each sinus opens into the
horizontal plate of the palatine bone. corresponding half of the nasal cavity through an aperture
Several bones take part in forming the roof of the nasal cavity. on the anterior aspect of the body of the sphenoid. The part
From front to back these are parts of the nasal bone, the frontal of the nasal cavity into which the sinus opens lies above the
bone, the cribriform plate of the ethmoid and the anterior
surface of the body of the sphenoid bone.
The medial wall or nasal septum (Fig. 35.19) is formed in its
upper part by the perpendicular plate of the ethmoid bone,
and its lower part by the vomer. Anteriorly, there is a gap in
the septum that is filled in by cartilage. Around the edges of
the septum there are small contributions from the nasal,
frontal, sphenoid, maxillary and palatine bones.
The openings into the nasal cavity are described along with
those of the paranasal sinuses (See below).
The Paranasal Sinuses
The paranasal sinuses are spaces present in bones around

the nasal cavity, and into which they open (Fig. 35.20).
The maxillary sinus lies within the maxilla. It opens into
the middle meatus of the nasal cavity.
The right and left frontal sinuses are present in the frontal
bone. Each sinus lies deep to a triangular area the angles of Fig. 35.20. Position of the openings of paranasal sinuses
which lie (a) at the nasion, (b) at a point about 3 cm above into the nasal cavity.
the nasion, and (c) at a point on the supraorbital margin at
329
330
superior nasal concha and is called sphenoethmoidal recess THE MANDIBLE
(Fig. 35.20).
The ethmoidal air sinuses are located within the lateral part
The mandible is the bone of the lower jaw and bears the
(or labyrinth) of the ethmoid bone. Each labyrinth (right or left)
lower teeth (Figs 35.21 to 35.24). It consists of an anterior U-
is bounded medially by the medial plate of the ethmoid, and
shaped body, and of two rami (right and left) that project
laterally by the orbital plate. The ethmoidal air sinuses lie
upwards from the posterior part of the body. The bone has
between these plates. They can be divided into anterior, middle
internal (or medial) and external (or lateral) surfaces. The
and posterior groups.
body has an upper part that bears the teeth (alveolar process),
The anterior ethmoidal sinuses open into the ethmoidal
and a lower border that is called the base. The ramus has a
infundibulum, or into the upper part of the hiatus semilunaris.
posterior border, a sharp anterior border, and a lower border
The middle ethmoidal sinuses open on or near the bulla
that is continuous with the base of the body. The posterior
ethmoidalis. The posterior ethmoidal sinuses open into the
and inferior borders of the ramus meet at the angle of the
superior meatus.
mandible. The anterior border of the ramus is continued
Other Apertures in the Nasal Cavity
downwards and forwards on the lateral surface of the body
In addition to the anterior and posterior nasal apertures, as the oblique line. This line ends anteriorly near the mental
and the openings of the paranasal sinuses, we see the tubercle (see below). A little above the anterior part of the
following openings in the nasal cavity.
a. The nasolacrimal canal opens into the inferior meatus.
The upper end of this canal is seen in the orbit.
b. The sphenopalatine foramen opens behind the superior
meatus, just above the posterior end of the middle concha
(Fig. 35.18). This foramen lies in the medial wall of the
pterygopalatine fossa.
c. The nasal cavity communicates with the anterior cranial
fossa through numerous apertures in the cribriform plate of

the ethmoid bone.
d. In the anterior part of the floor of the nasal cavity there is
a funnel shaped opening that leads into the incisive canals
that open on the lower surface of the palate.
The Fontanelles
In the skull of the newborn, there are some gaps in the vault
Fig. 35.21. Mandible seen from lateral side.
of the skull that are filled by membrane. These gaps are
called fontanelles or fonticuli. They are located in relation
to the angles of the parietal bone as follows.
a. The anterior fontanelle lies at the junction of the sagittal,
coronal and frontal sutures. (Note that at birth the frontal
bone is in two halves that are separated by a frontal suture).
b. The posterior fontanelle is triangular. It lies at the junction
of the sagittal and lambdoid sutures.
c. The sphenoidal (anterolateral) fontanelle is present in
relation to the anteroinferior angle of the parietal bone,
where it meets the greater wing of the sphenoid.
d. The mastoid fontanelle (posterolateral) is present in
relation to the posteroinferior angle of the parietal bone
(that meets the mastoid bone).
The fontanelles disappear (by growth of the bones around
them) at different ages after birth.
Fig. 35.22. Right half of mandible seen

from the lateral side.
oblique line we see the mental foramen that lies
vertically below the second premolar tooth. Just
below the incisor teeth the external surface of the
ramus shows a shallow incisive fossa.
Arising from the upper part of the ramus there are
two processes. The anterior of these is the
coronoid process. It is flat (from side to side) and
triangular. The posterior or condylar process is
separated from the coronoid process by the
mandibular notch. The upper end of the condylar
process is expanded to form the head of the
mandible. The head is elongated transversely and
is convex both transversely and in an
anteroposterior direction. It bears a smooth
articular surface that articulates with the
mandibular fossa of the temporal bone to form the
temporomandibular joint. The part immediately
below the head is constricted and forms the neck.
Its anterior surface has a rough depression called
the pterygoid fovea. In Figure 35.22 the mandible Fig. 35.23. Attachments on mandible seen from lateral side.
is seen from the medial side. A little above the
centre of the medial surface of the ramus we see the mandibular 3. The temporalis is inserted into the medial surface of the
foramen. It leads into the mandibular canal that runs forwards coronoid process including its apex, and its anterior and
in the substance of the mandible. posterior borders.
The medial margin of the foramen is formed by a projection 4. The lateral pterygoid is inserted into the fovea on the
called the lingula. Beginning just behind the lingula and running anterior aspect of the neck.
downwards and forwards we see the mylohyoid groove. A little
5. The medial pterygoid is inserted into the medial surface
above and anterior to the mylohyoid groove, the inner surface
of the angle and the adjoining part of the ramus.
of the body of the mandible is marked by a ridge called the
6. The anterior belly of the digastric arises from the digastric
mylohyoid line. The posterior end of this line is located a little
fossa (on the anterior part of the base near the midline).
below and behind the third molar tooth. From here the line
7. The mylohyoid muscle arises from the mylohyoid line.
runs downwards and forwards to reach the symphysis menti
(see below). The mylohyoid line divides the inner surface of 8. The capsule of the temporomandibular joint is attached
the body of the mandible into a sublingual fossa (lying above along the margins of the articular surface.
the line), and a submandibular fossa (lying below the line). 9. The inferior alveolar nerve and vessels enter the
Just below the anterior end of the mylohyoid line the base of mandibular canal (that lies within the bone) through the
the mandible is marked by a deep digastric fossa. In the newborn mandibular foramen.
the mandible consists of right and left halves that are joined to 10. The mylohyoid nerve and vessels run forwards in the
each other at the symphysis menti; but in later life the halves mylohyoid groove.
fuse to form one bone. 11. The facial artery is closely related to the mandible. Its
When viewed from the front the region of the symphysis menti initial part lies deep to the ramus, near the angle. The artery
is usually marked by a slight ridge. Inferiorly, the ridge expands then runs downwards and forwards deep to the ramus. It
to form a triangular raised area called the mental protuberance. reaches the lower border of the body of the mandible at the
The lateral angles of the protuberance are prominent and anteroinferior angle of the masseter. The artery then runs
constitute the mental tubercles. upwards and forwards superficial to the body of the
The posterior aspect of the symphysis menti also shows a median mandible.
ridge the lower part of which is enlarged and may be divided 12. The lingual nerve is closely related to the medial aspect
into upper and lower parts called the mental spines or genial of the body just above the posterior end of the mylohyoid
tubercles. line.
Some Attachments and Relations of the Mandible 13. The sublingual gland lies over the sublingual fossa; and
1. The masseter is inserted into the lateral surface of the ramus the submandibular gland over the submandibular fossa. The
and of the angle. parotid gland is related to the upper part of the posterior
2. The buccinator arises from the outer surface of the body just border of the ramus.
below the molar teeth.
331
332
The Hyoid Bone
The hyoid bone is not a part of the skull,

but is considered here for sake of
convenience.
The hyoid bone is present in the front of
the upper part of the neck. It is not attached
to any other bone directly; but is held in
place by muscles and ligaments that are
attached to it. The most important of these
are the stylohyoid ligaments by which it is
suspended from the base of the skull.
The bone consists of a central part called
the body, and of two cornua (greater and
lesser) on either side (Figs 35.25 and 35.26).
The body is roughly quadrilateral. It has
an anterior surface and a posterior surface.
The greater cornua are attached to the
lateral part of the body, from which they
project backwards and laterally.
The lesser cornua are small and conical.
They project upwards and laterally from
the junction of the body and the greater
cornua. Fig. 35.24. Attachments on mandible seen from medial side.
origin of the middle constrictor), and from the lateral part of the
body.
g. The stylohyoid muscle is inserted into the upper surface of the
greater cornu near its junction with the body.
h. The thyrohyoid muscle is inserted into the anterior part of the
lateral border of the greater cornu.
Fig. 35.25. Hyoid bone seen from the front.
Some Attachments on the Hyoid Bone

a. The lowest fibres of the genioglossus
are inserted into the upper border of the
body of the bone.
b. The geniohyoid is inserted on the
anterior surface of the body.
c. The mylohyoid is inserted on the anterior
surface of the body below the insertion of
the geniohyoid.
d. The sternohyoid is inserted into the
medial part of the inferior border of the
body.
e. The superior belly of the omohyoid is
attached to the lateral part of the inferior
border of the body.
f. The hyoglossus arises from the upper
Fig. 35.26. Attachments on the hyoid bone
surface of the greater cornu (lateral to the
SCALP, FACE, PAROTID REGION AND LACRIMAL APPARATUS
36 : Scalp, Face, Parotid Region and
Lacrimal Apparatus
THE SCALP
The term scalp is applied to the soft tissues covering the vault
of the skull. The scalp extends anteriorly up to the eyebrows
(and, therefore, includes the forehead), posteriorly up to the
superior nuchal lines, and laterally up to the superior temporal
lines.
Layers of the Scalp
These are shown in Figure 36.1A and are as follows:

1. The most superficial layer is skin. Being hairy it contains
numerous sebaceous glands. The skin is closely united to
underlying tissues.
2. The superficial fascia is represented by dense connective Fig. 36.1. Scheme to show the layers of the scalp.
tissue that is firmly united to the skin and to the underlying
epicranial aponeurosis.
3. The third layer of the scalp is partly muscular and partly The majority of the fibres of the frontalis merge with the
fibrous. It corresponds to deep fascia. The greater part of this upper edge of the orbicularis oculi.
layer is formed by the epicranial aponeurosis (or galea
aponeurotica). The muscular part is formed by a muscle called Nerve Supply:
the occipito-frontalis (see below). The occipital part is supplied by the posterior auricular branch
4. The three layers of the scalp described above are firmly united of the facial nerve, and the frontal part by the temporal
to one another. All the three layers move together over the fourth branches of the same nerve.
layer that is made up of loose areolar tissue. The extent of the
Actions:
layer of loose connective tissue corresponds to the extent of
Acting alternatively, the frontal and occipital parts can move
the scalp itself. This layer is traversed by emissary veins passing
the scalp forwards and backwards over the vault of the skull.
from the scalp to intracranial venous sinuses.
5. The deepest layer of the scalp is the pericranium (which is
the periosteum over the bones of the vault of the skull). Blood vessels and nerves of the scalp
The arteries that supply the scalp are the supratrochlear
Occipito-Frontalis and supraorbital branches of the ophthalmic artery in front,
the anterior and posterior branches of the superficial
The occipito-frontalis covers the upper curved roof of the skull temporal artery laterally, and the occipital artery posteriorly.
(Figs 36.2). The muscle consists of a posterior occipital part The veins of the scalp accompany the corresponding
(or occipitalis), and an anterior frontal part (or frontalis). Each arteries.
of these is divided into a right half and a left half. These four The nerves of the scalp may be divided into motor nerves
parts are continuous with each other through the epicranial that supply the occipito-frontalis and sensory nerves that
aponeurosis. supply skin and other tissues of the scalp (Fig. 36.2).
Each occipital part arises from the occipital bone (lateral two- As stated above the motor nerves are the temporal and
thirds of the highest nuchal line). The fibres of the occipitalis posterior auricular branches of the facial nerve.
run upwards and forwards to end in the epicranial aponeurosis. The sensory nerves are as follows:
The occipital parts of the two sides are separated from each 1. In front there are the supratrochlear and supraorbital
other by a part of the epicranial aponeurosis. nerves, which are branches of the frontal nerve (which is
The frontal parts are attached posteriorly to the epicranial itself derived from the ophthalmic division of the trigeminal
aponeurosis. Anteriorly, the fibres have no bony attachment. nerve).
333
334
2. Laterally there are the zygomatico-temporal, the
auriculo-temporal, and great auricular nerves.
3. Posteriorly, there are the greater occipital, lesser
occipital, and third occipital nerves.
The blood vessels are described in Chapter 41 and
the nerves in Chapter 42. The lymphatic drainage
of the scalp is described in Chapter 46.
THE FACE
The External Nose

The prominence on the face that a layman refers
to as the nose is strictly speaking the external nose.
(The nasal cavities constitute the internal nose).
Certain descriptive terms applied to parts of the
external nose are as follows. The upper end (where
the nose becomes continuous with the forehead) is Fig. 36.2. Nerves and arteries of the scalp.
called the angle. The ridge-like free border passing
downwards from the angle is called the dorsum nasi. The The Eyelids and Conjunctiva
dorsum nasi ends below in a rounded prominence that forms The white of the eye is really a part of the outermost coat
the tip, or apex, of the nose. On either side the external nose of the eyeball that is called the sclera. The sclera is lined by
has lateral surfaces that are continuous behind with the cheeks.
a thin transparent membrane, the ocular conjunctiva. The

The lowest parts of the lateral surfaces are rounded and mobile: circular dark part in the centre is the iris. We see it through
these are called the alae nasi. The upper parts of both lateral a transparent disc like structure the cornea that covers it. At
surfaces (just below the angle) together form the bridge of the the centre of the iris there is an aperture called the pupil.
nose. The pupil appears black because the interior of the eye (that
The shape of the nose is maintained by the presence of a we see through the pupil) is dark. When we view the eyes
skeleton made up partly of bone and partly of cartilage. we see only a small part of the eyeball in the interval between
The external nares (or anterior nares) are the external openings the upper and lower eyelids. This interval is called the
of the nasal cavities. They are located on the inferior aspect of palpebral fissure (Fig. 36.3).
the nose. They are bounded laterally by the alae nasi and The upper and lower eyelids (or palpebrae) protect the
medially by the lowest part of the nasal septum. eyeball, specially the cornea, from injury in several ways.
Lips and Cheeks Firstly, they provide protection against mechanical injury
Some facts worth noting about the lips and cheeks are as by reflex closure when any object suddenly approaches the
follows.
The lips, upper and lower, are lined on the outside by skin
and on the inside by mucous membrane. The junction
between the two forms the edge of each lip. The substance
of the lip is formed by the orbicularis oris muscle and by
numerous smaller muscles that blend with it (See below
under muscles of face). The points, on either side, where the
upper and lower lips meet are called the angles of the mouth.
The deep surface of each lip is connected to the gum by a
median fold of mucous membrane called the frenulum.
The cheeks are, like the lips, made up of an outer layer of
skin, an inner layer of mucous membrane and an intervening
layer of muscle, connective tissue and fat. The muscle layer
is formed chiefly by the buccinator. The fat is specially
prominent in infants and is responsible for the rounded
appearance of the cheeks. Numerous glands are present in
relationship to the lips and cheeks. They open into the Fig. 36.3. Some features of the eye as seen on the face. The
vestibule of the mouth. interval between the two eyelids is the palpebral fissure.
eye. The same happens when the cornea is touched
(corneal reflex).
Secondly, they help to keep the cornea moist as follows:
When the eyelids are closed (i.e. when the upper and
lower eyelids meet) a capillary space separates the
posterior surfaces of the lids from the cornea and the
anterior part of the sclera. This space is the conjunctival
sac. It contains a thin film of lacrimal fluid, which keeps
the cornea and conjunctiva moist.
With the eyes open the cornea has a tendency to dry
up, but this is prevented by periodic, unconscious
closure of the lids (blinking). Thirdly, lids protect the
eyes from sudden exposure to bright light by reflex
closure.
We have seen above that the space separating the upper
and lower eyelids is called the palpebral fissure. The
medial and lateral ends of the fissure are called the
angles of the eye. Each angle is also called the canthus Fig. 36.4. Scheme to show the tarsal plate and the palpebral
(Fig. 36.3). The lateral canthus is in contact with the ligament as seen from the front.
sclera. At the medial canthus the upper and lower lids
are separated by a triangular interval called the lacus lacrimalis. ophthalmic artery and by the lateral palpebral branches of
In the floor of this area there is a rounded pink elevation called the lacrimal artery.
the lacrimal caruncle. Each eyelid has a free edge to which
eyelashes are attached. Just lateral to the lacrimal caruncle each Nerves supplying the eyelids
lid margin has a slight elevation called the lacrimal papilla. The upper eyelid receives branches from the lacrimal,
On the summit of the papilla there is a small aperture called the supraorbital, supratrochlear and infratrochlear nerves (all
lacrimal punctum. It is important to note that the punctum is branches of the ophthalmic division of the trigeminal nerve).
normally in direct contact with the ocular conjunctiva. The lower eyelid receives branches from the infraorbital and
The skeleton of each eyelid is formed by a mass of fibrous infratrochlear nerves.
tissue called the tarsus, or tarsal plate. The shape of the tarsi is
shown in Figure 36.4. The tarsi narrow down laterally and
medially and become continuous with the lateral and medial The Lacrimal Apparatus
palpebral ligaments through which they are attached to the
walls of the orbit, just inside the orbital margin. The upper and The lacrimal apparatus consists of the organs concerned
lower tarsi are attached to the corresponding part of the orbital with the secretion and drainage of this fluid. Lacrimal fluid is
margin by a membrane called the orbital septum. secreted by the lacrimal gland and is poured into the
The inner surface of the eyelid is
lined by palpebral conjunctiva.
This is a thin transparent membrane
continuous with the ocular
conjunctiva lining the anterior part
of the sclera. The sharp line of
reflection (of the conjunctiva) from
the lid to the sclera is called the
conjunctival fornix.
The levator palpebrae superioris
muscle enters the upper eyelid
anterior to the tarsal plate to gain
insertion into it. This muscle
elevates the upper eyelid, in
opening the palpebral fissure. The
palpebral fissure is closed by
contraction of the orbicularis oculi.
Blood vessels of the eyelids:
Fig. 36.5. Scheme to show the parts of the lacrimal apparatus. The thick arrows
The eyelids are supplied by the
indicate the direction of flow of lacrimal fluid.
medial palpebral branches of the
335
336
conjunctival sac at the superior conjunctival fornix. The fluid
passes downwards and medially to reach the lacus lacrimalis.
Here it passes through the lacrimal puncta into narrow tubes
called the lacrimal canaliculi. These canaliculi open into the
lacrimal sac. The lacrimal sac drains into the inferior meatus
of the nasal cavity through the nasolacrimal duct.
The lacrimal gland lies in relation to the upper lateral part of
the wall of the orbit. An extension of the gland, that extends
into the upper eyelid, is called its palpebral part (Fig. 36.5).
The lacrimal gland drains into the superior conjunctival fornix
through about twelve ducts.
The Lacrimal Canaliculi
There are two lacrimal canaliculi, upper and lower, in relation
to each eye. Each canaliculus is a narrow tube that starts at the
lacrimal punctum and ends by joining the lacrimal sac.
The Lacrimal Sac
The lacrimal sac lies in the lacrimal groove on the medial wall of Fig. 36.6. The orbicularis oris and its relationship to
the orbit (Figs 36.4 and 36.5). The lacrimal sac is blind at its various muscles attached to the lips.
upper end. Inferiorly, the sac is continuous with the nasolacrimal
duct. Laterally, it receives the lacrimal canaliculi near its upper
end. Nine muscles converge on the orbicularis oris. These are
the levator labii superioris alaeque nasi, the levator labii
The Nasolacrimal Duct superioris, the levator anguli oris, the zygomaticus major
The nasolacrimal duct (Fig. 36.5) is a tube about 18 mm long. and minor, the risorius, the depressor anguli oris, and the
It may be regarded as the downward continuation of the depressor labii inferioris.

lacrimal sac. It is closely related to the lateral wall of the nasal All the muscles of the face are supplied by the facial nerve.
cavity, and opens below into the inferior meatus of the nose. The actions of most of them are indicated by their names.
The wall of the nasolacrimal duct is made up of bone lined by The zygomaticus minor elevates the upper lip while the
mucous membrane. zygomaticus major draws it upwards and laterally as in
The lower end of the nasolacrimal duct is separated from the laughing. The risorius retracts the angle of the mouth.
inferior meatus of the nose by a fold of mucous membrane
called the lacrimal fold. Orbicularis Oris
The fibres of the orbicularis oris surround the opening of
the mouth. Many of the Fibres are derived from other facial
muscles as shown in Figure 36.6. Some intrinsic fibres of the
lips run obliquely from the skin to the mucous membrane.
MUSCLES OF THE FACE The orbicularis oris is supplied by the lower buccal and
mandibular marginal branches of facial nerve. The
Deep to the skin of the face there are several muscles that orbicularis oris closes the lips. It is responsible for complex
produce varying facial expressions. Many of them converge movements of the lips associated with speech, eating and
upon the mouth. These are also concerned with speech and drinking.
with feeding. Orbicularis Oculi
The orbicularis oculi is made up of fasciculi that run The orbicularis oculi consists of muscle fasciculi arranged
concentrically round the palpebral aperture. Its upper margin concentrically around the palpebral fissure. The innermost
merges with the fibres of the frontalis. The oral aperture is rings lie within the eyelids and form the palpebral part of
also surrounded by concentrically arranged muscle bundles the muscle. Succeeding rings surround the margin of the orbit
that constitute the orbicularis oris. Underlying the eyebrows and extend on to the temple and cheek: they constitute the
there are two muscles. The corrugator supercilii runs obliquely orbital part. Some fibres closely related to the lacrimal sac
deep to the frontalis while the depressor supercilii consists of form the lacrimal part.
some muscle fibres continuous with the upper medial part of The orbicularis oculi muscle closes the palpebral fissure.
the orbicularis oculi. Over the upper part of the nose we have The lacrimal part draws the eyelids medially. It dilates the
some vertically running fibres that constitute the procerus. lacrimal sac thus helping to suck lacrimal fluid into it.
Lower down on the nose we have the nasalis . Just below the The muscle is supplied by the temporal and zygomatic
nasal septum we have the depressor septi. branches of the facial nerve.
Buccinator
Origin
The buccinator has a C shaped line of
origin. It arises mainly from the outer
aspect of the maxilla and the outer surface
of the body of the mandible.
Insertion
The fibres of the buccinator run forwards
where they are continuous with the
orbicularis oris (Fig. 36.6).
Nerve Supply:
Lower buccal branches of facial nerve.
Actions
The buccinator aids mastication by pushing
food between the teeth. The muscle
increases air pressure within the mouth as
in blowing. Fig. 36.7. Origin of the buccinator muscle.
For insertion see figure 36.6.
internal carotid artery and the internal jugular vein (Fig. 36.8).
PAROTID GLAND The parotid gland is related to several nerves and vessels
as follows:
1. The external carotid artery enters the lower part of the
The parotid gland lies on the lateral side of the face in a posteromedial surface. Ascending within the substance of
depression below the external acoustic meatus, behind the the gland it divides into its terminal branches (superficial
mandible, and in front of the sternocleidomastoid muscle (Fig. temporal and maxillary) that emerge on the anteromedial
36.2). It is roughly triangular in cross section. It has a lateral or surface of the gland.
superficial surface, an anteromedial surface, and a 2. The retromandibular vein lies in the substance of the
posteromedial surface (Fig. 36.8). At its upper end it has a small parotid gland superficial to the external carotid artery.
superior surface. Its lower end is rounded and is called the apex. 3. The trunk of the facial nerve enters the posteromedial
The superficial surface of the parotid gland extends upwards surface. Within the gland it divides into its terminal branches
to the zygomatic arch. Its lower end (apex) lies behind and that emerge from the anteromedial surface near its anterior
below the angle of the mandible. Anteriorly, it is prolonged
forwards superficial to the masseter.
Posteriorly, it overlaps the anterior
margin of the sternocleidomastoid
(Fig. 36.2).
The superior surface of the parotid is
concave and fits under the external
acoustic meatus. It is also in contact
with the temporomandibular joint.
The anteromedial surface is in contact
with the posterior border of the ramus
of the mandible, the masseter muscle,
and the medial pterygoid muscle.
The posteromedial surface is in
contact, in its upper part with the
mastoid process, and lower down with
the sternocleidomastoid (super-
ficially) and the posterior belly of the
digastric (deep). The deepest part of
the gland reaches the styloid process
and the structures attached to it. Fig. 36.8. Schematic transverse section through parotid gland to
These separate the gland from the show its relations.
337
338
margin. The cervical branch of the nerve emerges from the Veins
lower end of the gland (Fig. 36.2).
4. The auriculotemporal nerve passes laterally between the The veins to be seen in the face and parotid region are the
neck of the mandible and the superior surface of the gland. It facial vein, the superficial temporal vein, and the
gives branches to the gland. retromandibular vein.
Secretions of the parotid gland are collected by a system of The retromandibular vein is formed within the upper part of
ducts that unite to form the parotid duct. This duct emerges at the parotid gland by the union of the superficial temporal
the anterior margin of the gland and runs forwards across the and maxillary veins. Its lower end divides, within the gland,
masseter. At the anterior border of the masseter the duct turns into anterior and posterior divisions that emerge from the
medially and pierces the buccinator. The terminal part of the gland near its lower end. The posterior division, that is the
duct runs forwards deep to the mucous membrane of the cheek. main continuation of the retromandibular vein, joins the
It opens into the vestibule of the mouth opposite the crown of posterior auricular vein to form the external jugular vein.
the upper second molar tooth. The anterior division joins the facial vein to form the common
A detached part of the parotid gland present just above the facial vein.
parotid duct is called the accessory part of the parotid gland. The facial vein runs downwards and backwards just behind
The parotid gland is enclosed in a fibrous capsule derived from the facial artery, and receives tributaries corresponding to
the deep cervical fascia. branches of the artery. It ends by joining the anterior division
The parotid gland is supplied by small branches of the external of the retromandibular vein to form the common facial vein.
carotid artery or of its terminal divisions. The veins drain into The common facial vein ends in the internal jugular vein.
the retromandibular and external jugular veins. The lymph
vessels from the gland drain into the deep cervical nodes after
Lymphatics
passing through the superficial parotid nodes (lying on the
lateral surface of the gland) and the deep parotid nodes (lying
The lymphatics of the face drain into the superficial and
within the substance of the gland).
deep parotid lymph nodes, into the submental nodes, and
Secretomotor nerves reach the gland through branches from
also into the submandibular lymph nodes. As mentioned

the auriculotemporal nerve.
above the parotid gland drains into the superficial and deep
parotid nodes.
VESSELS OF THE FACE

AND PAROTID REGION NERVES OF THE FACE
Arteries The nerves seen on the face are motor and sensory. The motor
nerves are terminal branches of the facial nerve. After
The arteries to be seen in the face are the facial artery and the emerging from the skull, the facial nerve enters the parotid
transverse facial branch of the superficial temporal artery. gland and divides within it into several branches that emerge
along the borders of the gland.
Facial artery
The facial artery runs part of its course in the neck, and in the
submandibular region. It then enters the face by passing round
the lower border of the body of the mandible just in front of
the masseter muscle. It then runs upwards and forwards across
the body of the mandible and the buccinator to reach the angle
of the mouth. Finally it ascends along the side of the nose to
reach the medial angle of the eye. In the face the artery gives
off branches to the lower lip (inferior labial artery), the upper
lip (superior labial artery), and to the nose (lateral nasal artery).
The terminal part of the facial artery is called the angular artery.
For a complete description of the facial artery see Chapter 41.
The superficial temporal artery arises from the external carotid
artery within the parotid gland. It runs upwards behind the
temporomandibular joint and ends by dividing into frontal and
parietal branches that supply the scalp. It also gives off the Fig. 36.9. Areas of skin supplied by the
transverse facial artery that runs forwards across the masseter ophthalmic, maxillary and mandibular divisions of
muscle. the trigeminal nerve.
TEMPORAL AND INFRATEMPORAL REGIONS
The facial nerve gives off a temporal branch, a zygomatic external nasal nerves. Some branches are also given off to
branch, upper and lower buccal branches, a marginal mandibular the upper eyelid.
branch, and a cervical branch. These branches supply the various Branches of the maxillary division of the trigeminal nerve to
muscles of the face. For a complete description of the facial be seen on the face are the infraorbital nerve, the zygoma-
nerve see Chapter 42. ticofacial and zygomaticotemporal nerves. Branches of the
mandibular division seen on the face are the auriculotemporal,
The sensory nerves seen on the face are terminal ramifications buccal and mental nerves. The areas of the skin of the face
of the trigeminal nerve. Branches arising from the ophthalmic supplied by the three divisions of the trigeminal nerve are
division are the supratrochlear, supraorbital, infratrochlear and shown in Figure 36.9.
37 : Temporal and Infratemporal Regions
TEMPORAL REGION 1. The superficial temporal artery is a terminal branch of

the external carotid artery. It divides into branches that
supply the temporal region and scalp.
The temporal region overlies the temporal fossa present on 2. The superficial temporal vein is a tributary of the
the lateral aspect of the skull. The fossa is bounded above by retromandibular vein.
the temporal line and inferiorly by the zygomatic arch. The 3. The deep temporal arteries are branches of the maxillary
lower part of the temporal region is overlapped by the auricle. artery.
A thick fibrous membrane, the temporal fascia covers the These vessels are described in Chapter 41.
region. This fascia is attached superiorly to the temporal lines, The main content of the temporal fossa is the temporalis
and inferiorly to the zygomatic arch. Attached to the superficial muscle. It is described along with other muscles of
aspect of the temporal fascia there are some subcutaneous mastication below.
muscles attached to the auricle.
A number of nerves are seen in the temporal region.
1. The auriculotemporal nerve emerges from under cover of
the upper end of the parotid gland. The nerve ascends into the INFRATEMPORAL FOSSA
temporal region and scalp and divides into branches that supply
them.
2. The temporal branch of the facial nerve runs upwards and The term infratemporal fossa is applied to an irregular space
forwards to reach the frontalis muscle that it supplies. It also lying below the lateral part of the base of the skull.
helps to supply the orbicularis oculi and the auricular muscles. Superiorly, the lateral part of the fossa communicates with
3. The posterior auricular branch of the facial nerve is seen the temporal fossa through the gap between the zygomatic
behind the auricle in the lower part of the temporal region. It arch and the rest of the skull. Anteriorly, the infratemporal
runs backwards to reach and supply the occipitalis muscle. fossa communicates with the orbit through the inferior orbital
4. The zygomatico-facial nerve and the zygomatico-temporal fissure.
nerve are derived from the zygomatic branch of the maxillary The structures to be studied in the infratemporal fossa are
division of the trigeminal nerve. They help to supply the skin the muscles of mastication and the nerves and vessels related
of the region. to them.
5. Deep to the temporalis muscle there are the (anterior, middle
and posterior) deep temporal nerves. They arise from the Maxillary Artery
anterior division of the mandibular nerve. The deep temporal
nerves supply the temporalis muscle. The maxillary artery arises from the external carotid artery
The nerves mentioned above are described in Chapter 42. just behind the ramus of the mandible. The artery runs
forwards deep to the neck of the mandible to enter the
The vessels seen in the temporal region are as follows: infratemporal fossa. It first runs forwards along the lower
border of the lateral pterygoid muscle (first part) and then
339
340
Fig. 37.2. A. Lateral view of the skull showing the

origin of the temporalis muscle from the temporal
fossa. Note the bones involved. B. Ramus of
mandible seen from the medial side to show the
Fig. 37.1. Overall view of the muscles of
insertion of the temporalis.
mastication.
runs upwards and forwards across the lower head of the muscle Mandibular Nerve
(second part). Finally, it enters the interval between the two
heads and disappears into the pterygomaxillary fissure: This is the main nerve of the infratemporal fossa. The nerve
The branches arising from the maxillary artery in the enters the fossa through the foramen ovale. After a very short
infratemporal region are as follows. course the trunk of the nerve divides into a thin anterior
1. While still posterior to the mandible the maxillary artery division and a much thicker posterior division.
gives off the anterior tympanic and deep auricular arteries. The anterior division gives off the deep temporal nerves. It
2. Within the infratemporal fossa it gives off the middle also gives branches to the masseter and to the lateral
meningeal artery, the inferior alveolar artery, the buccal pterygoid. Finally the anterior division continues on to the
artery, and the deep temporal arteries. surface of the buccinator muscle as the buccal nerve.
3. Just before entering the pterygomaxillary fissure it gives off The thick posterior division gives off the auriculotemporal
the posterior superior alveolar artery. nerve which arises by two roots that are separated by the
The maxillary artery and its branches are described in Chapter middle meningeal artery. The posterior division then divides
41. into two main branches, the lingual nerve (anteriorly), and
the inferior alveolar nerve (posteriorly). The lingual nerve
MUSCLES OF MASTICATION
Temporalis
Origin:
The temporalis arises from the temporal fossa on the lateral
aspect of the skull (Fig. 37.2A). The area includes parts of
the frontal, parietal, and squamous temporal bones and of
the greater wing of the sphenoid. The tendon passes deep to
the zygomatic arch.
Insertion:
Into coronoid process of mandible (Fig. 37.2B).
Nerve Supply:
Deep temporal branches of the mandibular nerve.
Actions:
The temporalis helps to close the mouth by elevating the
mandible.
Masseter
Origin:
The muscle arises from the zygomatic arch (Fig. 37.3).
Fig. 37.3. Attachments of the masseter muscle. Insertion:
Into lateral surface of ramus and angle of the mandible.
is joined (posteriorly) by the chorda tympani (a branch of the Nerve Supply:
facial nerve). Anterior division of the mandibular nerve.
The upper part of the mandibular nerve lies under cover of the
lateral pterygoid muscle. The masseteric nerve and the deep Actions:
temporal nerves become superficial by passing above the lateral The masseter elevates the mandible to close the mouth. Its
pterygoid muscle. The buccal nerve emerges through the gap anterior fibres help in forward movement of the jaw.
between the two heads of the lateral pterygoid. The lingual and
inferior alveolar nerves emerge from under the lower border of
the lateral pterygoid muscle and descend over the surface of Lateral Pterygoid
the medial pterygoid. The inferior alveolar nerve enters the
mandibular canal and passes through it to supply the mandible The muscle has two heads of origin, upper and lower.
and the lower teeth. It gives a branch, the mental nerve, which
Origin:
emerges through the mental foramen. The mylohyoid nerve is
The upper head arises from the infratemporal surface of
given off by the inferior alveolar nerve just before it enters the
the greater wing of the sphenoid bone.
mandibular canal. The lingual nerve leaves the infratemporal
The lower head arises from the lateral surface of the lateral
region to pass through the submandibular region on its way to
pterygoid plate.
the tongue.
For a full description of the mandibular nerve see Chapter 42. Insertion:
Into a depression (pterygoid fovea) on the anterior aspect
of the neck of the mandible (Fig. 37.5).
Nerve Supply:
Mandibular nerve (anterior division).
Actions:
These are considered along with those of the medial
pterygoid below.
341
342
Medial Pterygoid 2. The medial and lateral pterygoids of the two sides acting
alternately produce side to side chewing movements.
3. The medial pterygoid elevates the jaw. The lateral pterygoid
Origin:
helps in opening the mouth by pulling the head of the
The medial pterygoid muscle takes origin mainly from the
mandible forwards.
medial surface of the lateral pterygoid plate. A superficial slip
arises from the lateral aspect of the maxillary tuberosity.
Insertion:
Medial surface of angle of mandible (Fig. 37.5).
THE TEMPOROMANDIBULAR JOINT
Nerve Supply:
Mandibular nerve.
This is a synovial joint of the condylar variety. Its cavity is
Actions of Pterygoid Muscles: divided into upper and lower parts by an intra-articular disc.
1. The medial and lateral pterygoids of both sides acting The upper articular surface of the joint is formed by the
together protract the mandible. mandibular fossa of the temporal bone. Anteriorly, the
surface extends onto the articular tubercle. The posterior
part of the surface is, therefore, concave downwards; and
the anterior part is convex.
Fig. 37.4. Scheme to show the arrangement of the medial

pterygoid muscle. Fig. 37.6. Ligaments of temporomandibular joint seen
from the lateral side.
Fig. 37.5. Medial aspect of the ramus of the mandible

showing areas for insertion of the lateral and medial Fig. 37.7. Ligaments of temporomandibular joint seen
pterygoid muscles. from the medial side.
The inferior articular surface is formed by the head of the Movements at the temporomandibular joint
mandible that is markedly convex anteroposteriorly, and more The movements at the joint can be divided into those between
gently convex from side to side. the upper articular surface and the articular disc, and those
The articular disc is made of fibrocartilage. Its upper surface between the disc and the head of the mandible. Most
is concavoconvex to fit the upper articular surface of the joint. movements occur simultaneously at the right and left
Its lower surface is concave, the head of the mandible fitting temporomandibular joints. In forward movement or
into the concavity. protraction of the mandible the articular disc glides forwards
The capsule of the joint is attached to the margins of the over the upper articular surface, the head of the mandible
articular surfaces. The inside of the capsule is lined by synovial moving with it. The reversal of this movement is called
membrane. The lateral part of the capsule is strengthened by retraction. In slight opening of the mouth (depression of
the lateral temporomandibular ligament (Fig. 37.6). In the mandible) the head of the mandible moves on the under-
addition the joint has two accessory ligaments (that are surface of the disc like a hinge. In wide opening of the mouth,
independent of the capsule and lie some distance away from this hinge like movement is followed by a forward gliding
it). The sphenomandibular ligament (Fig. 37.7) is attached of the disc along with the head of the mandible. These
above to the spine of the sphenoid, and below to the lingula of movements are reversed in closing the mouth (or elevation
the mandible. The stylomandibular ligament (Figs 37.6 and of the mandible). Chewing involve side to side movements
37.7) extends from the apex of the styloid process to the angle of the mandible.
and posterior border of the ramus of the mandible. The muscles responsible for these movements are
summarised in Figure 37.8.
Fig. 37.8. Scheme to show the muscles responsible for movements at

the temporomandibular joint.
343
344
38 : The Submandibular Region

and Tongue
SUBMANDIBULAR REGION
The structures we will study in this chapter are the The lateral surface is hidden from view by the body of the
submandibular gland, the sublingual gland, the suprahyoid mandible. It lies in contact with the medial surface of the
muscles (digastric, stylohyoid, mylohyoid), and the tongue and body of the mandible, below the attachment of the mylohyoid
its muscles. The related vessels and nerves will be mentioned muscle. The posterior part of the lateral surface is separated
but will be described in detail in Chapters 41 and 42. from the mandible by the medial pterygoid muscle.
The medial surface rests on several structures (Fig. 38.3).
The most important of these are the mylohyoid muscle (in
front), the hyoglossus (in the middle) and the wall of the
THE SUBMANDIBULAR GLAND pharynx (posteriorly). At the posterior margin of the
mylohyoid muscle a prolongation of the submandibular gland
called the deep part passes forward in the interval between
The submandibular gland is located partly below, and partly
the mylohyoid (laterally) and the hyoglossus (medially).

deep to the body of the mandible. The part below the mandible The following additional relationships may now be noted.
lies in the digastric triangle. The gland has three surfaces, 1. The submandibular gland is enclosed by two layers of
inferior, lateral and medial, that are best appreciated in a fascia formed by splitting of the investing layer of deep
coronal section through the gland (Fig. 38.2). cervical fascia. The superficial layer covers the inferior
The inferior surface is superficial, and is the one seen in the surface of the gland and is attached to the lower border of
digastric triangle. It is directed downwards and somewhat the mandible. The deeper layer covers the medial surface
laterally. and is attached above to the mylohyoid line of the mandible.
Fig. 38.1. Some structures in the submandibular region.

SUBMANDIBULAR REGION AND TONGUE
the facial and lingual arteries. The veins accompany the
arteries.
Lymphatics from the submandibular gland drain into the
submandibular lymph nodes and through them into the deep
cervical nodes, particularly the jugulo-omohyoid node.
THE SUBLINGUAL GLAND
The sublingual gland is present in relation to the floor of the

anterior part of the oral cavity. It is placed just deep to the
oral mucous membrane and is responsible for raising up the
sublingual fold (Fig. 38.7). Inferiorly, the gland rests on the
mylohyoid muscle. Laterally it is in contact with the anterior
part of the mandible above the mylohyoid line. Medial to
the gland there is the genioglossus muscle. The
Fig. 38.2. Coronal section through the submandibular duct lies between the gland and the muscle.
submandibular region to show the surfaces of the
These relationships are best appreciated in a coronal section
submandibular gland and their relations.
through the gland (Fig. 38.4).
Secretions of the sublingual gland leave it through a number
of small ducts that open into the oral cavity on the sublingual
2. Apart from skin and fascia the inferior surface is overlapped fold (Fig. 38.7).
by the platysma. It is crossed by the facial vein, and the cervical
branch of the facial nerve. The submandibular lymph nodes lie
over it. Some of the nodes may be embedded within the gland.
3. The relationship of the facial artery to the gland is worthy of
note. The artery first runs upwards along the posterior end of SUPRAHYOID MUSCLES
the gland (grooving it). It then runs downwards and forwards
between the lateral surface of the gland (deep to the artery) and These are the digastric, stylohyoid, mylohyoid and
the medial pterygoid muscle (superficial to it). geniohyoid muscles.
Some additional relations of the medial surface are shown in
Figure 38.3.
The Submandibular Duct
The submandibular duct emerges

from the medial surface of the
submandibular gland near the
posterior margin of the mylohyoid.
In company with the deep part of the
submandibular gland it runs forwards
in the interval between the mylohyoid
(laterally) and the hyoglossus
(medially). Its anterior part lies
between the sublingual gland
(laterally) and the genioglossus
(medially). The duct opens into the
oral cavity on the sublingual papilla
(located below the anterior part of the
tongue, Figure 38.7).
Blood vessels, nerves,

lymphatics
The arteries supplying the Fig. 38.3. Scheme to show structures deep to the submandibular gland. The outline
submandibular gland are branches of of the area covered by the gland is shown in bold line.
345
346
Actions
The digastric can elevate the hyoid bone. Acting
along with other muscles attached to the hyoid
bone it can fix the bone.
Stylohyoid muscle
The stylohyoid muscle arises from the posterior

aspect of the styloid process. It runs downwards
and forwards to end in a tendon that splits into
two to enclose the intermediate tendon of the
digastric muscle. The tendon is then inserted into
the hyoid bone at the junction of body and
greater cornu.
Nerve supply and action
Fig. 38.4. Schematic coronal section through anterior part
The stylohyoid muscle is supplied by the facial
of tongue and mouth to show relationships of the nerve. It elevates the hyoid bone and retracts it.
sublingual salivary gland, and the oral diaphragm.
Digastric muscle Geniohyoid muscle
The digastric muscle has two bellies, anterior and posterior, The geniohyoid is a narrow muscle situated above the
mylohyoid (Fig. 38.5), and below the genioglossus. It arises
united by an intermediate tendon. The posterior belly arises

from the base of the skull just deep to the mastoid process from the posterior aspect of the symphysis menti and runs
(mastoid notch of temporal bone: Figure 35.15). The anterior backwards to be inserted into the anterior aspect of the hyoid
belly is attached to the anterior part of the base of the mandible bone.
near the midline. The intermediate tendon passes through a Nerve supply and action
fibrous pulley that is attached to the hyoid bone (at the junction The muscle is supplied by fibres that are part of the first
of body and greater cornu (Fig. 38.5). The deep surface of the cervical nerve, but they travel through the hypoglossal nerve.
anterior belly rests on the mylohyoid. The muscle draws the hyoid bone upwards and forwards.
Nerve supply
The nerve supply of the anterior belly is by the mylohyoid Mylohyoid muscle and Oral diaphragm
branch of the inferior alveolar nerve, and that of the posterior
belly by the facial nerve. The mylohyoid muscles of the two sides bridge the gap
between the two halves of the mandible. In the median plane
the two muscles become continuous with each other at a
median raphe. In this way the right and left muscles form
the floor of the mouth. This floor is called the oral
diaphragm (Figs 38.4 and 38.5). This diaphragm is
strengthened above by the geniohyoid muscle, and below
by the anterior belly of the digastric muscle.
Attachments
On each side the mylohyoid muscle arises from the
mylohyoid line on the medial surface of the body of the
mandible. From this origin the fibres pass medially. The most
posterior fibres are attached to the anterior aspect of the
body of the hyoid bone. The remaining fibres are inserted
into a median fibrous raphe extending from the hyoid bone
to the mandible.
Fig. 38.5. Schematic diagram of floor of
mouth seen from above. Note the layout of the The mylohyoid muscle is supplied by the mylohyoid branch
mylohyoid and geniohyoid muscles. of the inferior alveolar nerve. The muscle helps in deglutition
by raising the floor of the mouth.
THE TONGUE
THE TONGUE
The tongue lies in the oral cavity.

The anterior part of the tongue (or
apex) can be protruded out of the
mouth. It has free upper and lower
surfaces. The greater part of the
tongue is attached below to the floor
of the mouth. The attached part is
called the root of the tongue. This
part of the tongue has a free upper
surface or dorsum. On either side,
the tongue has lateral edges that are
also free. The free surfaces of the
tongue are lined by mucous
membrane.
The substance of tongue is made up
mainly of muscle. Some of the
muscles of the tongue are intrinsic
i.e. they are confined to the tongue,
while others that are extrinsic enter
the tongue from outside. It is
through the root that the various Fig. 38.6. Tongue and some related structures seen from above.
extrinsic muscles enter the
substance of the tongue. Through
these muscles the tongue is anchored to the hyoid bone behind seen in a row just in front of the sulcus limitans. These are
(through the hyoglossus muscle) and to the mandible in front the vallate papillae.
(through the genioglossus muscle). The pharyngeal part of the tongue faces backwards and
forms part of the anterior wall of the oropharynx. Its surface
Features on the dorsum of the tongue
shows a number of rounded elevations that are produced by
The features seen when the tongue is viewed from above are
collections of lymphoid tissue. This lymphoid tissue is
shown in Figure 38.6. The upper surface (or dorsum) is seen.
referred to, collectively, as the lingual tonsil.
Identify the anterior end or apex, and the lateral edges.
Near its posterior end the dorsum of the tongue is marked by a
V-shaped groove called the sulcus terminalis. The apex of the
V points backwards and is marked by a depression called the
foramen caecum. The limbs of the sulcus terminalis runs
forwards and laterally to the lateral margin of the tongue. The
sulcus terminalis divides the dorsum into an anterior larger part
(two-thirds) and a posterior smaller part (one-third). The
anterior part lies in the oral cavity and is, therefore, called the
oral part. It faces upwards and comes into contact with the
palate. The posterior one-third faces backwards and is called
the pharyngeal part.
The mucous membrane covering the oral part of the dorsum of
the tongue is rough because of the presence of numerous finger
Fig. 38.7. Some structures seen on the undersurface of
like projections or papillae. The largest of these papillae are
the anterior part of the tongue.
347
348
The posterior part of the tongue is connected to the palate
(on either side) by a fold of mucous membrane called the
palatoglossal fold. Immediately posteriorly to this fold
we see the palatine tonsil (Fig. 38.6).
Posteriorly, the tongue is closely related to the epiglottis
(a part of the larynx). The mucosa of the tongue is
connected to the anterior aspect of the epiglottis by a
median glossoepiglottic fold; and to its lateral edges by
two lateral glossoepiglottic folds. The space between the
tongue and epiglottis on either side of the median
glossoepiglottic fold is called the vallecula.
Some features to be seen on the lower surface of the
anterior part of the tongue are shown in Figure 38.7. We
have seen that this part of the tongue is not attached to the
floor of the mouth, and that is why it can be protruded out
of the mouth. In Figure 38.7 note the frenulum linguae
lying in the middle line. It is a delicate fold of mucosa
passing from the tongue to the floor of the mouth. On
either side of the posterior end of the frenulum notice a
rounded projection. This is the sublingual papilla. The
submandibular duct opens on the summit of the papilla. Fig. 38.8. Drawing to show the extrinsic muscles of the tongue.
Running laterally from the papilla we see the sublingual fold. Genioglossus
This fold is produced by the underlying sublingual salivary The genioglossus lies next to the median plane. It arises from
gland. the posterior surface of the symphysis menti. The fibres

A little lateral to the frenulum a darkish line can be seen running spread out to be inserted into the whole length of the ventral
towards the tip of the tongue. This line is produced by the aspect of the tongue (Fig. 38.8). The lowest fibres of the
deep lingual vein seen through the mucosa. Further laterally muscle are attached to the body of the hyoid bone.
we see an irregular fold of mucosa called the fimbriated fold.
Hyoglossus
The hyoglossus arises from the hyoid bone (greater cornu,

MUSCLES OF THE TONGUE and lateral part of body). The fibres pass upwards to enter
the side of the tongue.
The hyoglossus is related to a large number of important
The extrinsic muscles of the tongue enter it from the outside.
structures (Fig. 38.1).
They are the styloglossus, the palatoglossus, the genioglossus,
1. After the lingual nerve passes from the infratemporal fossa
and the hyoglossus. The intrinsic muscles lie within the
to the submandibular region it runs across the hyoglossus,
substance of the tongue.
winds below the submandibular duct (see below), and enters
the tongue.
Styloglossus 2. The submandibular ganglion hangs from the lingual
The styloglossus arises from the anterior and lateral aspects of nerve by two roots.
the styloid process, and from the upper part of the 3. The submandibular duct (that drains the submandibular
stylomandibular ligament (Fig. 38.8). It runs downwards and gland) runs upwards and forwards over the hyoglossus to
forwards to merge with the side of the tongue. Here it divides reach the oral cavity inferior to the anterior part of the tongue.
into two slips one lying superficial to the hyoglossus and the 4. The mylohyoid nerve (branch of the inferior alveolar
other deep to it. nerve) crosses the hyoglossus muscle, the submandibular
duct and the hypoglossal nerve to reach the mylohyoid
Palatoglossus
muscle that it supplies. It also gives a branch to the anterior
The palatoglossus muscle arises from the anterior (oral) side
belly of the digastric muscle.
of the palatine aponeurosis (a sheet of fibrous tissue in the soft
5. The hypoglossal nerve runs downwards and forwards
palate). The muscle passes downwards and forwards to be
across the external carotid artery, and the (upward) loop
inserted into the side of the tongue. Along with the mucous
formed by the lingual artery, to reach the hyoglossus muscle.
membrane covering it, it forms the palatoglossal arch, which
The nerve then turns upwards over the muscle and divides
lies anterior to the tonsil.
into branches that supply muscles of the tongue (including
the hyoglossus).
6. The lower end of the stylohyoid muscle
crosses the hyoglossus.
7. Some structures that pass deep to the
posterior edge of the hyoglossus muscle are
(from above downwards) the glosso-
pharyngeal nerve, the stylohyoid ligament,
and the lingual artery.
Intrinsic Muscles:
Apart from the muscles entering the tongue
from the outside the tongue contains intrinsic
fibres that are arranged in several groups.
Nerve Supply of muscles of the tongue:
All muscles of the tongue are supplied by
the hypoglossal nerve except the
palatoglossus that is supplied by the cranial
part of the accessory nerve. Fig.38.9. Scheme to show the arteries and veins that supply the tongue.
Actions:
The muscles of the tongue move the tongue and alter its shape The lymphatic drainage of the tongue is very important
for movements concerned with speech, mastication and because of the frequent occurrence of cancer in this organ.
swallowing. The hyoglossus depresses the tongue; the It is described in detail in Chapter 46.
styloglossus pulls it upwards and backwards; and the The nerves supplying the tongue are of the three functional
genioglossus protrudes the tongue out of the mouth by pulling types.
the posterior part forwards. The palatoglossal muscles of the
(a) Nerves of ordinary sensation:
two sides acting together bring the palatoglossal arches together,
Sensations like touch, pain and temperature are carried from
thus shutting the oral cavity from the oropharynx. The intrinsic
the anterior two-thirds of the tongue by the lingual nerve,
muscles alter the shape of the tongue.
and from the posterior one-third by the glossopharyngeal
nerve.
(b) Nerves of taste:
Sensations of taste from the anterior two-thirds of the tongue
BLOOD VESSELS, LYMPHATICS, AND
are carried by fibres of the lingual nerve. These fibres pass
NERVES OF THE TONGUE
into the chorda tympani branch of the facial nerve.
Sensations of taste from the posterior one-third of the tongue
The main artery to the tongue is the lingual artery. The venous are carried by the glossopharyngeal nerve. Taste fibres from
drainage of the tongue is shown in Figure 38.9. Dorsal lingual the posterior-most part of the tongue (just in front of the
veins from the dorsum and sides of the tongue end in the lingual epiglottis) are carried by the superior laryngeal branch of
vein that accompanies the lingual artery and ends in the internal the vagus nerve.
jugular vein. Other veins including the deep lingual vein (see (c) The musculature of the tongue is supplied by the
above) drain through veins that accompany the hypoglossal hypoglossal nerve.
nerve. These veins may join the lingual vein, or the facial vein, Complete descriptions of the vessels and nerves mentioned
or may enter the internal jugular veins directly. are given in Chapters 41 and 42.
349
350
39 : Cranial Cavity and Vertebral Canal

Joints of the Head and Neck
CRANIAL CAVITY AND VERTEBRAL CANAL
Contents of the Cranial Cavity and Vertebral Canal In addition to the brain and meninges the cranial cavity
contains the proximal parts of cranial nerves as they travel
The most important structure in the cranial cavity is the brain; from their attachment to the surface of the brain to foramina
and that in the vertebral canal is the spinal cord. in the skull through which they leave the cranial cavity. The
The brain and spinal cord are surrounded by three membranes cranial cavity also contains blood vessels that supply the
called the meninges. The meninges are the dura mater, the brain, the meninges and other intracranial structures.
arachnoid mater and the pia mater. Between the arachnoid Lying in close relationship to the brain there are two
mater and the pia mater there is the subarachnoid space that endocrine glands of great importance. These are the
contains cerebrospinal fluid. In relation to the dura mater there hypophysis cerebri and the pineal gland.
are a series of venous sinuses that drain intracranial structures Apart from the spinal cord, meninges and cerebrospinal fluid,
including the brain. the vertebral canal contains the roots of spinal nerves. It
The cranial cavity is lined on the inside by a periosteum-like also contains blood vessels. The veins form an elaborate
membrane called the endocranium. The segment of the vertebral venous plexus.
vertebral canal lying within each vertebra is lined by
periosteum.
Fig.39.1. Orientation of the falx cerebri and tentorium cerebelli.

CRANIAL CAVITY, VERTEBRAL CANAL, JOINTS
The Endocranium
This is a fibrous membrane (similar to periosteum) lining the
inside of the cranial cavity. At the foramen magnum, and at
smaller apertures in the skull, it becomes continuous with
periosteum lining the exterior of the skull. At the superior
orbital fissure it becomes continuous with the periosteum
lining the orbit.
At places where cranial nerves leave the cranial cavity the
endocranium extends over them for some distance in the form
of a tubular sheath. At sites of sutures the endocranium blends
with sutural ligaments. It is, therefore, firmly anchored here.
THE MENINGES
The Cerebral Dura mater
The dura mater is a thick fibrous membrane. It can be divided

into a cerebral part lying in the cranial cavity and a spinal
part lying in the vertebral canal.
Over the greater part of its extent the cerebral dura mater is
closely adherent to the endocranium (and through the latter
to the skull). At places the dura mater separates from Fig. 39.3. Coronal section through posterior part of
endocranium forming double-layered folds that play an falx cerebri, and tentorium cerebelli. The falx cerebelli
essential role in supporting brain tissue (see below). is also shown.
At places where such folds are formed triangular spaces are lower edge, that is free, is markedly concave downwards.
left between the endocranium and the dura mater. These spaces The anterior end of the falx cerebri is narrow and pointed. It
are lined by endothelium forming venous sinuses (Fig. 39.2). is attached to the crista galli. At its posterior end the falx
The two largest folds of dura mater are the falx cerebri and the cerebri has a straight lower edge that is attached to the upper
tentorium cerebelli. Two smaller folds the falx cerebelli and surface of the tentorium cerebelli.
the diaphragma sellae are also present. A coronal section through the falx cerebri near its middle is
The Falx Cerebri shown in Figure 39.2. Note that near its upper end the two
The falx cerebri lies in the sagittal plane (Fig. 39.1). It is sickle layers of dura mater that form it diverge to enclose a
shaped. It has a convex upper edge that is attached to the vault triangular space. The third side of the triangle is formed by
of the skull, in the middle line (i.e. along the sagittal suture). Its endocranium. This space is the superior sagittal sinus. It is
an example of a sinus walled partly by dura mater and partly
by endocranium. Next, note that at the lower end of the falx
cerebri the dura mater folds on itself to form the free lower
edge. An oval space is left in the fold along the lower edge.
This space is the inferior sagittal sinus.
In Figure 39.2 we see a coronal section through the posterior
part of the falx cerebri. Observe that here the lower edge of
the falx is attached to the upper surface of the tentorium
cerebelli. At this junction we have a triangular space that is
occupied by the straight sinus.
The falx cerebri occupies the longitudinal fissure that
(partially) separates the right and left cerebral hemispheres.
The Tentorium Cerebelli

In Figure 39.3 observe that, on the whole, the tentorium
cerebelli is placed more or less transversely i.e. in a plane
Fig. 39.2. Coronal section through falx cerebri that is at right angles to that of the falx cerebri. Its central
midway between its anterior and posterior ends. part is higher than its right and left margins. It, therefore,
forms a tent-like roof over the posterior cranial fossa in which
351
352
Falx Cerebelli
Over the floor of the posterior cranial fossa, there is a
short fold of dura mater called the falx cerebelli (Fig.39.3).
The fold is crescentic in shape and is placed in the sagittal
plane. The occipital sinus lies along the posterior
attachment of the falx cerebelli.
The falx cerebelli occupies the median groove (vallecula
cerebelli) that separates the lower part of the right and left
cerebellar hemispheres.
Diaphragma sellae
The median region of the middle cranial fossa is Formed
by the body of the sphenoid bone. Here the bone shows a
median depression called the hypophyseal fossa.
The diaphragma sellae is a horizontal fold of dura mater
that roofs over the hypophyseal fossa. Anteriorly the
diaphragma is attached to the tuberculum sellae, and
posteriorly to the dorsum sellae.
The manner of formation of this fold is shown in figure
39.5 which is a coronal section across the median part of
the middle cranial fossa. Observe that on either side of the
body of the sphenoid bone the dura mater is widely
separated from the endocranium to form a space that is
Fig. 39.4. Scheme to show the tentorium cerebelli and its occupied by the cavernous sinus. Note that the diaphragma
attachments.
sellae roofs over the hypophyseal fossa in which the

hypophysis cerebri lies. At its centre the diaphragma shows
an aperture through which the stalk of the hypophysis
passes.
the cerebellum lies. That is why this fold of dura mater is called Blood supply and nerve supply of cerebral dura mater
the tentorium cerebelli. A large number of meningeal arteries take part in supplying
When the tentorium cerebelli is viewed from above it has the the cerebral dura mater. The largest meningeal artery is the
appearance shown in Figure 39.4. Observe the following. middle meningeal branch of the maxillary artery. It is
a. The anterior part of the tentorium cerebelli is marked by a described in Chapter 41.
deep tentorial notch. The U-shaped edge of this notch is called
the free margin of the tentorium cerebelli. Traced anteriorly,
the free margin extends into the middle cranial fossa and gains
Arachnoid mater and Pia mater
attachment to the anterior clinoid process.
b. Anteriorly and laterally, each half of the tentorium cerebelli
The arachnoid mater is a thin membrane. There are no blood
is attached to the superior border of the petrous temporal bone.
vessels in it. The arachnoid mater is separated from the dura
Medially this edge is prolonged to reach the posterior clinoid
mater by the subdural space.
process.
The pia mater is thicker than the arachnoid mater. In contrast
c. Posterolaterally, the tentorium cerebelli has a curved edge.
to the arachnoid mater it is highly vascular, and the blood
Along this edge the two layers of dura mater forming the
vessels in it are important for supply of the underlying brain.
tentorium separate and gain attachment to the lips of a broad
The pia and arachnoid are separated by the subarachnoid
groove (transverse sulcus) present mainly over the internal
space. This space is filled in by cerebrospinal fluid.
surface of the occipital bone. Along this attachment the two
The surface of the brain is marked by several grooves or
layers of dura mater forming the tentorium cerebelli separate
sulci that are of varying depth. At such sites the piamater
to leave a triangular interval that forms the transverse sinus
extends into the sulci lining them, but the arachnoid does
(Fig. 39.3).
not do so. As a result the subarachnoid space extends into
d. The triangular interval at the junction of the falx cerebri and
the sulci. The subarachnoid space also extends for some
the tentorium cerebelli is occupied by the straight sinus (Fig.
distance around blood vessels that penetrate brain substance
39.3).
(perivascular spaces).
The superior petrosal sinus is situated along the anterolateral
At some sites the subarachnoid space shows relatively large
attachment of the tentorium cerebelli.
dilatations. Such spaces, filled with cerebrospinal fluid, are
called cisterns.
Arachnoid villi and granulations
At several sites related to intracranial
venous sinuses, the arachnoid mater
passes through minute apertures in dura
mater to project into the sinuses. At
places such projections are microscopic
and are referred to as arachnoid villi.
At other places these villi form
aggregations that are visible to the
naked eye and are then called arachnoid
granulations. Arachnoid granulations
are most numerous in relation to the
superior sagittal sinus.
The importance of arachnoid villi is that
these are sites at which cerebrospinal
fluid is absorbed into the blood stream. Fig. 39.5. Coronal section through hypophyseal fossa, cavernous sinus
and diaphragma sellae.
Choroid plexuses
At certain sites in relation to the ventricles of the brain folds of pia mater (or
tela choroidea) project into the ventricles. Enclosed within the fold there are
tufts of capillaries. This highly vascular pia mater is covered by ependyma
that lines the inside of each ventricle. The masses of vascular pia mater covered
by ependyma are referred to as choroid plexuses. They are sites at which
cerbrospinal fluid is secreted into the ventricles of the brain.
MENINGES IN THE VERTEBRAL CANAL
The dura mater, arachnoid mater and pia mater that surround the brain continue
through the foramen magnum into the vertebral canal where they surround
the spinal cord. The subdural space, and the subarachnoid space (containing
cerebrospinal fluid), also continue into the vertebral canal.
The spinal dura mater forms a loose tubular covering for the spinal cord. It
extends downwards up to the level of the lower border of the second sacral
vertebra. The arachnoid mater also extends to the same level. The pia mater is
coextensive with the spinal cord that ends at the level of the lower part of the
first lumbar vertebra. Opposite vertebrae L2 to S2 the vertebral canal contains
cerebrospinal fluid (CSF), but not the spinal cord. A needle can, therefore, be
introduced into the subarachnoid space (to withdraw CSF or to inject
substances) without danger of damage to the spinal cord. For this procedure,
called lumbar puncture, the needle is most often introduced through the
interval between vertebrae L3 and L4.
The part of the vertebral canal below the level of the spinal cord contains
several roots of spinal nerves that collectively form the cauda equina. These
nerve roots are not injured during lumbar puncture as they are easily pushed
aside by the needle.
The spinal dura mater is separated from the wall of the vertebral canal by the
epidural space.
Filum Terminale
Below the level of the spinal cord pia mater becomes continuous with a fibrous
cord called the filum terminale. Fig. 39.6. Important vertebral levels in
Ligamentum denticulatum relation to the spinal cord
Running longitudinally along each lateral margin of the spinal cord there is a
thickening of pia mater that projects laterally. This thickening is the ligamentum
353
354
Fig. 39.7. Structures in the floor of the cranial fossae.
denticulatum. A number of pointed projections extend laterally THE SPINAL CORD

from this ligament: that is why it is called the ligamentum
denticulatum.
The spinal cord (or spinal medulla) is the most important
content of the vertebral canal. Many facts of importance
Other Structures seen in the Cranial cavity about the spinal cord will be considered in the section on
These will be described elsewhere. the brain. Here we will consider its gross anatomy in relation
1. Cranial nerves (Chapter 42) to other structures within the vertebral canal.
2. Intracranial venous sinuses (Chapter 41) The upper end of the spinal cord becomes continuous with
3. Intracranial parts of internal carotid, and vertebral arteries the medulla oblongata at the level of the upper border of the
(Chapter 42). first cervical vertebra. [A corollary of this fact is that it is
4. Hypophysis cerebri and pineal body (Chapter 45). the medulla oblongata that passes through the foramen
magnum, not the spinal cord]. The
lower end of the spinal cord lies at
the level of the lower border of the
first lumbar vertebra. The level is,
however, variable and the cord may
terminate one vertebra higher or
lower than this level. The level also
varies with flexion or extension of
the spine.
The lowest part of the spinal cord
is conical and is called the conus
medullaris. The conus is
continuous with the filum terminale
(described above).
When seen in transverse section the
grey matter of the spinal cord forms
an H-shaped mass (Fig. 39.8). In
each half of the cord the grey matter
is divisible into a larger ventral
mass, the anterior (or ventral) grey
column, and a narrow elongated
Fig. 39.8. Main features to be seen in a transverse section through the spinal cord.
posterior (or dorsal ) grey column.
The anterior and posterior grey
columns are frequently miscalled the anterior and posterior coccygeal regions the number of spinal segments, and of
horns). In some parts of the spinal cord a small lateral projection spinal nerves, does not correspond to the number of
of grey matter is seen between the ventral and dorsal grey vertebrae].
columns. This is the lateral grey column. The grey matter of The rootlets that make up the dorsal nerve roots are attached
the right and left halves of the spinal cord is connected across to the surface of the spinal cord along a vertical groove
the middle line by the grey commissure that is traversed by the opposite the tip of the posterior grey column (Fig. 39.8).
central canal. The lower end of the central canal expands to The rootlets of the ventral nerve roots are attached to the
form the terminal ventricle that lies in the conus medullaris. anterolateral aspect of the cord opposite the anterior grey
The white matter of the spinal cord is divided into right and column. The ventral and dorsal nerve roots join each other
left halves, in front by a deep anterior median fissure, and to form a spinal nerve. Just proximal to their junction the
behind by the posterior median septum. In each half of the dorsal root is marked by a swelling called the dorsal nerve
cord the white matter medial to the dorsal grey column forms root ganglion, or spinal ganglion (Fig. 39.9).
the posterior funiculus (or posterior white column). The white The spinal cord is not of uniform thickness. The spinal
matter medial and ventral to the anterior grey column forms segments that contribute to the nerves of the upper limbs
the anterior funiculus (or anterior white column), while the are enlarged to form the cervical enlargement of the cord.
white matter lateral to the anterior and posterior grey columns Similarly, the segments innervating the lower limbs form
forms the lateral funiculus. [The anterior and lateral funiculi the lumbar enlargement (Fig. 39.6).
are collectively referred to as the anterolateral funiculus].
Spinal Nerves and Spinal Segments
The spinal cord gives attachment, on either

side, to a series of spinal nerves. Each spinal
nerve arises by two roots, anterior (or ventral)
and posterior (or dorsal) (Fig. 39.8). Each
root is formed by aggregation of a number of
rootlets that arise from the cord over a certain
length. The length of the spinal cord giving
origin to the rootlets of one spinal nerve
constitutes one spinal segment. The spinal
cord is made up of thirtyone segments: 8
cervical, 12 thoracic, 5 lumbar, 5 sacral and Fig. 39.9. Relationship of a spinal nerve to the spinal cord.
one coccygeal. [Note that in the cervical and
355
356
In addition to spinal nerves the upper five or six cervical The veins draining the spinal cord are arranged in the form
segments of the spinal cord give origin to a series of rootlets of six longitudinal channels. These are anteromedian and
that emerge on the lateral aspect (midway between the anterior posteromedian channels that lie in the midline, and
and posterior nerve roots of spinal nerves). These rootlets join anterolateral and posterolateral channels that are paired.
to form the spinal root of the accessory nerve. The blood from these veins is drained into radicular veins
that open into a venous plexus lying between the dura mater
and the bony vertebral canal and through it into various
Blood supply of the spinal cord
segmental veins.
The spinal cord receives its blood supply from three
longitudinal arterial channels that extend along the length of
the spinal cord. The anterior spinal artery is present in relation VERTEBRAL VENOUS PLEXUS
to the anterior median fissure. Two posterior spinal arteries
(one on each side) run along the posterolateral sulcus (i.e. The vertebrae are surrounded by a dense plexus of veins.
along the line of attachment of the dorsal nerve roots). The plexus is divisible into an external part on the outer
The main source of blood to the spinal arteries is from the surface, and an internal part lining the vertebral canal. Apart
vertebral arteries (from which the anterior and posterior spinal from veins draining blood from the vertebrae, the plexus
arteries take origin). However, the blood from the vertebral receives veins from the meninges and from the spinal cord.
arteries reaches only up to the cervical segments of the cord. Opposite each intervertebral foramen the plexus drains into
Lower down the spinal arteries receive blood through radicular an intervertebral vein.
arteries that reach the cord along the roots of spinal nerves.
JOINTS OF HEAD AND NECK
The joints to be seen in the head and neck are as follows. The Atlantoaxial Joints
1. Joints between bones of the skull The atlas and axis vertebrae articulate with each other at
Adjacent edges of bones of the skull are united to each other three joints, one median, and two lateral.
by joints called sutures. The sutures are fibrous joints. The The median atlantoaxial joint is a synovial joint of the
names of some sutures have been mentioned while describing pivot variety. The dens of the axis (the pivot) lies in the ring
the skull. formed by the anterior arch of the atlas and its transverse
The bodies of the occipital and sphenoid bones are united by a ligament. In this situation there are really two synovial joints
synchondrosis. A synchondrosis is also present between the with independent capsules: one between the anterior surface
body of the sphenoid and the apex of the petrous temporal
bone. A synchondrosis is a primary cartilaginous joint. At such
a joint the two articulating surfaces are united by a plate of
hyaline cartilage. As age increases the cartilage is gradually
invaded by bone and the union becomes bony.
2. The temporomandibular joint
At this joint the head of the mandible articulates with the
articular fossa present on the temporal bone.
3. The atlanto-occipital joints
These are the joints between the occipital bone and the atlas.
They are described below.
4. Joints between cervical vertebrae.
Of these the joints between the atlas and axis vertebrae are Fig. 39.10. Schematic view of the inferior aspect of
atypical, and are described below. The remaining intervertebral the atlas to show the atlantoaxial joints.
joints are similar to typical intervertebral joints
Ligaments Uniting the Atlas, the Axis
and the Occipital Bone
Apart from the capsules of joints the atlas and axis are united
to each other and to the occipital bone by a number of
ligaments that are considered below.
1. The anterior longitudinal ligament (continued upwards
from lower vertebrae) is attached to the front of the body of
the axis; to the anterior arch of the atlas; and to the basilar
part of the occipital bone.
2. Between the atlas and the occipital bone, the anterior
longitudinal ligament is incorporated in the anterior atlanto-
occipital membrane. This membrane is attached below to
the upper border of the anterior arch of the atlas, and above
to the anterior part of the margin of the foramen magnum.
3. The posterior atlanto-occipital membrane is attached
Fig. 39.11. Median section through atlantoaxial joints. above to the posterior margin of the foramen magnum, and
below to the upper border of the posterior arch of the atlas.
4. The highest ligamentum flavum connects the posterior
of the dens and the posterior aspect of the anterior arch, and arch of the atlas to the laminae of the axis vertebra.
the other between the posterior surface of the dens and the 5. The membrana tectoria (Fig. 39.11) is an upward
transverse ligament. The transverse ligament is attached at each continuation of the posterior longitudinal ligament (that
end to the medial surface of the lateral mass of the atlas. connects the posterior surfaces of the bodies of adjacent
The lateral atlantoaxial joints are synovial joints of the plane vertebrae).
variety. 6. The dens (of the axis) is connected to the occipital bone
The ligaments connecting the atlas and axis, and the movements by the following:
at the atlanto-axial joints are considered below along with those a. The apical ligament passes upwards from the tip of
of the atlanto-occipital joints. the dens to the anterior margin of the foramen magnum (Fig.
39.11).
b. The right and left alar ligaments are attached below to
the upper part of the dens lateral to the apical ligament, and
The Atlanto-Occipital Joints
above to the occipital bone.
7. The transverse ligament of the atlas stretches between
There are two atlanto-occipital joints, right and left. At each
the two lateral masses of the bone, behind the dens of the
joint the occipital condyle articulates with a facet on the upper
axis (Fig. 39.11).
surface of the lateral mass of the atlas.
The occipital condyles lie on either side of the foramen magnum. Movements at the Atlanto-occipital and Atlantoaxial
They are large. The long axis of each condyle is directed Joints
forwards and medially. The condyle is convex both Being a pivot joint the median atlantoaxial joint allows the
anteroposteriorly and from side to side. The facet on the upper atlas (and with it the skull) to rotate around the axis provided
surface of the atlas is concave and corresponds in size and by the dens. This is accompanied by gliding movements at
direction to the occipital condyle. the lateral atlantoaxial joints. From a functional point of
These articular surfaces are enclosed in capsules to form view the two atlanto-occipital joints together form an
synovial joints. From a functional point of view the right and ellipsoid joint. The main movements allowed by it are those
left atlanto-occipital joints together form an ellipsoid joint. of flexion and extension (of the head) as in nodding. Slight
lateral movements are also allowed, but no rotation in
possible.
357
358
40 : Muscles and Triangles of the Neck

Deep Cervical Fascia
In Figure 40.1 we see a horizontal section through the lower parts. The part behind the sternocleidomastoid is called the
part of the neck. Such a section enables us to form a good posterior triangle, and the part in front of the muscle is the
picture of the arrangement of various structures present in the anterior triangle.
neck. The posterior triangle is bounded posteriorly by the anterior
Approximately in the centre of the drawing we see a cervical border of the trapezius, and inferiorly by the clavicle. The
vertebra. Immediately in front of the vertebra there is the inferior belly of the omohyoid (one of the infrahyoid
prevertebral region occupied by prevertebral muscles muscles) runs obliquely across the triangle and divides it
(represented at this level by the longus colli). The prevertebral into upper and lower parts.
region extends upwards right up to the base of the skull. The anterior triangle of the neck lies in front of the
In front of the prevertebral region, in the middle line, we see sternocleidomastoid. The superior belly of the omohyoid
the oesophagus, the trachea and the thyroid gland. runs upwards and forwards across the triangle. Also identify
The angular interval between the prevertebral region the digastric muscle. These muscles are used to divide the
(posteriorly) and the oesophagus and trachea (medially) is anterior triangle of the neck into four smaller triangles (Fig.
occupied by large blood vessels and nerves running up or down 40.2) as follows.
the neck. At the level shown the large vessels are the common a. The space between the anterior bellies of the right and left
carotid artery and the internal jugular vein. They are enclosed digastric muscles is called the submental triangle.
in a common fibrous covering called the carotid sheath. b. The digastric triangle is bounded above by the lower
Superficial to the foregoing visceral structures (oesophagus, border of the body of the mandible, behind by the posterior
trachea, thyroid gland, carotid sheath) we see a number of flat
ribbon like muscles. These are
collectively referred to as the
infrahyoid muscles. These include
the sternohyoid, sternothyroid,
thyrohyoid and omohyoid muscles.
The infrahyoid muscles are
overlapped by a large muscle the
sternocleidomastoid.
We will now turn our attention to
structures behind the vertebra. In
the angle between the spine and
transverse process of the vertebra
we see a mass formed by deep
muscles of the back. The deep
muscles of the back are overlapped
by two muscles already studied in
the upper extremity. These are the
levator scapulae, and the trapezius.
Just behind the carotid sheath there
are the lateral (or scalene) group
of muscles attached to the
transverse process. These are the
scalenus anterior, the scalenus
medius and the scalenus posterior.
Some muscles of the neck form the
boundaries of a number of triangles
(Fig. 40.2). The sternocleido-
mastoid is an important landmark.
It divides the side of neck into two Fig. 40.1. Transverse section through lower part of neck.
MUSCLES AND TRIANGLES OF NECK : DEEP CERVICAL FASCIA
Fig. 40.2. Triangles of the neck.
belly of the digastric, and in front by the anterior belly of the d. The muscular triangle is bounded medially (and
same muscle. anteriorly) by the anterior middle line of the neck,
c. The carotid triangle is bounded posteriorly by the anterior posterosuperiorly by the omohyoid, and posteroinferiorly
border of the sternocleidomastoid, above and in front by the by the sternocleidomastoid. In the floor of the muscular
posterior belly of the digastric muscle, and below and in front triangle we see the infrahyoid muscles.
by the superior belly of the omohyoid muscle.
MUSCLES OF THE NECK
The Platysma STERNOCLEIDOMASTOID

This muscle lies in the superficial fascia. The muscle arises
from the deep fascia covering the upper part of the pectoralis Origin:
major. The fibres passes upwards and forwards across the The muscle arises by two heads (Fig. 40.3).
clavicle, across the sternocleidomastoid, and then across the a. The sternal head arises from the anterior surface of the
lower border of the mandible. manubrium sterni.
The fibres end by merging with muscles at the angle of the b. The clavicular head arises from the upper surface of the
mouth. The muscle is supplied by the cervical branch of the medial part of the clavicle.
facial nerve.
Insertion:
The muscle is inserted into the:
a. lateral half of the superior nuchal line; and
b. the lateral surface of the mastoid process.
359
360
Sternothyroid
The sternothyroid takes origin from the posterior surface of
the manubrium sterni below the sternohyoid, and from the
medial end of the first costal cartilage. It is inserted into the
oblique line on the lamina of the thyroid cartilage just below
the origin of the thyrohyoid.
Omohyoid
The omohyoid has two bellies, superior and inferior, joined
by an intermediate tendon.
The inferior belly takes origin from the upper border of the
scapula (near the scapular notch). From here it passes
forwards, upwards and medially across the floor of the
posterior triangle (Fig. 40.2). It ends deep to the
sternocleidomastoid by joining the intermediate tendon.
The superior belly arises from the intermediate tendon and
passes upwards to reach the hyoid bone, where it is inserted
on the lower border of the body, lateral to the sternohyoid.
The intermediate tendon is kept in place by a band of deep
fascia that stretches from the tendon to the clavicle.
Nerve supply of infrahyoid muscles:
All the foregoing infrahyoid muscles are supplied by
branches from the ansa cervicalis except the thyrohyoid that
is supplied by fibres of the first cervical nerve that travel
Fig. 40.3. Attachments of the through the hypoglossal nerve.
sternocleidomastoid muscle. Actions of infrahyoid muscles:

The sternohyoid, the omohyoid and the thyrohyoid depress
the hyoid bone. The sternothyroid pulls the larynx
Nerve Supply: downwards, whereas the thyrohyoid can raise it when the
By accessory nerve (spinal part) and by branches from the hyoid bone is fixed.
ventral rami of spinal nerves C2, C3.
Actions:
When the muscle of one side contracts the head is tilted to the THE LATERAL VERTEBRAL MUSCLES
same side, and the face is rotated to the opposite side. When
the muscles of both sides act together the head and neck are
These are the scalenus anterior, the scalenus medius, the
flexed.
scalenus posterior and the scalenus minimus. Each muscle
is attached at one end to the transverse processes of one or
more cervical vertebrae, and at the other end to the first or
second rib.
INFRAHYOID MUSCLES
Scalenus Anterior
These are the sternohyoid, the sternothyroid, the thyrohyoid The scalenus anterior arises from the transverse processes
and the omohyoid muscles (Fig. 40.4). of vertebrae C3 to C6 (Fig. 40.5). It is inserted into the inner
border of the first rib.
Sternohyoid
The sternohyoid takes origin from: Nerve supply and action
a. posterior aspect of the manubrium sterni (upper part); It is supplied by the ventral rami of spinal nerves C4, C5,
b. medial end of the clavicle (posterior aspect). and C6. It bends the neck forwards and laterally.
The fibres of the muscle pass upwards and somewhat medially
to be inserted into the body of the hyoid bone (lower border).
Scalenus Medius
Thyrohyoid The scalenus medius takes origin from the transverse process
The thyrohyoid muscle takes origin from the oblique line on of the axis, and from the transverse processes of vertebrae
the lamina of the thyroid cartilage. It is inserted into the lower C3 to C7 (Fig. 40.5). The muscle is inserted into the upper
border of the greater cornu of the hyoid bone. surface of the first rib.
Fig. 40.4. Attachments of
infrahyoid muscles.
Nerve supply : Ventral rami of spinal nerves C3 to C8.

Action
The muscle bends the cervical spine to its own side.
Scalenus Posterior
The scalenus posterior takes origin from the transverse
processes of vertebrae C4, C5, C6. It is inserted into the
outer surface of the second rib.
The scalenus posterior is supplied by the ventral rami of
spinal nerves C6, C7, C8. It bends the cervical spine to
the same side.
ANTERIOR VERTEBRAL MUSCLES

(PREVERTEBRAL MUSCLES)
These are (a) the rectus capitis anterior, (b) the rectus
capitis lateralis, (c) the longus capitis, and (d) the longus
colli. The rectus capitis anterior and lateralis are short
muscles passing from the atlas vertebra to the base of
the skull. The longus capitis passes from cervical
transverse processes to the base of the skull. The longus
colli lies over the anterior aspect of the cervical and upper
thoracic vertebrae. For further details see Figure 40.6. Fig. 40.5. Attachments of scalenus anterior and
scalenus medius.
361
362
DEEP MUSCLES OF THE BACK
The deep muscles of the back come into view after the
superficial muscles that cover them (namely the trapezius,
the latissimus dorsi, the levator scapulae, rhomboids, and
the serratus posterior superior and inferior) are removed.
They are arranged in various groups. The names of the groups
and their arrangement is shown in Figure 40.7. A few muscles
are considered briefly below.
Splenius capitis
The attachments of this muscle are shown in Figure 40.8. It
is supplied by dorsal rami of cervical nerves. When the
muscle of both sides contract the head is pulled backwards.
When one muscle contracts the face is rotated to the same
side.
The Erector Spinae
The erector spinae is the most important muscle of the back.
It extends all the way from the back of the sacrum to the
skull, slips ending or taking origin from vertebral spines,
transverse processes and from ribs. It consists of a lateral
part, the iliocosto-cervicalis; an intermediate part called the
longissimus; and a small medial part, the spinalis (Fig. 40.7).
Each part has several subdivisions.
Nerve Supply and Actions of Erector Spinae:

The erector spinae is supplied by dorsal primary rami of
spinal nerves.
As a whole the erector spinae is an extensor and lateral flexor
of the vertebral column. The longissimus capitis turns the
Fig. 40.6. The prevertebral muscles. face to its own side.
The erector spinae is a very important postural muscle. In
persons who lead a sedentary life, and with old age, the
muscle becomes weak. The vertebral column then tends to
bend forwards. This puts excessive strain on ligaments of
the vertebral column and also predisposes to prolapse of
Fig. 40.7. Transverse section to show arrangement of deep muscles of the back.
Semispinalis Capitis
Origin:
The semispinalis capitis arises from:
a. the transverse processes of the upper thoracic and
seventh cervical vertebrae; and
b. the articular processes of the fourth, fifth and sixth cervical
vertebrae.
Insertion:
The muscle is inserted into the occipital bone on the medial
part of the area between the superior and inferior nuchal
lines.
The muscle forms the roof of the suboccipital triangle.
Nerve Supply and Actions:
The semispinalis group is supplied by dorsal rami of cervical
and thoracic spinal nerves.
The main action of the semispinalis capitis is to extend the
head.
SUBOCCIPITAL MUSCLES
This is a group of small muscles placed in the uppermost

Fig. 40. 8. Attachments of splenius capitis. part of the back of the neck, deep to the semispinalis capitis.
They form the boundaries of the suboccipital triangle (Fig.
40.9).
intervertebral discs. These are common causes of backache. The rectus capitis posterior minor arises from the posterior
Tone in the erector spinae can be maintained by exercises and arch of the atlas. Its fibres pass upwards to be inserted into
also by brisk walking. the occipital bone in the medial part of the area below the
inferior nuchal line (i.e. between the line and the foramen
magnum).
Fig. 40.9. Attachments of suboccipital muscles.
363
364
The rectus capitis posterior major arises from the spine of Nerve Supply and Actions:
the axis vertebra. It is inserted into the lateral part of the area The suboccipital muscles are supplied by the dorsal ramus
below the inferior nuchal line. of the first cervical nerve.
The obliquus capitis inferior arises from the spine of the The main action of the suboccipital muscles is to maintain
axis vertebra. It is inserted into the transverse process of the the posture of the head. Note that the head tends to fall
atlas vertebra. forwards due to gravity. This is resisted by the two recti and
The obliquus capitis superior arises from the transverse the superior oblique that extend it. They can rotate the head
process of the atlas. It inserted into the lateral part of the area and tilt it laterally.
between the superior and inferior nuchal lines.
TRIANGLES OF THE NECK
THE POSTERIOR TRIANGLE 4. The trunks of the brachial plexus are seen in the lower part
of the triangle. A number of branches arising from the plexus
are related to the triangle.
Boundaries: 5. The subclavian artery runs across the lowest part of the
The posterior triangle is bounded anteriorly by the posterior posterior triangle. The transverse cervical artery runs
border of the sternocleidomastoid, posteriorly by the anterior backwards a little above the posterior belly of the omohyoid
border of the trapezius, and inferiorly (base) by the clavicle. muscle. The occipital artery crosses the apex of the posterior
triangle.
Floor:
The floor of this triangle is formed mainly by the splenius
capitis, the levator scapulae, and the scalenus medius. Other
muscles that may occasionally be seen in the floor are the
semispinalis capitis, the scalenus posterior, and the scalenus SUBDIVISIONS OF
anterior. THE ANTERIOR TRIANGLE
The lower part of the posterior triangle is crossed by the inferior
belly of the omohyoid muscle that divides the triangle into an
upper part (also called the occipital triangle), and a lower part Submental Triangle
(also called the supraclavicular triangle). Above and laterally, this triangle is bounded on each side
The muscles forming the floor are covered by the prevertebral (right and left) by the anterior belly of the digastric muscle.
layer of deep cervical fascia. The third side of the triangle (base) is formed by the hyoid
bone. The floor of the triangle is formed by the mylohyoid
Roof: muscle.
The roof of the posterior triangle is formed by the investing The only contents of the triangle are the submental lymph
layer of deep cervical fascia. nodes, and some small blood vessels.
Several nerves and vessels are present in relation to the roof
of the posterior triangle. These include the supraclavicular, Digastric Triangle
lesser occipital, greater auricular, and transverse cutaneous This triangle is bounded above by the base of the mandible,
nerves; and the external jugular vein. and below by the anterior and posterior bellies of the digastric
muscle. Its floor is formed by the mylohyoid and hyoglossus
Contents: muscles, and by the anterior part of the middle constrictor
1. Cutaneous branches of the cervical plexus (supraclavicular, of the pharynx. The roof of the triangle is formed by skin,
lesser occipital, greater auricular and transverse cutaneous) superficial fascia (containing the platysma, the cervical
enter the posterior triangle by piercing the fascia over its floor, branch of the facial nerve and some cutaneous nerves) and
and run for some distance between the floor and roof, before the investing layer of deep fascia. The main content of this
piercing the latter to become subcutaneous. triangle is the submandibular gland.
2. Muscular branches arising from the cervical plexus for the The contents of this triangle have been studied in detail in
levator scapulae and trapezius run deep to the fascia of the the submandibular region.
floor.
3. The spinal accessory nerve runs downwards and laterally Carotid Triangle
across the triangle lying between the two layers of the fascia This triangle is bounded posteriorly by the anterior margin
forming the roof. of the sternocleidomastoid muscle, superiorly by the
posterior belly of the digastric muscle, and anteroinferiorly by SUBOCCIPITAL TRIANGLE
the superior belly of the omohyoid muscle. Its roof is formed by
skin, superficial and deep fascia. The floor of the triangle is
formed by the thyrohyoid and hyoglossus muscles, and the Boundaries
middle and inferior constrictors of the pharynx. The suboccipital muscles form the boundaries of the
The carotid triangle contains several important blood vessels suboccipital triangle as follows (Fig. 40.9).
and nerves. These are as follows: 1. Medially and above, there are the rectus capitis posterior
1. Common carotid artery, along with carotid sinus and carotid major and minor muscles.
body. 2. Laterally and above, there is the obliquus capitis superior.
2. Internal carotid artery. 3. Inferiorly, there is the obliquus capitis inferior.
3. External carotid artery and the following branches arising
Roof
from it.
The roof of the suboccipital triangle is formed by the
(a) Superior thyroid artery.
semispinalis capitis muscle. Deep to the semispinalis capitis
(b) Lingual artery.
the triangle is covered by dense fascia.
(c) Facial artery.
(d) Ascending pharyngeal artery. Floor
(e) Occipital artery. The floor of the suboccipital triangle is formed by the
4. Internal jugular vein, and some tributaries draining into it. posterior arch of the atlas, and the posterior atlanto-occipital
5. Vagus nerve, and its superior laryngeal branch dividing into membrane.
external and internal laryngeal nerves.
Contents
6. Spinal accessory nerve.
1. The third part of the vertebral artery enters the suboccipital
7. Hypoglossal nerve and upper root of ansa cervicalis.
region after emerging from the foramen transversarium of
8. Sympathetic trunk.
the atlas. It then runs medially over the posterior arch of the
The common carotid and internal carotid arteries, the internal
atlas and disappears under the lateral free edge of the
jugular vein and the vagus nerve are surrounded by the carotid
posterior atlanto-occipital membrane.
sheath.
2. The dorsal ramus of the first cervical nerve runs backwards
Muscular Triangle above the posterior arch of the atlas, lying below the vertebral
This triangle is bounded posteroinferiorly by the artery. It gives branches to the suboccipital muscles and to
sternocleidomastoid muscle, posterosuperiorly by the superior the semispinalis capitis.
belly of the omohyoid muscle, and anteriorly (or medially) by 3. The greater occipital nerve winds round the lower border
the anterior middle line of the neck. of the obliquus capitis inferior. It then runs upwards (and
The triangle contains the infrahyoid muscles. Deep to these slightly medially) across the suboccipital triangle. It leaves
muscles it contains the thyroid gland, the larynx and the trachea. the triangle by piercing the semispinalis capitis.
On either side of the trachea we see the carotid sheath and its
contents.
DEEP CERVICAL FASCIA
In several planes in the neck the connective tissue is condensed separate to enclose the trapezius, and end by gaining
to form recognisable sheets that are collectively referred to as attachment to the ligamentum nuchae.
deep cervical fascia. The layers are as follows. Note the following additional points about the investing
1. Investing layer layer of deep cervical fascia.
Deep to the skin, superficial fascia and platysma we see the 1. When traced upwards over the submandibular region the
investing layer of deep fascia. This layer is made up of two two laminae separate to enclose the submandibular gland.
laminae that go right round the neck enclosing all structures 2. In the interval between the mandible and the mastoid
deep to them. Anteriorly, near the middle line of the neck the process the two laminae enclose the parotid gland. Here the
two laminae are fused to each other. Traced laterally, the laminae superficial lamina is thick and forms the parotid fascia. The
separate to enclose the sternocleidomastoid muscle. At the deep lamina forms the stylomandibular ligament that
posterior edge of this muscle the layers meet again and form intervenes between the parotid gland and the submandibular
the roof of the posterior triangle. Passing posteriorly they again gland.
365
366
3. Just above the manubrium sterni the two laminae enclose scapulae, and then over the deep muscles of the back to reach
the suprasternal space. the ligamentum nuchae. The prevertebral fascia covers the
4. Above the clavicle (near the base of the posterior triangle) floor of the posterior triangle.
the two laminae of the investing layer enclose the The axillary sheath is an extension of this fascia around the
supraclavicular space. subclavian artery and brachial plexus. The sheath extends
5. The accessory nerve runs across the posterior triangle lying into the axilla.
between the two laminae.
4. Carotid sheath
2. Pretracheal fascia The tubular sheath of fascia surrounding the common and
The thyroid gland is enclosed in a layer of fascia. When traced internal carotid arteries, and the internal jugular vein, is also
downwards this fascia lies in front of the trachea and is, described as part of the deep cervical fascia. It extends from
therefore, called the pretracheal fascia. the lower end of the neck to the base of the skull. The vagus
nerve lies within the sheath behind the interval between the
3. Prevertebral fascia
common (or internal) carotid artery and the internal jugular
This layer of deep cervical fascia lies behind the oesophagus
vein. The sympathetic trunk descends just outside the sheath
and pharynx. It covers the prevertebral muscles. Traced
posterior to the arteries. The ansa cervicalis is closely related
laterally, it passes onto the scalene muscles and levator
to the front of the carotid sheath.
41 : Blood Vessels of Head and Neck

ARTERIES
THE COMMON CAROTID ARTERIES
On the right side the common carotid artery is a branch of

the brachiocephalic trunk, while on the left side it is a direct
branch of the arch of the aorta. It follows that the left common
carotid artery runs parts of its course in the thorax.
The courses and relations of the cervical parts of the right
and left common carotid arteries are similar. Starting behind
the corresponding sternoclavicular joint each artery runs
upwards and somewhat laterally up to the level of the upper
border of the thyroid cartilage (Fig. 41.1). Here it terminates
by dividing into the internal and external carotid arteries. It
(normally) gives no other branches. In its upward course
each common carotid artery lies in a triangular area bounded
behind by the transverse processes of the cervical vertebrae
(fourth to sixth); medially in the lower part, by the
oesophagus and trachea, and higher up by the pharynx and
larynx; and anterolaterally by the sternocleidomastoid
muscle. The artery is enclosed in a fibrous carotid sheath
that also encloses the internal jugular vein (lateral to the
artery) and the vagus nerve (lying posterior to the interval Fig. 41.1. Relationship of common carotid artery to the
between the artery and the vein). larynx, trachea and thyroid. Some structures deep to the
artery are also shown.
Some additional relations of the artery are as follows:
BLOOD VESSELS OF HEAD AND NECK
Fig. 41.2. Lateral side of the neck. Note the thyroid gland and its arteries, the
subclavian vessels and the carotid arteries.
367
368
1. Running vertically behind the carotid sheath there
is the sympathetic trunk. Fig. 41.5. Scheme to show
2. The inferior thyroid artery runs transversely behind the branches of the internal
the lower part of the artery (Fig. 41.1). carotid artery.
3. The artery is overlapped by the sternocleidomastoid,
the sternohyoid and sternothyroid muscles.
4. The artery is crossed by the superior belly of the
omohyoid muscle.
5. The artery is related medially to the thyroid gland,
and the recurrent laryngeal nerve (running vertically
between trachea and oesophagus).
INTERNAL CAROTID ARTERY
Internal Carotid Artery in the Neck of the skull where they enter the carotid canal. Each artery
The internal carotid arteries begin at the upper border may be considered as the main upward continuation of the
of the thyroid cartilage and ascend to reach the base common carotid artery and occupies a similar position.
Like the latter it is surrounded by the carotid sheath along
with the internal jugular vein and the vagus nerve. The
superior cervical sympathetic ganglion lies behind the carotid
sheath. On the medial side the artery is related to the pharynx.
At its upper end the internal jugular vein lies posterior to
the artery; and the glossopharyngeal, vagus, accessory and

hypoglossal nerves lie between them.
Cranial Part of the Internal Carotid Arteries
The cranial part of the internal carotid artery has a
complicated course (Fig. 41.4). On reaching the base of the
skull the artery enters the petrous part of the temporal bone
through the external opening of the carotid canal.
It then bends sharply (Fig. 41.4, first bend) to run horizontally
forwards and medially through the carotid canal to reach
the foramen lacerum. It now undergoes a second bend to
Fig. 41.3. T.S. neck to show some relations of the run vertically through the upper part of this foramen to enter
internal carotid artery. the cranial cavity. It then lies within the cavernous sinus.
Here it undergoes a third bend to run forwards on the side of
the body of the sphenoid bone. Near the anterior end of the
body it again bends upwards (fourth bend) on the medial
side of the anterior clinoid process. Here it pierces the dura
mater forming the roof of the cavernous sinus and comes
into relationship with the cerebrum. The artery now turns
backwards (fifth bend) to reach the anterior perforated
substance of the brain. The artery terminates here by dividing
into the anterior and middle cerebral arteries. From the above
it is seen that the cranial part of the internal carotid artery
can be divided into a petrous part, a cavernous part and a
cerebral part.
Additional relations of importance are as follows:
a. As it lies in the carotid canal the artery is closely related to
the middle ear, the auditory tube and the cochlea.
b. As the artery passes through the cavernous sinus it is
related to several cranial nerves that are embedded in the
Fig. 41.4. Scheme to show the intracranial course of lateral wall of the sinus. From above downwards these are
the internal carotid artery. the oculomotor nerve, the trochlear nerve, the ophthalmic
division of the trigeminal nerve, and the maxillary division of The further branches given off by the lacrimal artery are
the same nerve. The abducent nerve lies in close contact with shown in Figure 41.6.
the inferolateral side of the artery. The other branches of the ophthalmic artery arise from the
c. After piercing the dura mater the artery has the optic nerve main stem of the artery (Fig. 41.6).
above it and the oculomotor nerve below it. The anterior and posterior ciliary arteries supply the
The internal carotid artery gives off three large branches. These eyeball. The supraorbital branch supplies the skin of the
are the ophthalmic artery to the orbit, and the anterior and forehead. The anterior and posterior ethmoidal branches
middle cerebral arteries to the brain. The ophthalmic artery supply the ethmoidal air sinuses. Some ramifications of these
is described in detail below. The cerebral arteries will be arteries reach the anterior cranial fossa and the nose. The
considered in the section on the brain (Chapter 56). medial palpebral branches supply the eyelids.
In addition to these, the internal carotid artery gives off several The supratrochlear artery is one of the terminal branches
smaller branches that are shown in Figure 41.5. of the ophthalmic artery. It supplies the skin of the forehead
(along with the supraorbital artery).
The Ophthalmic Artery
The ophthalmic artery passes forwards to enter the cavity of THE EXTERNAL CAROTID ARTERIES
the orbit through the optic canal. In this canal it is inferolateral
to the optic nerve. Having entered the orbit the artery is at
Each external carotid artery arises from the common carotid
first lateral to the optic nerve (Fig. 41.6). It then crosses above
at the level of the upper border of the thyroid cartilage (or
the nerve to reach the medial wall of the orbit and runs
the level of the disc between the third and fourth cervical
forwards along this wall.
vertebrae) (Fig.41.7). It gives off several branches through
Branches of the Ophthalmic artery which it is widely distributed to structures of the head and
The branches of the ophthalmic artery are shown in Figure neck outside the cranial cavity. From its origin the artery
41.6. runs upwards and terminates behind the neck of the
1. The central artery of the retina is the first branch of the mandible. The lower part of the artery is anterior and medial
ophthalmic artery. It arises from the ophthalmic artery when to the internal carotid. Its upper part is lateral to the internal
the latter is still within the optic canal. It enters the substance carotid. The lower part of the artery is located within the
of the optic nerve and runs forwards in its centre to reach the carotid triangle. Above the triangle the artery lies deep to
optic disc. Here it divides into branches that supply the retina. the posterior belly of the digastric muscle and the parotid
2. The largest branch of the ophthalmic artery is the lacrimal gland. Deep to the artery there is the pharynx.
artery that runs forwards along the lateral wall of the orbit.
BRANCHES OF THE
EXTERNAL CAROTID
ARTERY
The branches of the external

carotid artery and their levels of
origin are as follows (in order of
origin) (Fig. 41.7).
1. The ascending pharyngeal
artery arises from the deep aspect
of the external carotid artery just
above its lower end.
2. The superior thyroid artery
arises from the front of the external
carotid just below the level of the
greater cornu of the hyoid bone.
3. The lingual artery arises from
the front of the external carotid
artery opposite the tip of the
greater cornu of the hyoid bone.
4. The facial artery arises from the
front of the external carotid a little
Fig. 41.6. Scheme to show the branches of the ophthalmic artery. above the origin of the lingual
artery.
369
370
5. The occipital artery arises from the back of the
external carotid opposite the origin of the facial
artery.
6. The posterior auricular artery arises from the
back of the external carotid just above the level at
which the latter is crossed by the posterior belly
of the digastric muscle.
7 and 8. The superficial temporal artery and the
maxillary artery are terminal branches of the
external carotid artery. They begin behind the neck
of the mandible, in the substance of the parotid
gland.
These branches will be considered one by one.
Ascending Pharyngeal Artery

The ascending pharyngeal artery runs upwards to
the base of the skull, lying between the pharynx
and the internal carotid artery. Its distribution is
shown in Figure 41.8
Superior Thyroid Artery

Fig. 41.7. Scheme to show the landmarks to which the external
The superior thyroid artery runs downwards and carotid artery and its branches, are related. The boundaries of
medially to reach the upper pole of the thyroid the carotid triangle are shown in interrupted line.
gland. Here it divides into anterior and posterior
thyroid branches (Fig. 41.9). These branches ramify over the third or deep part of the artery runs upwards along the
corresponding surfaces of the gland. The terminal part of the anterior margin of the hyoglossus, and then forwards to the
anterior branch runs across the upper part of the isthmus of the tip of the tongue. The branches of the lingual artery are shown
gland to anastomose with the artery of the opposite side. The in Figure 41.10.
posterior branch runs downwards along the posterior border
of the thyroid to anastomose with the inferior thyroid artery.
Other branches of the superior

thyroid artery are shown in Figure
41.9.
Lingual Artery
The lingual artery arises from the

external carotid artery opposite
the tip of the greater cornu of the
hyoid bone. The first part of the
artery lies in the carotid triangle,
superficial to the middle
constrictor of the pharynx (Fig.
41.10). It forms a characteristic
upward loop that is crossed by the
hypoglossal nerve. The second
part of the artery lies deep to the
hyoglossus muscle that separates
it from the hypoglossal nerve. The
Fig. 41.8. Scheme to show the distribution of the ascending pharyngeal artery.
aspect of the body of the mandible,
and across the buccinator muscle
to reach the angle of the mouth. It
then runs upwards along the side
of the nose to reach the medial angle
of the palpebral fissure.
The branches of the facial artery are
shown in Figure 41.11. They are as
follows:
1. The ascending palatine artery
ascends on the lateral wall of the
pharynx. It supplies the pharynx,
the palate, the tonsil and the
auditory tube.
2. The tonsillar branch reaches the
tonsil by piercing the superior
constrictor muscle.
3. Some branches are given off to
the submandibular gland.
Fig. 41.9. Scheme to show the distribution of the superior thyroid artery. 4. The submental artery runs
forwards along the lower border of
the mandible (over the mylohyoid
muscle).
5. The superior and inferior labial
branches supply the lips.
6. The lateral nasal branch
supplies the side of the nose.
7. The terminal part of the facial
artery is the angular artery.
The Occipital Artery
This artery arises from the posterior
aspect of the external carotid
opposite the origin of the facial
artery. It runs backwards along the
lower border of the posterior belly
of the digastric muscle to reach the
skull medial to the mastoid process.
It then becomes superficial and
supplies the posterior part of the
Fig. 41.10. Scheme to show the branches of the lingual artery. scalp.
The Facial Artery
The facial artery arises from the external carotid

just above the greater cornu of the hyoid bone (Fig.
41.11). Its initial part lies deep to the ramus of the
mandible, near the angle. This part is closely related
to the submandibular gland. The artery first runs
upward along the posterior border of the gland and
then downwards and forwards between the gland
(deep to it) and the medial pterygoid muscle
(superficial to it). It reaches the lower border of
the mandible at the anterior edge of the masseter
(Fig. 41.11). Curving round this border the artery Fig. 41.11. Scheme to show branches of the facial artery.
runs upwards and forwards across the superficial
371
372
The Maxillary Artery
This is one of the terminal branches of the external

carotid artery. It begins behind the neck of the mandible,
within the substance of the parotid gland. For
convenience of description it is divided into three parts.
The first part passes forwards deep to the neck of the
mandible to reach the infratemporal fossa. Here it runs
forwards along the lower border of the lateral pterygoid
muscle (Figs. 37.1, 41.14). The second part of the artery
runs forwards and upwards superficial to the lower head
of the lateral pterygoid muscle. The third part of the
artery passes between the upper and lower heads of the
lateral pterygoid muscle to pass through the
pterygomaxillary fissure thus entering the
Branches of first part:
The branches of the first part of the maxillary artery are
shown in Figure 41.15. They are described below.
1. The deep auricular artery supplies the external
Fig. 41.12. Distribution of the occipital artery. acoustic meatus, the tympanic membrane and the
temporomandibular joint.
The occipital artery gives off several branches that are shown
in Figure 41.12. These are as follows. (Numbers correspond to
those in the figure).

1, 2. Branches to the sternocleidomastoid. 3. The stylomastoid
branch enters the stylomastoid foramen to supply the middle
ear and related structures. 4. The auricular branch supplies
the pinna. 5. Mastoid branch. 6. Meningeal branches.
7. The descending branch runs down through the deep muscles
of the back of the neck. It divides into a superficial branch and
a deep branch. 8. The occipital branches supply the posterior
part of the scalp. 9. Meningeal branch.
The Posterior Auricular Artery
Fig. 14.14. Course of the maxillary artery.
This artery arises from the external carotid just above the
posterior belly of the digastric muscle (and stylohyoid muscle).
It passes backwards and upwards deep to the parotid gland to 2. The anterior tympanic branch supplies the middle ear
reach the mastoid process. The branches of the artery are shown and the tympanic membrane.
in Figure 41.13.
3. The middle meningeal artery runs
upward deep to the lateral pterygoid muscle.
It passes between the two roots of the
auriculotemporal nerve (Figs. 41.15). The
artery enters the cranial cavity through the
foramen spinosum. It runs forwards and
laterally over the floor of the middle cranial
fossa and divides into frontal and parietal
branches (Fig. 39.7). The frontal branch of
the artery lies deep to the pterion (circular
area at which the frontal, parietal, temporal
and sphenoid bones meet); and it can be
approached surgically by drilling a hole in
the skull in this situation.
4. The accessory meningeal artery enters
the cranial cavity through the foramen ovale.
Fig. 41.13. Distribution of the posterior auricular artery.
molar and premolar teeth, and the maxillary air sinus.
2. The infraorbital artery enters the orbit through the inferior
orbital fissure. It runs forwards in relation to the floor of the
orbit, first in the infraorbital groove and then in the
infraorbital canal to emerge on the face through the
infraorbital foramen. It gives off some orbital branches to
structures in the orbit, and anterior superior alveolar
branches that reach the incisor and canine teeth. After
emerging on the face the infraorbital artery gives branches
to the lacrimal sac, the nose and the upper lip.
The remaining branches of the third part arise within the
3. The greater palatine artery runs downwards in the greater
palatine canal to emerge on the hard palate through the
Fig. 41.15. Branches of the first part of the maxillary artery. greater palatine foramen. It then runs forwards near the
lateral margin of the palate. Branches of the artery supply
the palate and gums. Within the greater palatine canal it gives
5. The inferior alveolar artery (Fig. 41.16) runs downwards off the lesser palatine arteries that emerge on the palate
and forwards medial to the ramus of the mandible to reach the through lesser palatine foramina and run backwards into the
mandibular foramen. Passing through this foramen the artery soft palate and tonsil.
enters the mandibular canal (within the body of the mandible) 4. The pharyngeal branch supplies part of the nasopharynx,
in which it runs downwards and then forwards. Before entering the auditory tube and the sphenoidal air sinus.
the mandibular canal the artery gives off a lingual branch to 5. The artery of the pterygoid canal helps to supply the
the tongue; and a mylohyoid branch that descends in the pharynx, the auditory tube and the tympanic cavity.
mylohyoid groove (on the medial aspect of the mandible) and 6. The sphenopalatine artery passes medially through the
runs forwards above the mylohyoid muscle. Within the sphenopalatine foramen to enter the cavity of the nose. It
mandibular canal the artery gives branches to the mandible and gives off branches to the nose and the paranasal sinuses.
to the roots of each tooth attached to the bone. It also gives off
a mental branch that
passes through the mental
foramen to supply the chin.
Branches of second part:
The branches of the second
part of the maxillary artery
(Fig. 41.16) are mainly
muscular. The deep tem-
poral branches (anterior
and posterior) ascend on
the lateral aspect of the
skull deep to the tem-
poralis muscle. Branches
are also given off to the
pterygoid muscles and to
the masseter. A buccal
branch supplies the
buccinator muscle.
Branches of third part:
The branches of the third
part of the maxillary artery
are shown in Figure 41.16.
They are as follows:
1. The posterior superior
alveolar artery descends
on the posterior surface of
the maxilla and gives Fig. 41.16. Branches of the maxillary artery.
branches that supply the
373
374
Fig. 41.18. Relationship of subclavian artery to the vagus

nerve. The phrenic nerve is also shown.
Fig. 41.17. Branches of the superficial

temporal artery.
The Superficial Temporal Artery

This is the second terminal branch of the external carotid artery.
It begins behind the neck of the mandible in the substance of
the parotid gland. It runs upwards behind the
temporomandibular joint and ramifies in the scalp over the
temporal region. It is accompanied by the auriculotemporal
nerve. The branches of the artery are shown in Figure 41.17.
THE SUBCLAVIAN ARTERIES Fig. 41.19. Scheme to show the branches of the
subclavian artery.
We have seen that the right subclavian artery is a branch of the
brachiocephalic trunk and begins behind the right
3. The internal jugular vein runs vertically across the
sternoclavicular joint. The left subclavian artery is a direct
subclavian artery to join the subclavian vein.
branch of the aorta. It has a thoracic part that ends behind the
4. The subclavian vein lies below and in front of the artery
left sternoclavicular joint. Thereafter, the course and relations
separated from it by the scalenus anterior muscle.
of the right and left subclavian arteries are similar.
5. The artery is also crossed vertically by the vagus nerve.
Each subclavian artery is the initial part of a long channel that
The right vagus nerve gives off its recurrent laryngeal branch
supplies the upper limb. Entering the neck behind the
just as it reaches the lower margin of the subclavian artery.
corresponding sternoclavicular joint the artery loops upwards
The recurrent laryngeal nerve curves around the inferior and
into the neck. It leaves the neck by passing into the axilla,
posterior aspects of the artery and runs medially to reach
where it becomes the axillary artery. The subclavian artery
the groove between the trachea and the oesophagus.
(whole of right, and cervical part of left) extends from the
6. The relationship of the right and left phrenic nerves to the
sternoclavicular joint to the outer border of the first rib.
subclavian arteries is shown in Figure 41.18. Note that the
Some important relationships of the artery are as follows.
nerves descend across the corresponding scalenus anterior
1. The artery lies in front of the apex of the lung and the cervical
muscle. On the left side the nerve passes across the medial
pleura. It arches across the lower part of the neck.
border of the muscle on to the front of the first part of the
2. The artery is crossed anteriorly by the lower part of the
subclavian artery. On the right side the nerve usually crosses
scalenus anterior muscle. It divides the artery into the first
the medial border of the muscle lower down so that the nerve
part, medial to the muscle; the second part deep to it; and the
does not come into direct contact with the first part of the
third part lateral to it.
subclavian artery, but is separated from the second part by the
scalenus anterior.
7. The first part of the subclavian artery lies below the level of
the brachial plexus, but the second and third parts come into
relationship with the trunks of the plexus. The lower trunk lies
behind and below the second and third parts of the artery. The
upper and middle trunks lie above the second part of the artery,
and above and lateral to its third part.
8. The terminal part of the thoracic duct descends in front of
the first part of the left subclavian artery.
Fig. 41.20. Relationship of vertebral artery to

Branches of the Subclavian Artery
atlas vertebra.
The subclavian artery gives origin to several branches that are

shown in Figure 41.19. A brief introduction to these branches is
given below. Each branch is considered in detail in subsequent
pages.
a. The vertebral artery arises from the first part. It runs upwards
to enter the foramen transversarium of the sixth cervical vertebra
b. The internal thoracic artery arises from the first part and
runs downwards into the thorax.
c. The thyrocervical trunk is a short vessel arising near the
medial edge of the scalenus anterior muscle. It divides into the
inferior thyroid, suprascapular and transverse cervical arteries.
d. The costocervical trunk arises either from the first or second
part. It runs backwards to reach the neck of the first rib. Here it
divides into the deep cervical and superior intercostal arteries.
e. The dorsal scapular artery is an occasional branch of the
third part. When present it replaces the deep branch of the
transverse cervical artery.
The internal thoracic artery is described on in the thorax. The
other arteries are considered one by one below.
The Vertebral Artery
The vertebral artery arises from the first part of the subclavian
artery (Fig. 41.2). It ascends to enter the foramen transversarium
of the sixth cervical vertebra (not the seventh) and then
continues upwards through the foramina of higher vertebrae.
Emerging through the foramen transversarium of the atlas it Fig. 41.21. Scheme to show the branches of the
winds round the lateral mass of this bone. It then lies in the vertebral artery.
groove on the upper surface of the posterior arch of the atlas.
Finally, it passes forwards into the vertebral canal and running
upwards passes through the foramen magnum to enter the cranial b. The part of the artery passing through the foramina
cavity. Here it lies lateral to the lower end of the medulla transversaria constitutes its second part.
oblongata. Continuing its ascent it gradually passes forwards c. The part of the artery winding round the lateral mass of
and medially over the medulla and ends at the lower border of the atlas is its third part. This part lies in the suboccipital
the pons by anastomosing with the opposite vertebral artery to triangle.
form the basilar artery. The following additional points about The vertebral artery enters the vertebral canal through an
the vertebral artery may now be noted. aperture bounded laterally by the lateral mass of the atlas
a. The part of the artery between its origin from the subclavian and medially by the free lateral margin of the posterior
artery and its entry into the foramen transversarium of vertebra atlanto-occipital membrane.
C6 constitutes its first part. The branches of the vertebral artery that supply structures
in the neck are shown in Figure 41.21.
375
376
The anterior spinal arteries of the two sides join to form a
single trunk that descends on the anterior aspect of the spinal
cord, in the midline. The posterior spinal artery descends
along the posterolateral aspect of the spinal cord. The anterior
and posterior spinal arteries are joined by spinal branches
arising from several arteries.
In addition to the branches described above the vertebral artery
gives off the posterior inferior cerebellar artery that takes
part in supplying the brain. It will be considered in the section
on the blood supply of the brain. The basilar artery and its
branches will also be considered therein.
The Thyrocervical Trunk
The thyrocervical trunk is a short artery that arises near the

junction of the first and second parts of the subclavian artery.
On the left side it usually arises just medial to the scalenus
anterior muscle i.e. from the first part of the subclavian artery.
On the right side the trunk usually arises deep to the scalenus Fig. 41.23. Scheme to show the branches of the
costocervical trunk.
anterior, being a branch of the second part of the subclavian
artery.
After a short course the trunk divides into three branches, Other named branches arising from the inferior thyroid artery
namely the inferior thyroid artery, the suprascapular artery are the ascending cervical artery and the inferior laryngeal
and the transverse cervical artery. The transverse cervical artery.
artery further divides into a superficial and a deep branch.

Quite frequently the deep branch arises directly from the third The Costocervical Trunk
part of the subclavian artery. In that case the transverse cervical
artery is represented only by its superficial branch and is called The costocervical trunk takes origin from the posterior aspect
the superficial cervical artery. The deep branch, arising directly of the subclavian artery.
from the subclavian artery is called the dorsal scapular artery. On the left side it arises from the first part, but on the right
The Inferior Thyroid Artery side the origin is from the second part. It runs backwards
This artery is a branch of the thyrocervical trunk. It runs with an upward convexity following the curve of the cervical
upwards for some distance and then turns medially to reach pleura to reach the neck of the first rib. Here it divides into
the thyroid gland. The artery is distributed mainly to this gland the deep cervical and superior intercostal arteries.
through an ascending and a descending glandular branch. The deep cervical artery passes backwards above the
neck of the first rib to reach the back of the neck. Here
it ascends through the deep muscles supplying them.
The superior intercostal artery descends across the
neck of the first rib to reach the first intercostal space
The Dorsal Scapular Artery
The dorsal scapular artery is an occasional branch
arising from the third part of the subclavian artery.
When present it replaces the deep branch of the
transverse cervical artery.
Fig. 41.22. Branches of the inferior thyroid artery.

THE VEINS
THE INTERNAL
JUGULAR VEINS
The right and left internal jugular veins

are the chief veins of the head and neck.
On either side the upper end of the vein
lies in the jugular foramen on the base
of the skull. Here the internal jugular
vein becomes continuous with the
sigmoid sinus. The lower end of the vein
lies behind the sternal end of the clavicle
where the internal jugular joins the
subclavian vein to form the
corresponding brachiocephalic vein.
In its course through the neck the
internal jugular vein lies alongside the
internal carotid and common carotid
arteries being enclosed along with them
in the carotid sheath. These arteries are
medial to the vein, but just below the
skull the internal carotid artery is in
front of the vein. The vagus nerve that
is also within the carotid sheath, lies
posteromedial to the vein.
Tributaries of the Internal Jugular Fig. 41.24. Scheme to show the structures superficial to the internal jugular vein
Vein (lateral view). The parotid gland (not shown) is superficial to the vein above the
The tributaries of the internal jugular posterior belly of the digastric muscle.
vein include the intracranial venous
sinuses and several other veins that are
shown in Figure 41.25. They will be
described after we have considered the
subclavian vein that is the second largest
vein of the neck.
THE SUBCLAVIAN VEINS
Each subclavian vein (right and left)

begins at the outer border of the first
rib, as a continuation of the axillary
vein. It runs medially parallel to the
subclavian artery, but lies anterior and
inferior to the artery. The two vessels
are separated by the scalenus anterior.
The subclavian vein ends at the medial
margin of this muscle by joining the
internal jugular vein. Anteriorly, the
subclavian vein is related to the clavicle.
Fig. 41.25. Scheme to show the tributaries of the internal jugular vein.
377
378
Below, the vein rests on the first rib and on the cervical pleura. Each sinus runs in a curve at first laterally and then forwards,
The tributaries of the subclavian vein are the external jugular along the line of attachment of the tentorium cerebelli. It
vein and the dorsal scapular vein. The thoracic duct enters it at produces a transverse groove of the inner surface of the
its junction with the internal jugular. occipital bone, and on the posteroinferior angle of the parietal
bone. Finally it reaches the petrous part of the temporal bone
where it becomes continuous with the sigmoid sinus.
6. The right and left sigmoid sinuses are continuations of
the corresponding transverse sinuses. As indicated by the
THE INTRACRANIAL
name each sigmoid sinus is S-shaped. It first runs downwards
VENOUS SINUSES
and medially in a deep groove on the mastoid part of the
temporal bone, and then across the jugular process of the
occipital bone. Finally it runs forwards to reach the jugular
UNPAIRED SINUSES LYING IN THE MIDLINE
foramen where it ends by becoming continuous with the
upper end of the internal jugular vein.
1. The superior sagittal sinus occupies the triangular space
7. The right and left cavernous sinuses lie in the middle
produced by the reflection of the inner layer of duramater to
cranial fossa. They are placed anteroposteriorly on either
form the falx cerebri. It begins anteriorly in front of crista galli.
side of the body of the sphenoid bone. Anteriorly each sinus
It then runs backwards deeply grooving the frontal bone (in
reaches the superior orbital fissure. Posteriorly it reaches
the midline); the two parietal bones (where they join at the
the apex of the petrous part of the temporal bone (Fig. 41.27).
sagittal suture); and the occipital bone (again in the midline).
The cavernous sinus has important relations (Fig. 41.28).
The sinus ends at the internal occipital protuberance where it
The internal carotid artery passes anteriorly within the cavity
becomes continuous (usually) with the right transverse sinus
of the sinus. The artery is accompanied by the abducent nerve
(See below). Sometimes it is continuous with the left transverse
that lies below and lateral to it. Three cranial nerves are
sinus.
embedded in the lateral wall of the sinus. From above
2. The inferior sagittal sinus lies within the lower free margin
downwards these are the oculomotor nerve, the trochlear
of the falx cerebri. It begins anteriorly and ends posteriorly by

nerve, and the ophthalmic division of the trigeminal nerve.
joining the straight sinus (Fig. 41.26).
The maxillary division of the trigeminal nerve runs along
3. The straight sinus lies in the triangular interval where the
the inferior angle of the sinus. Medially, the sinus is related
lower edge of the posterior part of the falx cerebri joins the
above to the hypophysis cerebri, and below it is separated
tentorium cerebelli. Anteriorly, it receives the inferior sagittal
from the sphenoidal air sinus by a plate of bone.
sinus, and a vein from the interior of the brain called the great
cerebral vein). Posteriorly the straight sinus ends by becoming
continuous with the transverse sinus of the side opposite to
that with which the superior sagittal sinus is continuous i.e.
usually the left side.
Note that several sinuses meet at the internal

occipital protuberance. These are the superior
sagittal sinus, the straight sinus and the right and
left transverse sinuses (see below). This region is,
therefore, called the confluence of sinuses.
4. The occipital sinus lies in the midline in relation
to the floor of the posterior cranial fossa within a
fold called the falx cerebelli. The occipital sinus
ends posteriorly in the confluence of sinuses (Fig.
41.27).
LARGE PAIRED SINUSES
5. The right and left transverse sinuses lie

horizontally as indicated by their names. Each sinus
begins posteriorly at the internal occipital
protuberance. The right sinus is usually a
continuation of the superior sagittal sinus and the Fig. 41.26. Scheme to show the intracranial venous sinuses. The
left sinus is usually a continuation of the straight cavernous and petrosal sinuses are paired but are shown only on one
sinus, but this arrangement is sometimes reversed. side for sake of clarity.
Other Intracranial Sinuses and Veins
We have now completed the consideration of the major

intracranial venous sinuses. Brief mention will now be made
of some smaller intracranial sinuses and veins.
Each sphenoparietal sinus (right or left) runs medially along
the sharp posterior edge of the floor of the anterior cranial
fossa (formed by the lesser wing of the sphenoid).
Each superior petrosal sinus runs backwards and laterally
along the sharp upper margin of the petrous temporal bone.
Each inferior petrosal sinus runs downwards and somewhat
laterally in the groove between the petrous temporal bone
and the basilar part of the occipital bone. The inferior petrosal
sinuses of the right and left sides are connected by a basilar
plexus of veins lying on the basal parts of the sphenoid and
occipital bones (Fig. 41.27).
The vein accompanying the middle meningeal artery is called
the middle meningeal sinus.
Veins Draining the Eyeball and Orbit
The superior ophthalmic vein accompanies the ophthalmic

artery. Anteriorly it communicates with the facial vein.
Posteriorly, it passes through the superior orbital fissure and
ends in the cavernous sinus.
The inferior ophthalmic vein lies below the eyeball. It
terminates in the cavernous sinus either directly or by joining
the superior ophthalmic vein.
The central vein of the retina accompanies the artery of the
same name. It ends in the cavernous sinus directly or through
the superior ophthalmic vein.
Tributaries of Internal Jugular Veins

Fig. 41.27. Relationship of the cranial venous sinuses to
in the Neck
the floor of the cranial cavity.
These are shown in Figure 41.25. They will now
be considered one by one
The Facial Vein
The facial vein begins near the medial angle of
the eye by the union of two superficial veins of
the forehead, namely, the supratrochlear and
the supraorbital veins (Fig. 41.29). The vein
runs downwards and backwards across the face
and terminates by joining the anterior branch
of the retromandibular vein to form the common
facial vein that ends in the internal jugular vein.
The Lingual Vein
The lingual vein accompanies the lingual artery
and joins the internal jugular vein near the
greater cornu of the hyoid bone. Some veins of
the tongue run along the hypoglossal nerve.
They may join the lingual vein or the facial vein
Fig. 41.28. Coronal section through cavernous sinus
or may terminate directly in the internal jugular
to show its relations.
vein.
379
380
The Retromandibular Vein
The retromandibular vein lies behind the
ramus of the mandible (as implied by its
name). It is formed by union of the
superficial temporal and maxillary veins. It
is embedded in the parotid gland.
Descending within the substance of the gland
the vein divides into anterior and posterior
branches. The anterior branch joins the facial
vein. The posterior branch joins the posterior
auricular vein to form the external jugular
vein.
The Posterior Auricular Vein
The posterior auricular vein drains the
posterior part of the scalp. It ends by joining
the posterior division of the retromandibular
vein.
Fig. 41.29. Scheme to show the course and tributaries of the
facial vein.
The Superior Thyroid Vein The External Jugular Vein

The superior thyroid vein corresponds in its course and The external jugular vein is formed, as seen above, by union
tributaries with the superior thyroid artery (Figs 41.30 and 41.9). of the posterior division of the retromandibular vein with
the posterior auricular vein (Fig. 41.31). The origin lies
The Middle Thyroid Vein within the lower part of the parotid gland or just below it.
The middle thyroid vein drains the lower part of the gland. It From here the vein runs downwards and somewhat
crosses the common carotid artery to enter the internal jugular backwards and ends by joining the subclavian vein. The
vein (Fig. 41.30). termination lies behind the middle of the clavicle, near the
The Inferior Thyroid Veins lateral margin of the scalenus anterior muscle.
The inferior thyroid veins are not tributaries of the internal
jugular, but are described here for sake of convenience. They
arise from the lower part of the thyroid gland and descend
over the front of the trachea forming a plexus over it. The
right and left veins end in the corresponding brachiocephalic
veins (Fig. 41.30).
In addition to the tributaries described above the internal
jugular vein also receives some veins from the pharynx.
Other Veins of the Head and Neck
Superficial Temporal Vein

The superficial temporal vein accompanies the corresponding
artery. It ends by joining the maxillary vein to form the
retromandibular vein.
The Maxillary Vein
The maxillary vein runs alongside the first part of the maxillary
artery. It has its origin in the pterygoid plexus of veins that is
present in the infratemporal fossa. The veins corresponding to
the branches of the maxillary artery drain into this plexus. The
plexus is drained by the maxillary vein, which ends by joining
the superficial temporal vein to form the retromandibular vein. Fig. 41.30. Scheme to show the veins
draining the thyroid gland.
hyoid bone and extends
downwards to a point a
little above the sterno-
clavicular joint. Here the
vein turns laterally deep to
the sternocleidomastoid,
and ends by joining the
lower end of the external
jugular vein. Just above the
sternum, the right and left
anterior jugular veins are
united by a transverse vein
called the jugular arch (Fig.
41.31).
The Occipital Vein
The occipital vein drains
the posterior part of the
scalp. It pierces the
trapezius to reach the
suboccipital triangle where
it ends in a venous plexus.
The Deep Cervical Vein
The deep cervical vein
begins in a venous plexus
present in the suboccipital
region. It accompanies the
corresponding artery
through the deep muscles
of the back of the neck and
ends by joining the lower
part of the vertebral vein.
The Vertebral Vein
The vertebral vein begins in
the suboccipital venous
Fig. 41.31. Scheme to show some veins of the head and neck.
plexus. It enters the fora-
The greater part of the vein is superficial being covered by men transversarium of the atlas and runs downwards in the
skin, superficial fascia and platysma. As a result the vein can be form of a dense plexus around the vertebral artery. It is only
clearly seen in the living. It pierces the deep fascia near its at the foramen transversarium of the sixth cervical vertebra
termination to reach the subclavian vein. The vein crosses the that the plexus takes the form of a single vessel.
sternocleidomastoid obliquely running downwards and
backwards across it. The vein runs downwards behind the internal jugular vein
and ends in the upper part of the corresponding
The Anterior Jugular Vein
brachiocephalic vein.
The anterior jugular vein runs down the front of the neck a
short distance from the midline (Fig. 41.31). It begins near the
381
382
42 : Nerves of Head and Neck
CERVICAL NERVES
In the thoracic, lumbar and sacral regions the number of spinal nerves corresponds
to that of vertebrae, each nerve lying below the numerically corresponding vertebra.
However, in the neck we have seven cervical vertebrae, and eight cervical nerves.
The reason for this will be clear from Figure 42.1. Note that the upper seven
cervical nerves lie above the numerically corresponding vertebrae. The eighth
cervical nerve lies below vertebra C7.
THE DORSAL RAMI OF CERVICAL NERVES
The dorsal ramus of a typical spinal nerve is smaller than the ventral ramus. It
passes backwards and divides into medial and lateral branches that supply the
deep muscles and skin of the back. The area of skin supplied by dorsal rami is
shown in Figure 4.5. This is all that needs to be known about the dorsal rami of
most spinal nerves. The dorsal rami of the upper three cervical nerves, however,
have some atypical features and are briefly described below.
Dorsal Ramus of the First Cervical Nerve

The dorsal ramus of the first cervical nerve is larger than the ventral ramus. It is
seen the suboccipital triangle which it reaches by passing above the posterior
arch of the atlas. Here the nerve lies between the arch and the vertebral artery.
The dorsal ramus divides into branches that supply the rectus capitis posterior
major and minor, the superior and inferior oblique muscles and the semispinalis
Fig. 42.1. Scheme to show the
capitis (Fig. 42.2). Some branches may reach the skin of the scalp.
relationship of cervical and
upper thoracic nerves to
Dorsal Ramus of the Second Cervical Nerve vertebrae.
The dorsal ramus of the second cervical nerve is large. It reaches the suboccipital
region by passing below the posterior arch of the atlas, and below the inferior
oblique muscle. Of its medial and
lateral branches, the medial
branch is much more prominent
and is called the greater occipital
nerve (Fig. 42.2B). Winding
around the lower border of the
inferior oblique muscle this nerve
passes upwards and medially
across the suboccipital triangle,
lying deep to the semispinalis
capitis. It becomes superficial by
piercing first the semispinalis
capitis and then the trapezius.
Finally it divides into branches
that ramify in the scalp supplying
its posterior part. It also gives a
branch to the semispinalis capitis Fig. 42.2A. Distribution of the dorsal Fig. 42.2B. Course of the greater
ramus of the first cervical nerve. occipital nerve.
muscle.
NERVES OF HEAD AND NECK
Dorsal Ramus of the Third Cervical Nerve supraclavicular nerves arise from the third and fourth
The dorsal ramus of the third cervical nerve behaves like a nerves. These nerves are considered in detail on pages that
typical dorsal ramus. The only special feature about it is that it follow.
also gives a small branch to the skin of the occipital region. The muscular branches of the cervical plexus are shown in
This branch is called the third occipital nerve. Figure 42.4.
Lesser Occipital Nerve
THE VENTRAL RAMI OF CERVICAL NERVES The lesser occipital nerve arises from the descending branch
of the ventral ramus of the second cervical nerve. The origin
The ventral rami of the first, second, third and fourth cervical lies deep to the sternocleidomastoid muscle. The nerve forms
nerves unite with each other to form the cervical plexus. The a loop round the accessory nerve. It then runs upwards and
ventral rami of the fifth, sixth, seventh and eighth cervical backwards for some distance along the posterior border of
nerves, and the greater part of the ventral ramus of the first the sternocleidomastoid. It becomes subcutaneous behind
thoracic nerve, join one another to form the brachial plexus. the auricle and divides into branches that supply the skin of
The brachial plexus has been described with the upper limb. this region. It also gives off an auricular branch that supplies
The cervical plexus is described below. the upper part of the cranial surface of the auricle (Figs 42.3,
42.5A and 42.6).
Greater Auricle Nerve
THE CERVICAL PLEXUS The greater auricular nerve arises from the ventral rami of
AND ITS BRANCHES the second and third cervical nerve. Its origin lies deep to
the sternocleidomastoid. The nerve runs upwards and
somewhat forwards over the surface of the
The cervical plexus is formed by the ventral rami of the first,
sternocleidomastoid. A little below the auricle it divides into
second, third and fourth cervical nerves as follows. With the
anterior and posterior branches. The anterior branch supplies
exception of the ramus of the first cervical nerve each of them
the skin over the parotid gland. The posterior branch supplies
divides into ascending and descending branches. The ascending
most of the auricle.
branch of the second nerve joins the first nerve; and its
descending branch joins the ascending branch of the third nerve. Transverse Cutaneous Nerve of Neck
Similarly the descending branch of the third nerve joins the The transverse cutaneous nerve of the neck is also called
ascending branch of the fourth nerve. The descending branch the anterior cutaneous nerve. It arises from the ventral rami
of the fourth nerve is small and joins the fifth cervical nerve. of the second and third cervical nerves. It first runs laterally
The cervical plexus gives off a large number of branches. The deep to the sternocleidomastoid. Reaching the posterior
cutaneous branches are shown in Figure 42.3 and are as follows. border of this muscle it curves around it and then runs
The lesser occipital nerve arises from the second cervical nerve. forwards across the muscle. The nerve becomes superficial
The greater auricular nerve and the transverse cutaneous
nerve of the neck arise from the second and third nerves. The
Fig. 42.3. Cervical plexus and its cutaneous branches. Fig. 42.4. Scheme to show the muscular branches of the
cervical plexus.
383
384
Fig. 42.5B.
Fig. 42.5A. Course and
Course and distribution of
distribution of greater auricular
lesser occipital and transverse
nerve cutaneous nerves
and divides into ascending and descending branches that branches descend over the posterior triangle of the neck.
supply the skin on the front of the neck (Fig. 42.3). They pierce the deep fascia a little above the clavicle and
then run downwards across this bone to reach the pectoral
region.
The Supraclavicular Nerves

The supraclavicular nerves arise (as a single ramus) from the
third and fourth cervical nerves (Fig. 42.3) deep to the The Ansa Cervicalis
sternocleidomastoid. Reaching the posterior border of the The ansa cervicalis is also called the ansa hypoglossi. It is a
muscle the trunk divides into three branches called the medial, nerve loop lying in front of the common carotid artery (ansa
intermediate and lateral supraclavicular nerves. These = loop).
Fig. 42.6. Areas of skin of neck supplied by various Fig. 42.7. Scheme to show the mode of innervation of the
cutaneous nerves. infrahyoid muscles from the cervical plexus.
Branches arising from the ansa cervicalis innervate the and then through the thorax to reach the diaphragm. Some
sternohyoid, the sternothyroid and the omohyoid muscles (viz. terminal branches enter the abdomen.
all infrahyoid muscles other than the thyrohyoid).
Some Relations in the neck:
1. The phrenic nerve descends vertically over the scalenus
The Phrenic Nerve anterior muscle. It crosses in front of the first part of the
subclavian artery (but may be separated from the artery by
The phrenic nerve is important as it is the only motor supply to a part of the scalenus anterior).
the diaphragm. 2. Lower down the nerve lies behind the lower end of the
This nerve arises from the (ventral rami of) spinal nerves C3, internal jugular vein. Still lower down the nerve passes
C4 and C5 the contribution from C4 being the greatest. The behind the medial end of the subclavian vein.
nerve descends vertically through the lower part of the neck, The course and relations of the phrenic nerve in the thorax
are described in Chapter 21.
THE CRANIAL NERVES
Introduction The eleventh cranial nerve is called the accessory nerve

There are twelve pairs of cranial nerves that emerge from the because it appears to be a part of the vagus nerve (or
surface of the brain. They are identified by number (in cranio- accessory to the vagus).
caudal sequence) and also bear names as follows. The twelfth cranial nerve is called the hypoglossal nerve
The first cranial nerve is called the olfactory nerve. It is the (because it runs part of its course below the tongue before
nerve of smell (Olfaction = smell). supplying the muscles in it (hypo = below; glossal =
The second cranial nerve is called the optic nerve. It is the pertaining to tongue).
nerve of sight (Optics = science of formation of images). Each nerve is considered below.
The third cranial nerve is called the oculomotor nerve as it
supplies several muscles that move the eyeball (Ocular =
pertaining to the eye).
The fourth cranial nerve is called the trochlear nerve. It is so Cranial Nerve Nuclei
called because it supplies a muscle (superior oblique) that passes
through a pulley (trochlea = pulley). Cranial nerves begin or end in groups of neurons, or nuclei,
The fifth cranial nerve is called the trigeminal nerve because present in the brain. The olfactory and optic nerves are
it has three major divisions. These are ophthalmic division to present in relation to the cerebral hemispheres. The nuclei
the orbit, the maxillary division to the upper jaw, and the of remaining cranial nerves are located in the brainstem.
mandibular division to the lower jaw. Nuclei supplying skeletal muscle
The sixth cranial nerve is called the abducent nerve because it
supplies a muscle (lateral rectus) that abducts the eyeball. 1. Nuclei supplying muscles derived from somites
The seventh cranial nerve is the facial nerve because it supplies These are called somatic efferent nuclei.
the muscles of the face. 1. The oculomotor nucleus is situated in the midbrain (upper
The eighth cranial nerve is called the vestibulo-cochlear nerve part).
because it supplies structures in the vestibular and cochlear 2. The trochlear nucleus is situated in the midbrain (lower
parts of the internal ear. It is sometimes called the auditory part).
nerve (auditory = pertaining to hearing) or the stato-acoustic 3. The abducent nucleus is situated in the lower part of the
nerve (stato = pertaining to equilibrium; acoustic = pertaining pons.
to sound or hearing). 4. The hypoglossal nucleus lies in the medulla.
The ninth cranial nerve is called the glossopharyngeal nerve 2. Nuclei supplying muscles derived from branchial arch
as it is distributed to the pharynx and to part of the tongue mesoderm
(glossal = pertaining to the tongue). These are also called special visceral efferent nuclei
The tenth cranial nerve is called the vagus. It has an extensive 1. The motor nucleus of the trigeminal nerve lies in the
course through the neck, the thorax and the abdomen. (The upper part of the pons.
word vagus may be correlated with vagrant = wandering from 2. The nucleus of the facial nerve lies in the lower part of
place to place). the pons.
385
386
3. The nucleus ambiguus lies in the medulla. It contributes
fibres to the glossopharyngeal, vagus and accessory nerves.
Nuclei Supplying Smooth Muscle or Glands
These are also called general visceral efferent nuclei
1. The Edinger-Westphal nucleus lies in the midbrain. Fibres
arising in this nucleus pass through the oculomotor nerve. They
relay in the ciliary ganglion to supply the sphincter pupillae
and the ciliaris muscle.
2. The salivatory nuclei (superior and inferior) lie in the lower
part of the pons. They are concerned with the innervation of
salivary glands. The superior nucleus sends fibres into the facial
nerve. These fibres relay in the submandibular ganglion to
supply the submandibular and sublingual salivary glands. The
inferior nucleus sends fibres into the glossopharyngeal nerve.
These fibres relay in the otic ganglion to supply the parotid
gland.
3. The dorsal (motor) nucleus of the vagus lies in the medulla.
Fibres arising in this nucleus supply several thoracic and
abdominal viscera.
Fig. 42.8. Scheme to show course of the optic nerve.
Nuclei receiving afferents from viscera
The nucleus of the solitary tract is present in the medulla. It
is connected with the vagus and glossopharyngeal nerves.
Fibres of taste carried by the facial, glossopharyngeal and vagus (anterior cranial fossa) where they terminate in the olfactory
nerves end in the upper part of the nucleus. bulb. Olfactory impulses carried by these fibres pass to other
neurons located in the olfactory bulb. From the bulb they

Nuclei receiving afferents from skin and muscle pass into the olfactory tract and ultimately end in several
All these belong to the trigeminal nerve. small areas located on the inferior surface of the cerebral
1. The main sensory nucleus lies in the upper part of the pons. hemisphere.
2. The spinal nucleus extends from the main nucleus down
into the medulla and into the upper part of the spinal cord. In
addition to fibres of the trigeminal nerve it also receives fibres
through the facial, glossopharyngeal and vagus nerves.
3. The mesencephalic nucleus of the trigeminal nerve lies in THE OPTIC NERVE
the midbrain.
Nuclei of the vestibulocochlear nerve The optic nerve forms an important part of the visual
1. The cochlear nuclei are two in number, dorsal and ventral. pathway. It lies partly in the orbit and partly in the cranial
They are placed at the level of the junction of the pons and the cavity. Its anterior end is attached to the posterior pole of
medulla. They are concerned with hearing. the eyeball. The attachment lies a little medial to the
2. The vestibular nuclei lie partly in the medulla and partly in anteroposterior axis of the eyeball. From here the nerve
the pons. They are functionally related to the maintenance of passes backwards and medially first through the orbit, next
equilibrium. through the optic canal and finally through part of the cranial
cavity. The nerve ends by joining the nerve of the opposite
side to form the optic chiasma (Fig. 42.8). The total length
of the nerve is about 40 mm. Of this 25 mm is in the orbit,
5 mm in the optic canal and 10 mm in the cranial cavity.
THE OLFACTORY NERVES The intraorbital part of the nerve is surrounded by the
superior, inferior, medial and lateral recti. The ophthalmic
The olfactory (first cranial) nerves are purely sensory and are artery is inferolateral to the nerve in the optic canal and in
concerned with smell. The peripheral end organ for smell is the posterior part of the orbit. The artery then crosses above
the olfactory mucosa that lines the upper and posterior part of the nerve from lateral to medial side. The central artery of
the nasal cavity (both on the lateral wall and on the septum). the retina runs forwards in the substance of the nerve to reach
The fibres of the olfactory nerves are processes of olfactory the eyeball. The intracranial part of the optic nerve is related
receptor cells located in the olfactory epithelium. These fibres to the internal carotid artery that is on its lateral side; and to
collect to form about twenty bundles that together constitute the anterior cerebral artery that crosses above it.
an olfactory nerve. The bundles pass through foramina in the
cribriform plate of the ethmoid bone to enter the cranial cavity
The Visual Pathway Some fibres of the oculomotor nerve arise from the Edinger-
Westphal nucleus that forms part of the oculomotor complex.
To understand the functional importance of the optic nerve it is Fibres arising in this nucleus relay in the ciliary ganglion.
necessary to briefly consider some facts about the visual Postganglionic fibres arising in this ganglion supply the
pathway. (Details will be considered in the section on the brain). sphincter pupillae and the ciliaris muscle.
The peripheral receptors for light are situated in the retina. Arising from these nuclei the fibres of the oculomotor nerve
Nerve fibres arising in the retina constitute the optic nerves. pass forwards through the substance of the midbrain and
The two optic nerves join to form the optic chiasma in which emerge on the anteromedial side of the cerebral peduncle
many of their fibres cross to the opposite side. The uncrossed (Figs 42.10 and 42.11). Just in front of the midbrain the nerve
fibres of the optic nerve, along with the fibres that have crossed passes between the superior cerebellar artery (that lies below
over from the opposite side form the optic tract. The optic tract it) and the posterior cerebral artery (that lies above it). It
terminates predominantly in the lateral geniculate body. Fresh pierces the inner layer of dura mater in the triangular interval
fibres arising in the lateral geniculate body form the bounded by the free and attached margins of the tentorium
geniculocalcarine tract (or optic radiation) that ends in the cerebelli (Fig. 42.10). The nerve now comes to lie in the
visual areas of the cerebral cortex. Vision is actually perceived lateral wall of the cavernous sinus (Fig. 42.12). In the anterior
in the cerebral cortex. part of this wall the nerve divides into superior and inferior
Nerve fibres arising in the retina converge upon an area on the rami.
posteromedial part of the eyeball called the optic disc. Here The superior and inferior rami enter the orbit by passing
the fibres pass through the thickness of the retina, the choroid through the superior orbital fissure (Fig. 42.14). They pass
and the sclera. In this situation the sclera has numerous through the part of the fissure that lies within the tendinous
perforations and is, therefore, called the lamina cribrosa (crib ring that gives origin to the four recti of the eyeball. Within
= sieve). The optic nerve is formed by the aggregation of fibres the orbit the superior ramus supplies the superior rectus and
passing out through the lamina cribrosa.
Fibres responsible for sharp vision arise
from an area of the retina called the
macula.
The fibres of the optic nerve arising in
the medial (or nasal) half of each retina
enter the optic tract of the opposite side
after crossing in the optic chiasma.
Fibres of the lateral (or temporal) half
of each retina enter the optic tract of the
same side. Thus, the right optic tract
comes to contain fibres from the right
Fig. 42.9. Scheme to show the distribution of the oculomotor nerve.
halves of both retinae; and the left tract
from the left halves. The optic tract
carries these fibres to the lateral
geniculate body of the corresponding
side. From here they are relayed to the
corresponding cerebral hemisphere.
THE OCULOMOTOR
NERVE
The oculomotor is the third cranial nerve.

Most of the fibres of this nerve arise from
the oculomotor nuclear complex that is
situated in the upper part of the midbrain.
Fibres arising in the complex supply all
extrinsic muscles of the eyeball except
the lateral rectus and the superior
oblique. These fibres also supply the Fig. 42.10. Diagram to show the sites of penetration of dura mater by the
levator palpebrae superioris. oculomotor, trochlear and abducent nerves.
387
388
Fig. 42.13. Distribution of oculomotor nerve.
THE TROCHLEAR NERVE
The trochlear nerve is the fourth cranial nerve. It is made up of

fibres that arise in the trochlear nucleus located in the lower
part of the midbrain. The fibres emerge on the posterior surface
of the brainstem just below the inferior colliculus.
Having emerged from the midbrain the nerve winds round the
cerebral peduncle to reach the front of the brainstem (Fig.
42.11). While winding round the cerebral peduncle the nerve

Fig. 42.11. Attachment of cranial nerves to the lies between the posterior cerebral
surface of the brainstem. artery (above it) and the superior
cerebellar artery (below it). The nerve
now runs forwards and pierces the dura
mater just below the free margin of the
tentorium cerebelli (Fig. 42.10). Having
pierced the dura the nerve comes to lie
in the lateral wall of the cavernous
sinus, below the oculomotor nerve, but
above the ophthalmic division of the
trigeminal nerve (Fig. 42.12).
Continuing forwards it passes through
the superior orbital fissure (Fig. 42.14).
In the fissure it lies above the tendinous
ring for origin of the recti of the eyeball
(Fig. 42.14). Having entered the orbit
Fig. 42.12. Relationship of cranial nerves to the cavernous sinus.
the levator palpebrae superioris. The inferior ramus

supplies the medial rectus the inferior rectus and
the inferior oblique (Fig. 42.13).
The ciliary ganglion lies lateral to the optic nerve
(between it and the lateral rectus. Its connections
are shown in Figure 42.15.
Fig. 42.14. Position of cranial nerves in the superior orbital fissure.

THE TRIGEMINAL NERVE
Introductory remarks:
The trigeminal nerve is so called because
it consists of three main divisions. These
are the ophthalmic nerve, the maxillary
nerve and the mandibular nerve. These
nerves arise from a large trigeminal
ganglion. The ganglion is connected to
the brainstem (pons) by a thick sensory
root. The trigeminal nerve also has a
motor root (Fig. 42.11) which emerges
from the pons medial to the sensory root
and joins the mandibular nerve.
Fig. 42.15. Scheme to show the connections of the ciliary ganglion. The trigeminal nerve contains both
afferent and efferent fibres.
the nerve runs forwards, above the orbital muscles, and ends in Afferent fibres are peripheral processes of unipolar neurons
the superior oblique muscle. located in the trigeminal ganglion. They are distributed
through all three divisions of the nerve. They carry sensations
The next cranial nerve, in order of numerical sequence, is the from the skin of the face, the mucous membrane of the mouth,
fifth or trigeminal. However, the abducent nerve (sixth) is and the mucous membrane of the nose. The central processes
considered first as its course and distribution are similar to those of the neurons in the trigeminal ganglion form the sensory
of the oculomotor and trochlear nerves. root. After entering the pons these processes terminate in
relation to neurons in the main sensory nucleus, and in the
spinal nucleus of the nerve.
The muscles of mastication (and some other muscles) are
THE ABDUCENT NERVE supplied through the mandibular division of the trigeminal
nerve. The cell bodies of the neurons giving origin to these
fibres are located in the motor nucleus of the trigeminal
This is the sixth cranial nerve. It is made up of fibres that arise nerve. The muscles supplied by the motor fibres are as
in the abducent nucleus and supply the lateral rectus muscle of follows:
the eyeball. The abducent nucleus is located in the lower part A. Muscles of mastication: Masseter, temporalis, medial and
of the pons. The fibres of the nerve pass through the substance lateral pterygoids.
of the pons and emerge on the surface of the brainstem at the B. Other muscles: Mylohyoid, anterior belly of digastric,
lower border of the pons. The nerve then runs upwards, forwards tensor palati, tensor tympani.
and laterally. It pierces the dura lateral to the dorsum sellae of
the sphenoid bone (Fig. 42.19). It then runs
upwards to reach the upper border of the
petrous temporal bone and bends round it to
enter the middle cranial fossa. The nerve now
comes to lie within the cavernous sinus, where
it is closely related to the internal carotid artery.
The nerve is first lateral to the artery and then
inferolateral to it. At the anterior end of the
cavernous sinus the nerve passes through the
superior orbital fissure to enter the orbit. Its
position in the fissure is shown in figure 42.14.
The nerve ends by supplying the lateral rectus
muscle.
Fig. 42.16. Roots and divisions of the trigeminal nerve.
389
390
The trigeminal ganglion: The supratrochlear nerve passes above the trochlea (for
This ganglion is shaped like a crescent. It has a convex border the tendon of the superior oblique muscle). Reaching the
facing anterolaterally and a concave border facing upper margin of the orbital aperture, near its medial end,
posteromedially. the nerve turns upwards into the forehead giving branches
The convex border is continuous with the ophthalmic, maxillary to the skin over its lower and medial part.
and mandibular nerves, while the concave posterior border is We have seen that on entering the orbit the nasociliary
continuous with the sensory root. The ganglion is placed in a nerve lies between the optic nerve and the lateral rectus.
depression (called the trigeminal impression) on the anterior The nerve then runs medially crossing above the optic nerve
aspect of the petrous temporal bone (near its apex). The (Fig. 42.17). Reaching the medial wall of the orbit the nerve
ganglion is enclosed within a pouch like recess of dura mater. ends by dividing into the anterior ethmoidal and
This recess is called the trigeminal cave. infratrochlear nerves. The branches of the nasociliary
nerve are as follows (Fig. 42.17):
a. Just after entering the orbit the nasociliary nerve receives
the sensory root of the ciliary ganglion.
THE OPHTHALMIC NERVE
b. The long ciliary nerves (two or three) arise from the
nasociliary nerve as it crosses the optic nerve. They run
The fibres of the ophthalmic nerve are purely sensory. However,
forwards to the eyeball and supply sensory fibres to the
some sympathetic fibres for the eyeball travel for part of their
ciliary body, the iris and the cornea. They also carry
course through the nerve and some of its branches.
postganglionic sympathetic fibres meant for the dilator
The ophthalmic nerve arises from the anteromedial part of the
pupillae.
trigeminal ganglion (Fig. 42.17). It comes to lie in the lateral
c. The posterior ethmoidal branch enters the posterior
wall of the cavernous sinus, below the trochlear nerve (Fig.
ethmoidal foramen (on the medial wall of the orbit) and
42.12). It divides into three branches. These are the lacrimal,
supplies the ethmoidal and sphenoidal air sinuses.
the frontal, and the nasociliary nerves.
d. The anterior ethmoidal nerve has a complicated course
These branches enter the orbit by passing through the superior
through the orbit, the anterior cranial fossa, and the nasal
orbital fissure. Their positions in the fissure are shown in figure

42.14. From this figure it will be
obvious that on entering the orbit
the lacrimal and frontal branches
will lie above the orbital muscles;
while the nasociliary nerve will lie
between them, lateral to the optic
nerve. The further course of each
of these branches is as follows.
The lacrimal nerve runs along the
lateral wall of the orbit (along the
upper border of the lateral rectus).
It ends in the lacrimal gland. Some
branches pass through the gland to
supply the conjunctiva and the skin
of the upper eyelid.
The frontal nerve runs forwards
between the levator palpebrae
superioris and the periosteum
lining the roof of the orbit. It ends
by dividing into supraorbital and
supratrochlear branches.
The supraorbital nerve runs
forwards to reach the orbital
margin. Here it passes through the
supraorbital notch (on the medial
part of the upper margin of the
orbit) and turns upwards into the
forehead. It divides into medial and
lateral branches that supply the
scalp.
Fig. 42.17. Distribution of ophthalmic nerve.
cavity. Its terminal part is seen on the face as the external nasal bone. It emerges from the bone through the zygomaticofacial
nerve. foramen present on the lateral surface of the bone and
e. The infratrochlear nerve (Figs. 42.17) runs forwards on the supplies the skin of the cheek.
medial wall of the orbit and ends by supplying part of the skin 6. The posterior superior alveolar nerve arises from the
of the upper and lower eyelids and over the upper part of the maxillary nerve in the pterygopalatine fossa. It divides into
nose. branches that supply the molar teeth.
Branches arising in the infraorbital groove and canal:
The middle superior alveolar nerve and the anterior
THE MAXILLARY NERVE superior alveolar nerve supply teeth borne on the maxilla.
Branches of infraorbital nerve in the face:
Like the ophthalmic nerve, the maxillary nerve is purely sensory.
The infraorbital nerve divides into the following branches
It arises from the trigeminal ganglion (Fig. 42.16).
after emerging from the infraorbital foramen.
It comes to lie in the lower part of the lateral wall of the
The palpebral branches supply the lower eyelid. Nasal
cavernous sinus. The nerve leaves the middle cranial fossa
branches supply the skin on the lateral side of the nose.
through the foramen rotundum. It passes through the
Superior labial branches supply the skin of the upper lip
pterygopalatine fossa and the inferior orbital fissure to enter
and part of the cheek. The area of the skin of the face supplied
the orbit. The part of the maxillary nerve distal to the inferior
by the maxillary nerve is shown in Figure 36.9.
orbital fissure is called the infraorbital nerve. This nerve lies
first in the infraorbital groove, and then in the infraorbital canal.
It appears on the face through the infraorbital foramen and ends
here by dividing into a number of terminal branches. Several
branches are also given off by the

maxillary and infraorbital nerves as
follows.
Branches arising in pterygopalatine
fossa:
Two ganglionic branches connect the
maxillary nerve to the pterygopalatine
ganglion. Some branches arise from the
ganglion while other branches arise
directly from the maxillary nerve.
1. The greater and lesser palatine
nerves supply the palate.
2. The posterior superior and the Fig. 42.18. Course of maxillary nerve.
posterior inferior nasal branches
supply the walls of the nasal cavity.
3. Some orbital branches supply the
orbitalis muscle.
4. The pharyngeal branch reaches the
nasopharynx.
5. The zygomatic nerve enters the orbit
through the inferior orbital fissure and
runs forwards along its lateral wall. It
divides into two branches, the
zygmaticotemporal and the
zygomaticofacial. Both these branches
enter foramina present on the orbital
surface of the zygomatic bone.
Travelling through the zygomatic bone
the zygomaticotemporal nerve
emerges from the temporal surface of
the bone. The nerve ends by supplying
the skin over the temple. The
zygomaticofacial nerve also passes Fig. 42.19. Scheme to show direct branches arising from the maxillary nerve
through the substance of the zygomatic (including its infraorbital continuation).
391
392
THE MANDIBULAR NERVE petrosal nerve relay in the otic ganglion. Postganglionic
fibres starting in this ganglion reach the roots of the auriculo-
The mandibular nerve is formed by union of two roots. The temporal nerve through communicating twigs. They travel
sensory root arises from the trigeminal ganglion, and leaves through this nerve and through its branches to the parotid
the skull through the foramen ovale. The motor root also passes gland.
through the foramen ovale and unites with the sensory root The auriculotemporal nerve supplies (a) skin (of the temple);
just below the foramen (Fig. 42.16). Emerging from the (b) a gland (parotid); (c) a joint (temporo-mandibular); (d) a
foramen ovale the nerve enters the infratemporal fossa. After tube (external acoustic meatus); and (e) a membrane
a short downward course the trunk of the mandibular nerve (tympanic).
divides into a smaller anterior division and a larger posterior
division. The trunk and both divisions give off a number of
The lingual nerve
branches that are as follows.
The lingual nerve arises from the posterior division of the
Branches from the trunk (or main stem): mandibular nerve (Fig. 42.21). Its upper part runs downwards
A meningeal branch accompanies the middle meningeal artery. deep to the lateral pterygoid muscle. It is joined here by the
The nerve to the medial pterygoid supplies this muscle. It gives chorda tympani nerve (a branch of the facial nerve). Lower
a branch to the otic ganglion. The fibres in this branch pass down the lingual nerve runs downwards and forwards
through the ganglion without relay and supply the tensor between the medial pterygoid (deep to it) and the ramus of
tympani and the tensor palati muscles. the mandible (superficial to it). It then enters the mouth and
lies deep to mucous membrane just below the-third molar
Branches from the anterior division:
tooth. The nerve then enters the side of the tongue. The
The buccal nerve is sensory. It runs downwards and forwards
further course of the lingual nerve is shown in figure 42.21.
through the muscles of the infratemporal fossa to reach the
The nerve runs forwards across the lateral surface of the
surface of the buccinator muscle. Here it supplies the skin
hyoglossus. At the anterior margin of the hyoglossus the
superficial to the muscle and the mucous membrane lining its
nerve passes on to the genioglossus and divides into a
deep surface.
number of branches.
The remaining branches of the anterior division of the
The lingual nerve carries three types of the fibres that are
mandibular nerve are motor. They supply the masseter, the
distributed as follows:
lateral pterygoid and the temporalis as follows.
a. Most of the fibres of the lingual nerve are those of ordinary
The nerve to the masseter passes laterally in front of the neck
sensation. They carry the sensations of touch, pain and
of the mandible to reach the masseter (Fig. 37.1).
temperature from the anterior two-thirds of the tongue. They
The nerve to the lateral pterygoid may be independent or may
also supply the mucous membrane of the floor of the mouth
arise from the buccal nerve.
and the gums related to the lower teeth.
The temporalis is supplied through the anterior, middle and
b. The part of the lingual nerve distal to the attachment of
posterior deep temporal nerves (Fig. 37.1). These nerves pass
the chorda tympani carries the fibres for taste from the part
upwards to reach the deep surface of the temporalis.
Branches from the posterior division:
The posterior division of the mandibular nerve
gives rise to three important nerves. These are
the auriculotemporal, the lingual and the inferior
alveolar nerves.
The auriculotemporal nerve

The auriculotemporal nerve arises by two roots
that form a ring through which the middle
meningeal artery passes upwards (Fig. 42.20).
The nerve runs backwards deep in the
infratemporal fossa; and crosses deep to the neck
of the mandible. It then turns laterally behind
the temporomandibular joint. In this part of its
course it is closely related to the upper part of
the parotid gland. The nerve finally turns
upwards into the scalp and ends by dividing into
branches that supply the skin over the temple.
The auriculotemporal nerve serves as a pathway
for secretomotor fibres to the parotid gland. Fig. 42.20. Scheme to show the branches of the mandibular nerve.
Preganglionic fibres travelling through the lesser
of the tongue in front of the sulcus
terminalis, but excluding the vallate
papillae. These fibres pass from the
lingual nerve into the chorda
tympani.
c. Secretomotor fibres for the
submandibular and sublingual glands
reach the lingual nerve through the
chorda tympani. They end in the
submandibular ganglion. Post-
ganglionic fibres reach the
submandibular gland through
branches to it from the ganglion. The
fibres for the sublingual gland re-
enter the lingual nerve and pass
through its distal part to reach the
gland.
The Inferior alveolar nerve
The inferior alveolar nerve is a
branch of the posterior division of the
mandibular nerve. At its upper end
the nerve lies deep to the lateral
pterygoid. Emerging at the lower Fig. 42.21. Course and some relations of the lingual nerve and of some other
border of this muscle the nerve runs branches of the mandibular nerve.
downwards and forwards deep to the
ramus of the mandible (Fig. 42.21). Reaching the mandibular the internal acoustic meatus (on the posterior aspect of
foramen it passes through it into the mandibular canal. It runs the petrous temporal bone).
forwards in this canal just below the teeth, and ends at the mental The nerve has a complicated course through the substance
foramen by dividing into the incisive and mental branches. of the petrous temporal bone in relation to the internal ear
Within the mandibular canal the nerve gives branches that and the middle ear. This part of the nerve bears the
supply the molar and premolar teeth. The incisive branch genicular ganglion. The nerve emerges on the base of the
supplies the canine and incisor teeth. The mental branch skull through the stylomastoid foramen. It immediately
emerges from the mental foramen and supplies the skin over enters the substance of the parotid gland and runs forwards
the chin, and that over the lower lip. The mylohyoid nerve arises within it and ends behind the neck of the mandible by
from the inferior alveolar nerve just before the latter enters the dividing into several branches. Some details of the course
mandibular foramen. It runs in a groove on the medial side of of the nerve are considered below. The motor fibres of the
the mandible, below the mylohyoid muscle. It supplies the
mylohyoid, and the anterior belly of the digastric muscle.
THE FACIAL NERVE
Preliminary remarks:
The facial nerve is the seventh cranial nerve. It is attached to
the brainstem by two roots: a large motor root, and a smaller
sensory root. These roots are attached in the lateral part of the
groove between the lower border of the pons and the upper
border of the medulla (Fig. 42.11). The motor root is medial to
the sensory root. The sensory root is attached midway between
the motor root (medially) and the vestibulocochlear nerve
(laterally). It is, therefore, called the nervus intermedius.
From this attachment the motor and sensory roots pass forwards
Fig. 42.22. Scheme to show the course of the
and laterally and leave the posterior cranial fossa by entering facial nerve.
393
394
facial nerve arise from the facial nucleus
that lies in the pons.
Course through parotid gland:
As the facial nerve runs forwards through
the parotid gland it crosses the styloid
process, the retromandibular vein and the
external carotid artery. It divides into
several branches while still within the
gland. These branches emerge from the
anteromedial surface of the gland and
come into view along the anterior margin
of the gland.
Branches of the facial nerve:

The branches of the facial nerve are
shown in Figure 42.23. They are as follows:
1. The greater petrosal nerve arises from
the genicular ganglion. It emerges from the
petrous temporal bone through the hiatus
for the greater petrosal nerve. The nerve
then enters the foramen lacerum within
which it ends by joining the deep petrosal
nerve to form the nerve of the pterygoid
canal. The greater petrosal nerve and the
nerve of the pterygoid canal serve as

pathways for secremotor supply of the
lacrimal gland.
2. The nerve to the stapedius supplies this Fig. 42.23. Scheme to show the branches of the facial nerve.
muscle.
3. The chorda tympani is so called because it has an intimate foramen. They end by supplying the muscles concerned.
relationship to the middle ear (tympanum). It arises from the The remaining branches of the facial nerve arise within the
facial nerve about 6 mm above the stylomastoid foramen. The parotid gland.
nerve passes forwards through the substance of the tympanic 6. The temporal branches enter the scalp in the temporal
membrane (lying between its fibrous basis and the mucous region. They supply the frontal belly of the occipitofrontalis,
membrane lining its internal surface). As it does so it crosses the corrugator supercilii, and some muscles of the auricle.
the handle of the malleus (that is embedded in the membrane). Some twigs are also given to the orbicularis oculi.
It then emerges on the base of the skull and enters the 7. The zygomatic branches supply the orbicularis oculi.
infratemporal fossa. The chorda tympani
ends by joining the lingual nerve from
behind. The chorda tympani carries fibres
of taste from the anterior two-thirds of the
tongue and secretomotor fibres to the
submandibular and sublingual glands.
4. The posterior auricular nerve is given
off just after the facial nerve emerges from
the stylomastoid foramen. It runs upwards
into the scalp passing behind the external
acoustic meatus. It divides into an
auricular branch, which supplies some
muscles of the auricle; and an occipital
Fig. 42.24. Course
branch that supplies the occipital belly of of the chorda
the occipitofrontalis. tympani as seen
5. The nerve to the posterior belly of the from the medial side.
digastric muscle and the nerve to the
stylohyoid arise near the stylomastoid
8. The buccal branches are in two sets upper and lower. The Taste pathway for anterior part of tongue and palate
upper branches (sometimes called the lower zygomatic The facial nerve contains special visceral afferent fibres
branches) supply the zygomaticus major and minor, the levator that carry the sensations of taste from the part of the tongue
labii superioris, the levator anguli oris, the levator labii in front of the sulcus terminalis, and from the soft palate.
superioris alaeque nasi, and some small muscles related to the These fibres are processes of unipolar neurons located in
nose. The lower buccal branches supply the buccinator and the the genicular ganglion. Peripheral processes reach the tongue
orbicularis oris. by passing successively through part of the intrapetrous
9. The marginal mandibular branch is related to the lower segment of the facial nerve, the chorda tympani and the
border of the mandible. It supplies the muscles of the lower lip lingual nerve (Fig. 42.25). Those for the soft palate pass
and chin. through the greater petrosal nerve, the nerve of the pterygoid
10. The cervical branch emerges from the parotid gland near canal, the pterygopalatine ganglion, and the lesser palatine
its lower end. It enters the neck and supplies the platysma. nerves. The central processes leaving the genicular ganglion
pass through the nervus intermedius to reach the brainstem.
The facial nerve is involved in a number of pathways that are Here they terminate in relation to the upper part of the
briefly considered below. nucleus of the solitary tract.
Secretomotor supply to submandibular and sublingual The Pterygopalatine Ganglion
glands This ganglion is related functionally to the facial nerve. It is
Preganglionic secretomotor fibres for the submandibular and located in the pterygopalatine fossa and is suspended from
sublingual glands (Fig. 42.25) arise from neurons located in the maxillary nerve by two ganglionic branches.
the superior salivatory nucleus. The fibres leave the pons a. Functionally the ganglion is autonomic and is a peripheral
through the nervus intermedius and run for some distance in ganglion of the cranial parasympathetic outflow. Its motor
the intrapetrous part of the facial nerve. They then enter the (or parasympathetic) root is formed by the nerve of the
chorda tympani to reach the lingual nerve. They leave the lingual pterygoid canal that conveys pre-ganglionic secretomotor
nerve through branches to the submandibular ganglion. fibres for the supply of the lacrimal gland, and for the glands
Postganglionic neurons are located in this ganglion. Some of of the nasal and palatine mucosa.
the nerve fibres arising from them supply the submandibular b. The ganglion also receives some sympathetic fibres. These
gland. Others re-enter the lingual nerve and pass through its fibres, pass through the ganglion, without relay, and enter
distal part to reach the sublingual gland. its orbital branches to supply the orbitalis muscle.
c. Fibres of taste from the soft palate reach the ganglion
Secretomotor innervation of lacrimal gland
through the lesser palatine nerves. They pass through the
Preganglionic secretomotor fibres for the lacrimal gland arise
in the lacrimatory nucleus, which lies near the salivatory nuclei.
They leave the pons
through the nervus
intermedius, pass into the
greater petrosal nerve and
through it into the nerve of Fig. 42.25. Scheme to show the
the pterygoid canal to end secretomotor pathway for the
submandibular and sublingual
in the pterygopalatine
glands. The pathway for taste
ganglion.
from the anterior two-thirds of
Postganglionic neurons are the tongue is also shown.
located in this ganglion.
Fibres arising from them
pass successively through a
ganglionic branch con-
necting the pterygopalatine
ganglion to the maxillary
nerve; the maxillary nerve
itself; its zygomatic branch;
the zygomatico-temporal
branch of the zygomatic
nerve; the loop of com-
munication between the
zygomaticotemporal and
lacrimal nerves; and finally
through the lacrimal nerve
to reach the lacrimal gland.
395
396
nerve of the pterygoid canal and the greater petrosal nerve to ganglion. Peripheral processes of the neurons of the spiral
reach the geniculate ganglion. ganglion reach the organ of Corti, that is the peripheral
receptor for sound. Sound is ultimately perceived in the
The Submandibular Ganglion
auditory area of the cerebral cortex.
a. Functionally the ganglion is concerned with the secretomotor
innervation of the submandibular and sublingual salivary
glands. These fibres are parasympathetic. The pathway
concerned is shown in Figure 42.25 and has already been
described.
THE GLOSSOPHARYNGEAL NERVE
b. The ganglion receives sympathetic fibres from the plexus on
the facial artery. They pass through the ganglion and supply
the blood vessels of the submandibular and sublingual glands. This is the ninth cranial nerve. It is attached to the lateral
side of the upper part of the medulla (between the olive and
the inferior cerebellar peduncle) by three or four roots (Fig.
42.11). It runs forwards and laterally and leaves the cranial
cavity by passing through the jugular foramen. Emerging at
THE VESTIBULOCOCHLEAR NERVE the base of the skull the nerve passes forwards and laterally
between the internal jugular vein and the internal carotid
The vestibulocochlear nerve is eighth cranial nerve. It consists artery. It then descends in front of the internal carotid artery,
of two distinct parts, vestibular and cochlear. Both of these passing deep to the styloid process and the structures attached
are purely sensory. The vestibular nerve carries impulses to it. Reaching the posterior border of the stylopharyngeus
necessary for the maintenance of equilibrium from the muscle it curves forwards passing lateral to the muscle. The
vestibular part of the internal ear. The cochlear nerve carries nerve then enters the pharynx by passing through the interval
impulses of hearing from the cochlear part of the internal ear. between the lower border of the superior constrictor of the
The vestibulocochlear nerve is attached to the surface of the pharynx and the upper border of the middle constrictor.
brainstem at the lower border of the pons. From here the nerve Passing forwards the nerve reaches the side of the tongue.
passes forwards and enters the internal acoustic meatus along Here it passes deep to the hyoglossus muscle and terminates
with the motor and sensory roots of the facial nerve. Here the by dividing into branches to the tongue.
nerve divides into vestibular and cochlear parts.
The Vestibular Nerve
A plan of the vestibular nerve is

shown in Figure 42.26. The fibres of
the nerve are processes of cells in the
vestibular ganglion, that is located
within the internal acoustic meatus.
The cells of this ganglion are bipolar
(not unipolar as in typical sensory Fig. 42.26. Basic plan of the vestibular nerve.
ganglia). Peripheral processes
arising from neurons in the ganglion
supply end organs in the vestibular
part of the membranous labyrinth.
The central processes of neurons in
the vestibular ganglion form the
vestibular nerve. Entering the
brainstem they end in relation to the
vestibular nuclei. Fibres arising in the
vestibular nuclei carry impulses for
equilibrium to the cerebellum.
The Cochlear Nerve
A plan of the cochlear nerve is shown

in Figure 42.27. The cochlear nerve
is made up of the central processes Fig. 42.27. Basic plan of the vestibular nerve.
of neurons located in the spiral
anterior surface of the petrous temporal bone. It leaves the
cranial cavity by passing through the foramen ovale. The
nerve ends by joining the otic ganglion. Its importance is
considered below.
3. The carotid branch supplies the carotid sinus and
carotid body.
4. Pharyngeal branches are given off to the mucous
membrane of the pharynx.
5. As the glossopharyngeal nerve winds round the
stylopharyngeus it supplies this muscle.
6. Some tonsilar branches supply the palatine tonsil and
the soft palate.
7. The lingual branches supply the part of the tongue
(mucous membrane) behind the sulcus terminalis. They
also supply the vallate papillae. As described below these
branches carry fibres for both general sensation and taste.
The glossopharyngeal nerve is involved in the following
pathways.
Fig. 42.28. Branches of the glossopharyngeal nerve.
Secretomotor pathway for the parotid gland
The preganglionic neurons concerned are located in the
inferior salivatory nucleus that lies at the junction of the
pons and medulla. These fibres pass successively through
the proximal part of the glossopharyngeal nerve, its
tympanic branch, the tympanic plexus and the lesser
petrosal nerve to end in the otic ganglion. Postganglionic
fibres in the otic ganglion pass through a nerve connecting
the otic ganglion to the auriculotemporal nerve, and then
through the auriculotemporal nerve itself. They leave the
latter through its parotid branch to reach the parotid gland.
Taste pathway for posterior part of tongue
The fibres are peripheral processes of neurons in the
inferior ganglion of the glossopharyngeal nerve. They pass
through the glossopharyngeal nerve and its lingual branches
to reach the tongue. Central processes of the neurons
concerned pass through the proximal part of the
glossopharyngeal nerve and enter the medulla where they
end in the upper part of the nucleus of the solitary tract.
The Otic Ganglion
The otic ganglion is situated just below the foramen ovale
Fig. 42.29. Secretomotor pathway for the parotid gland. medial to the trunk of the mandibular nerve (Fig. 42.20).
It is connected to the nerve to the medial pterygoid muscle.
The fibres passing through the otic ganglion are as follows:
a. Functionally the ganglion is a peripheral ganglion of the
The proximal part of the glossopharyngeal nerve bears two cranial parasympathetic outflow. It is the relay station for
ganglia, superior and inferior. The superior ganglion is small secretomotor fibres to the parotid gland. The pathway
and lies within the jugular foramen. The inferior ganglion is concerned has been described above.
larger and lies just below the foramen (Fig. 42.28). b. Sympathetic fibres reach the ganglion from the plexus
The branches of the glossopharyngeal nerve are shown in on the middle meningeal artery.
Figure 42.28 and are considered below: c. Motor fibres reach the ganglion through the nerve to
1. The tympanic branch arises from the inferior ganglion. It the medial pterygoid. They pass through the ganglion
enters a canal within the petrous temporal bone to reach the (without relay) and enter branches of the ganglion that
tympanic cavity where it forms a plexus (tympanic plexus). supply the tensor tympani and the tensor palati muscles.
2. The lesser petrosal nerve arises from the tympanic plexus. It
leaves the tympanic cavity through a canal that opens on the
397
398
6. The course of the recurrent
laryngeal nerve is different on
the right and left sides.
On the right side the nerve arises
from the vagus as the latter
passes in front of the subclavian
artery. It passes backwards below
the artery and then upwards
behind the artery forming a loop.
The nerve then runs upwards
and medially deep to the common
carotid artery to reach the side of
the trachea.
On the left side the recurrent
Fig. 42.30. Connections of the otic ganglion. laryngeal nerve arises from the
vagus in the thorax, as the latter
crosses lateral to the arch of the aorta. The nerve
winds below the arch, immediately behind the
THE VAGUS NERVE ligamentum arteriosum and then passes upwards
and medially to reach the side of the trachea.
The vagus nerve arises from the lateral side of the medulla. The nerve Having reached the trachea both the right and left
leaves the skull through the jugular foramen. The part of the nerve nerves ascend in the groove between it and the
within the jugular foramen shows an enlargement called the superior oesophagus, deep to the medial surface of the
ganglion. Just below the foramen the nerve has a much larger enlargement thyroid gland. At the upper end of the trachea and
called the inferior ganglion. oesophagus the nerve passes deep to the lower
The vagus nerve descends vertically in the neck. It is enclosed within border of the inferior constrictor muscle and enters
the carotid sheath. Here it lies in the interval between the posterior part the larynx. It is distributed as follows.
of the internal or common carotid artery and the internal jugular vein. In
the lower part of the neck the nerve crosses anterior to the first part of
the subclavian artery, and enters the thorax. After descending through
the thorax the nerve enters the abdomen. The vagus nerve has a wide
distribution.
Branches of the Vagus Nerve in the Neck
The vagus nerve gives off numerous branches in the neck, in the thorax
and in the abdomen. Branches arising in the thorax and the abdomen are
considered in the appropriate sections. Here we will consider the branches
that arise from the nerve in the neck.
1. A meningeal branch arises near the upper end of the nerve.
2. The auricular branch arises from the superior ganglion. It is
distributed to the skin of the auricle, the external acoustic meatus and
the tympanic membrane.
3. The pharyngeal branch arises from the inferior ganglion. It divides
into numerous branches that form the pharyngeal plexus. Fibres of the
plexus supply the muscles of the pharynx and of the soft palate (except
the tensor palati that is supplied by the mandibular nerve).
4. One or more branches are given off to the carotid body.
5. The superior laryngeal nerve arises from the inferior ganglion. It
descends on the lateral wall of the pharynx. It ends by dividing into the
internal and external laryngeal nerves.
The internal laryngeal nerve is sensory. It enters the larynx and divides
into branches that supply:
a. the mucous membrane of the upper-half of the larynx (up to the vocal
folds); and
b. the mucous membrane of part of the pharynx, and of the most posterior
part of the tongue. Fig. 42.31. Some branches of the vagus
nerve in the neck.
The external laryngeal nerve supplies the cricothyroid muscle.
a. The nerve provides the motor supply to all
intrinsic muscles of the larynx (except the
cricothyroid supplied by the external laryngeal
nerve).
b. The nerve provides the sensory supply to
the mucous membrane of the lower half of the
larynx i.e. the part below the level of the vocal Fig. 42.32. Formation
folds). and distribution of the
c. It gives sensory branches to the trachea, the accessory nerve.
oesophagus and to the inferior constrictor. It also
gives branches to the cardiac plexus.
7. Cardiac branches: Each vagus gives one (or
more) superior cervical cardiac branch in the
upper part of the neck, and an inferior cervical
cardiac branch in its lower part. These branches
end in the superficial and deep cardiac plexuses.
Functional Components of the Vagus

Nerve
1. The vagus nerve is composed predominantly
of parasympathetic fibres. These fibres are very
widely distributed. The vagi are responsible for parasympathetic through its pharyngeal and laryngeal branches to muscles
innervation of the thoracic viscera including the heart and of the pharynx, soft palate and larynx.
bronchi and of the greater part of the gastrointestinal tract. b. The fibres of the spinal part arise from the lateral part of
The fibres in the vagus nerves are preganglionic. They arise the ventral grey column of the upper five or six cervical
from the dorsal nucleus of the vagus and pass through the nerve segments of the spinal cord. They supply the
and its ramifications to reach the viscera supplied. As a rule sternocleidomastoid and trapezius muscles.
postganglionic neurons are located in plexuses situated close
to the viscera, or in the walls of the viscera themselves. They
Cranial part of Accessory Nerve
innervate (a) smooth muscle and (b) glands present in the walls
The cranial part of the nerve is attached, by four or five
of the viscera.
rootlets, to the side of the medulla. From here the nerve
2. Fibres arising from the nucleus ambiguus pass through the
runs laterally to reach the jugular foramen where it is joined
superior laryngeal, recurrent laryngeal and pharyngeal branches
by the spinal root (see below). After passing through the
and supply muscles of the pharynx, soft palate and larynx.
jugular foramen the cranial root again separates from the
3. Afferent fibres from the pharynx, larynx, trachea, and
spinal root and merges with the inferior ganglion of the
oesophagus, and from the thoracic and abdominal viscera travel
vagus. The fibres of the cranial root of the accessory nerve
through the vagus nerve to reach the nucleus of the solitary
pass into the pharyngeal and recurrent laryngeal branches
tract.
of the vagus and contribute to the innervation of the muscles
4. The vagus carries the sensation of taste from the posterior
of the pharynx and larynx.
most part of the tongue and from the epiglottis. The fibres pass
through the superior laryngeal nerve and end in the nucleus of
the solitary tract. Spinal Part of Accessory Nerve
5. Finally the vagus also contains some fibres that supply skin. The spinal part of the accessory nerve is formed by union of
They pass through the auricular branch to reach the skin of the a number of rootlets that emerge from the upper five or six
auricle. cervical segments of the spinal cord. The spinal root ascends
lateral to the spinal cord. It then runs upwards and laterally
to reach the jugular foramen. The spinal root joins the cranial
root within the foramen, but leaves it again on emerging
from the foramen.
THE ACCESSORY NERVE In the neck the spinal accessory nerve first runs backwards
and laterally to reach the transverse process of the atlas;
This is the eleventh cranial nerve. It consists of two distinct and then downwards and backwards across the lateral side
parts, cranial and spinal. Both parts consist predominantly of of the neck. In this part of its course the nerve passes
efferent fibres as follows: through the sternocleidomastoid. The nerve now runs
a. The fibres of the cranial part arise from the nucleus downwards and backwards across the posterior triangle to
ambiguus. These fibres join the vagus nerve and are distributed reach the anterior margin of the trapezius about 5 cm above
399
400
the clavicle. The terminal part of the nerve runs
down the back deep to the trapezius.
The spinal part of the accessory nerve supplies the
sternocleidomastoid (as it passes through it) and
the trapezius (by its terminal branches).
THE HYPOGLOSSAL NERVE
This is the twelfth cranial nerve. Its fibres are purely

motor. They supply the muscles of the tongue. The
neurons that give origin to these fibres are located
in the hypoglossal nucleus.
The hypoglossal nerve emerges from the medulla
by ten to fifteen rootlets that are attached in the
vertical groove separating the pyramid from the
olive (Fig. 42.11). The hypoglossal nerve leaves
the cranial cavity through the hypoglossal canal.
Fig. 42.33. Scheme to show the distribution of the
On emerging at the base of the skull the nerve lies
hypoglossal nerve.
deep (medial) to the internal jugular vein and
internal carotid artery. It passes laterally and
downwards to reach the interval between these vessels, and 2. A meningeal branch arises from the nerve as it passes
then runs vertically between them, up to the level of the angle through the hypoglossal canal.
of the mandible (Fig. 42.34). Here the nerve passes forwards 3. The nerve gives a descending branch that forms the
crossing the internal and external carotid arteries, and enters superior root of the ansa cervicalis. Its fibres are derived
the submandibular region. from the first cervical nerve (Fig. 42.33).
In the submandibular region the hypoglossal nerve at first lies 4. Branches from the hypoglossal nerve also supply the
superficial to the hyoglossus muscle and then to the thyrohyoid and geniohyoid muscles (Fig. 42.33). Like the
genioglossus. It ends by dividing into its terminal branches. fibres of the descending branch the fibres of these branches
These supply all the intrinsic and extrinsic muscles of the are also derived from the first cervical nerve.
tongue (except the palatoglossus
that is supplied, along with other
muscles of the palate, by the cranial
accessory nerve).
Branches of the hypoglossal
nerve:
The branches of the hypoglossal
nerve may be divided (a) into
branches of the nerve proper and
(b) branches that represent fibres
that reach it from the first cervical
nerve.
1. We have seen that the
hypoglossal nerve itself supplies
the muscles of the tongue
(styloglossus, hyoglossus,
genioglossus, and intrinsic
muscles).
Fig. 42.34. Some relations of the hypoglossal nerve.

2. Branches from the cervico-
thoracic ganglion travel into the
upper limb through a plexus over
the subclavian artery, and through
branches to the brachial plexus.
3. Grey rami are given off to the
cervical nerves: from the superior
ganglion to C1 to C4, from the
middle ganglion to C5 and C6; and
from the inferior ganglion to C7,
C8 and T1.
4. Each ganglion gives off a
cardiac branch. These travel into
the thorax and supply the heart
through the superficial and deep
cardiac plexuses.
5. Laryngopharyngeal branches
reach the pharyngeal plexus and
Fig. 42.35. Distribution of the carotid body.
internal carotid nerve 6. A nerve loop that connects the
middle ganglion to the
cervicothoracic ganglion passes
around the subclavian artery. This
is the ansa subclavia.
CERVICAL PART OF SYMPATHETIC TRUNK
The cervical part of the sympathetic trunk bears three ganglia, superior,
middle and cervicothoracic. The superior ganglion represents fused
ganglia C1 to C4. The middle ganglion represents ganglia C5 and C6.
The cervicothoracic ganglion represents ganglia C7, C8 and T1. This
ganglion has numerous branches that give it a star like appearance
because of which it is also called the stellate ganglion.
The superior cervical ganglion lies in front of the transverse processes
of vertebrae C2 and C3; the middle ganglion in front of C6; and the
cervicothoracic ganglion between the transverse process of C7 and the
neck of the first rib.
Branches of Cervical Sympathetic Trunk
1. The internal carotid nerve arises from the superior cervical ganglion.
The nerve ascends along the internal carotid artery and divides into
branches that form a plexus over it. Many structures in the cranial
cavity receive sympathetic innervation through the plexus.
a. Some fibres reach the middle ear and join the tympanic plexus.
b. Some fibres pass through the deep petrosal nerve, the nerve of the
pterygoid canal and the pterygopalatine ganglion to supply the orbitalis
muscle.
c. Some fibres pass into the ophthalmic division of the trigeminal nerve, Fig. 42.36. Some connections of middle cervical
its nasociliary branch, and the long ciliary nerves to reach the eyeball sympathetic and cervicothoracic ganglia.
where they supply the dilator pupillae muscle, and the blood vessels of
the eyeball.
401
402
43 : Orbit, Eye and Ear
THE ORBIT
Nerves to be seen in the orbit

The nerves to be seen in the orbit are the optic nerve, the
oculomotor nerve, the trochlear nerve, the abducent nerve, the
lacrimal and frontal nerves, the nasociliary nerve, and the
infraorbital nerve. They have been described in Chapter 42.
Blood vessels
The main artery of the orbit is the ophthalmic branch of the
internal carotid artery. The artery and its branches are
considered in Chapter 41.
The veins of the orbit end in superior and inferior ophthalmic
veins. These are also described in Chapter 41.
Lymph vessels from structures in the orbit drain into the parotid
lymph nodes.
Fig. 43.1. Diagram showing the common tendinous ring for

origin of the rectus muscles. Note its relationship to the
optic canal and to the superior orbital fissure.
Fig. 43.2. Extraocular muscles seen from the lateral side.

ORBIT, EYE AND EAR
MUSCLES OF THE ORBIT Actions of Rectus and Oblique Muscles:
Movements of the Eyeball
The muscles of the orbit include the extraocular muscles that
As a convention movements of the eyeball are described
are the four recti (superior, inferior, medial and lateral), two
with reference to its anterior end (or more simply, the
oblique muscles (superior and inferior), and the levator
cornea).
palpebrae superioris. In addition we have some muscles made
A. The cornea can move upwards or downwards, the
up of smooth muscle fibres and supplied by autonomic nerves.
movement occurring on an imaginary axis passing
These are the superior tarsal, inferior tarsal and orbitalis
transversely through the equator of the eyeball. Upward
muscles. Some muscles that lie within the eyeball (sphincter
movement can be produced (1) by pulling the anterior part
and dilator pupillae, ciliaris) will be considered when we study
of the eyeball upwards (superior rectus), or (2) by pulling
that organ.
the posterior part downwards (inferior oblique). Similarly,
downward movement can be produced by (1) pulling the
The Four Recti anterior part downwards (inferior rectus) or (2) pulling the
posterior part upwards (superior oblique).
Origin B. The cornea can move medially or laterally on an axis
The superior rectus, the inferior rectus, the medial rectus and passing vertically through the equator of the eyeball. Medial
lateral rectus muscles all arise from the posterior part of the movement can be produced by pulling the anterior part of
orbit through a common tendinous ring that surrounds the optic the eyeball medially. This action is performed by the medial
canal, and encloses a part of the superior orbital fissure (Fig. rectus. The superior and inferior recti can also move the
43.1). The superior, inferior, medial and lateral recti arise from
the corresponding parts of the ring.
Insertion
The muscles run forwards (Fig.43.2) first around the
optic nerve and then around the eyeball (in the positions
indicated by their names) to be inserted into the sclera
about 6 mm behind the junction of the sclera and cornea
(Also see figure 43.3). Note that the insertions are in
front of the equator of the eyeball.
The nerve supply and actions of the recti are considered
below along with those of the oblique muscles.
The Oblique Muscles
Superior Oblique
The superior oblique muscle arises from the body of
the sphenoid bone just above and medial to the optic
canal (Fig. 43.1). It runs forwards in the upper medial
part of the orbit. Near the orbital margin the muscle
ends in a tendon that passes through a tendinous pulley
(trochlea). This pulley is attached to the wall of the orbit
at the junction of its roof and medial wall. The tendon
then runs backwards and laterally to be inserted into
the upper lateral quadrant of the eyeball behind the
equator.
Inferior Oblique
The inferior oblique muscle arises from the anterior and
medial part of the floor of the orbit (from the maxilla
just lateral to the nasolacrimal groove). The muscle
winds round the eyeball first passing laterally and
backwards (below the inferior rectus) and then
backwards and upwards (deep to the lateral rectus) to Fig. 43.3. Scheme showing the movements of the
be inserted into the lateral part of the sclera behind the eyeball produced by individual extraocular muscles,
equator of the eyeball. The insertion is below and behind and the muscles responsible for each movement.
that of the superior oblique muscle (Fig. 43.2).
403
404
cornea medially as they pass forwards and laterally from origin levator palpebrae superioris by its superior ramus; and the
to insertion. Lateral movement can be produced (1) by pulling rectus medialis, rectus inferior and the inferior oblique by its
the anterior part of the eyeball laterally (lateral rectus) or (2) by inferior ramus.
pulling the posterior part medially (superior and inferior
oblique).
The movements produced by individual muscles, and the
combinations of muscles producing a given movement, are
THE LACRIMAL GLAND
summarised in Figure 43.3.
Levator Palpebrae Superioris
The lacrimal gland lies in relation to the upper lateral part
The levator palpebrae superioris arises from the posterior part
of the wall of the orbit (formed here by the zygomatic process
of the orbit. The area of origin is on the lesser wing of the
of the frontal bone). The gland is related inferiorly to the
sphenoid bone (Fig. 43.1) a little above the optic canal. The
levator palpebrae superioris and to the lateral rectus muscle.
muscle passes forwards above the superior rectus and enters
An extension of the gland, that extends into the upper eyelid,
the upper eyelid. The muscle is responsible for keeping the
is called its palpebral part. The palpebral part is continuous
palpebral fissure open.
with the main (or orbital) part around the lateral side of the
aponeurosis of the levator palpebrae superioris. In other
Nerve Supply of Muscles of the Eyeball: words the palpebral part lies deep to the aponeurosis of the
levator. The lacrimal gland drains into the superior
The lateral rectus is supplied by the abducent nerve, and the conjunctival fornix through about twelve ducts. The lacrimal
superior oblique by the trochlear nerve. All other muscles are gland is supplied by twigs from the lacrimal branch of the
supplied by the oculomotor nerve: the superior rectus and the ophthalmic artery. The secretomotor fibres to the gland
follow a complicated course that is described in Chapter 42.
THE EYEBALL
Preliminary Remarks A horizontal section across an eyeball is shown in Figure

It is common knowledge that the right and left eyes are the 43.4. Note the following features:
peripheral organs of vision. Each eyeball is like a camera. It The wall of the eyeball is made up of three main layers.
has a lens that produces images of objects that we see. The 1. The outermost layer is called the fibrous coat. It is formed
images fall on a membrane called the retina. Cells in the retina posteriorly by the sclera; and anteriorly by the cornea.
convert the light images into nervous impulses that pass through 2. The next layer is the vascular coat. It has the following
the optic nerves and other parts of the visual pathway to reach subdivisions. The part lining the inner surface of most of
visual areas of the cerebral cortex. It is in the cortex that vision the sclera is thin and is called the choroid. Near the junction
is actually perceived. of the sclera with the cornea the vascular coat is thick and
The greater part of the eyeball (posterior five sixths) is shaped forms the ciliary body. The ciliary body is continuous with
like a sphere and has a diameter of about 24 mm. The anterior the iris that lies a short distance behind the cornea.
one sixth is much more convex than the posterior part. The The space between the iris and the cornea is called the
outer wall of the posterior five sixths of the eyeball is formed anterior chamber. The space between the iris and the front
by a thick white opaque membrane called the sclera. The wall of the lens is called the posterior chamber.
of the anterior one sixth is transparent and is called the cornea. 3. The innermost layer of the wall of the eyeball is called the
When the eye is viewed in the living person we see only a retina.
small part of the eyeball that appears in the interval between Light falling on the retina has to pass through a number of
the upper and lower eyelids (i.e. in the palpebral fissure). The refracting media before reaching the retina and forming an
white of the eye is formed by the sclera. The dark central image on it. These are (a) the cornea; (b) a fluid, the aqueous
part is formed by the cornea. The cornea itself is transparent: humour, which fills the anterior and posterior chambers;
the dark appearance is because of the presence of a pigmented (c) the lens; and (d) a jelly like vitreous body that fills the
diaphragm, the iris, deep to the cornea. In the centre of the iris eyeball posterior to the lens.
there is an aperture called the pupil. The pupil appears black The centre of the cornea is called the anterior pole of the
as the interior of the eye is dark. eyeball. The opposite end is called the posterior pole. The
ORBIT, EYE AND EAR
The Cornea
As the cornea is more convex than the sclera the

junction of the two is marked, on the exterior of the
eyeball, by a groove called the sulcus sclerae.
The cornea is made up of five layers that are shown in
Figure 43.5.
The Choroid
The choroid consists of a network of blood vessels

supported by connective tissue containing many
pigmented cells that give it a dark brown colour. It is
the dark colour of the choroid that darkens the interior
of the eyeball. It also prevents reflection of light within
the eyeball. Both these factors are necessary for
formation of sharp images on the retina.
Fig. 43.4. Horizontal section across the eyeball to show the main
features of its structure.
visual axis of the eye passes from the anterior pole to the The Ciliary Body
posterior pole. In Figure 43.4 note that the optic nerve is
attached to the back of the eyeball a short distance medial to The ciliary body represents an anterior continuation of the
the posterior pole. An imaginary line passing round the eyeball choroid. Anteromedially, it becomes continuous with the
midway between the anterior and posterior poles is called the iris. It is made up of vascular tissue, muscle and connective
equator of the eyeball. Any line passing through both the poles tissue.
(i.e. at right angles to the equator) is called a meridian. The ciliary body can be divided into a posterior part called
the ciliary ring, and an anterior part made of the ciliary
processes. The ciliary processes secrete the aqueous humour.
The Sclera
The sclera is made up mainly of fibrous tissue. Its external

surface gives attachment to the extrinsic muscles of the eyeball.
Posteriorly, in the region of the attachment of the optic nerve,
the sclera is perforated like a sieve. This area is called the
lamina cribrosa. Bundles of nerve fibres arising in the retina
pass through these perforations to form the optic nerve.
Anteriorly, the sclera becomes continuous with the cornea at
the sclerocorneal junction. A circular channel called the sinus
venosus sclerae (or canal of Schlemm) is located in the sclera
just behind the sclerocorneal junction. A triangular mass of
scleral tissue projects into the cornea just medial to the sinus:
this projection is called the scleral spur.
The anterior part of the external surface of the sclera is covered
by the ocular conjunctiva. The rest of the sclera is in contact
with a fascial sheath that surrounds the eyeball.
The sclera provides a smooth external surface that facilitates
movements of the eyeball. This surface also provides
attachment to the extrinsic muscles of the eyeball.
Fig. 43.5. Diagram of a section through the cornea
to show its layers.
405
406
A meridional section (i.e. a section along a line joining the
anterior and posterior poles of the eyeball) is shown in Figure
43.6. In such a section the ciliary body appears to be triangular.
Lateral to the ciliary processes (and medial to the anterior part
of the sclera) there is the ciliary muscle. Contraction of this
muscle relaxes the fibres of the suspensory ligament. Release
of tension on the lens makes it more convex and enables it to
focus images of near objects on the retina. This is called
accommodation.
The ciliary muscle (or ciliaris) is supplied by parasympathetic
fibres that travel to it through the oculomotor nerve and the
ciliary ganglion.
The Iris
The iris is the most anterior part of the vascular coat of the
eyeball. It forms a diaphragm placed immediately in front of
Fig. 43.6. Section through the ciliary body and iris.
the lens. At its periphery it is continuous with the ciliary body.
In its centre there is an aperture, the pupil.
The iris is composed of a stroma of connective tissue containing passes through the pupil into the anterior chamber. From
numerous pigment cells, and in which are embedded blood here it filters through the spaces of the iridocorneal angle to
vessels and smooth muscle. enter the sinus venosus sclerae through which it is drained
The pupil regulates the amount of light passing into the eye. into the veins of the region. With advancing age these spaces
In bright light the pupil contracts, and in dim light it dilates. In may get blocked resulting in increased tension within the
this way the optimum amount of light required for proper vision eyeball. This disease, called glaucoma, may have serious
reaches the retina, within a considerable range in intensity of consequences.
illumination. Changes in the size of the pupil are produced by
the smooth muscle of the iris that consists of two parts.
a. The sphincter pupillae is a ring of circularly arranged
muscle situated just around the pupil. Its contraction narrows THE RETINA
the pupil.
b. The dilator pupillae is in the form of muscle fibres that are The retina has two layers. The outer layer is the pigment
arranged radially in the iris. It dilates the pupil. cell layer that is only one cell thick. The second layer is the
nervous layer. It is made up of several layers of cells.
The essential features of the structure of the retina are shown
Nerve supply of the sphincter and dilator pupillae in Figure 43.7. It contains photoreceptors that convert the
The sphincter pupillae has a parasympathetic nerve supply stimulus of light into nervous impulses. These receptors are
(similar to that of the ciliary muscle). Preganglionic neurons of two kinds, rods and cones. There are about seven million
that are located in the Edinger-Westphal nucleus (in the upper cones in each retina. The rods are far more numerous: they
part of the midbrain) give off axons that pass through the number more than 100 million. The cones respond best to
oculomotor nerve and its branches to reach the ciliary ganglion. bright light. They are responsible for sharp vision and for
Postganglionic nerve fibres pass through the short ciliary nerves discrimination of colour.
to reach the muscle. Opposite the posterior pole of the eyeball the retina shows a
The dilator pupillae is supplied by sympathetic nerves. central region about 6 mm in diameter. This region is
responsible for sharp vision. In the centre of this region an
The Iridiocorneal Angle area about 2 mm in diameter has a yellow colour and is called
the macula lutea. The fovea centralis, is a depression in the
The angle between the peripheral margins of the iris and of centre of the macula. Cones are most numerous in the central
the cornea is a region of importance (Fig. 43.6). In it there are region. The fovea centralis is believed to contain cones only.
spaces of the iridocorneal angle. These spaces communicate Each rod or cone consists of a cell body, a peripheral process
medially with the anterior chamber, and laterally with the sinus and a central process. The basic neuronal arrangement within
venosus sclerae. Aqueous humour secreted by the ciliary the retina is shown in Figure 43.7. The central processes of
processes passes into the posterior chamber of the eye (i.e. the rods and cones synapse with the peripheral processes of
space between the posterior surface of the iris and the lens). It bipolar cells. The central processes of bipolar cells synapse
ORBIT, EYE AND EAR
with dendrites of ganglion cells. Axons The veins draining the iris, the ciliary
arising from ganglion cells form the fibres body and the choroid form a dense plexus
of the optic nerve. deep to the sclera. The veins of this plexus
We have seen that the optic nerve is converge on four or five venae
attached to the eyeball a short distance vorticosae. These veins pierce the sclera
medial to the posterior pole. The nerve a little behind the equator of the eyeball
fibres arising from the ganglion cells all to end in the ophthalmic veins.
over the retina converge on to this region, The main blood supply to the retina
where they pass through the lamina reaches it through the central artery of the
cribrosa to form the optic nerve. When retina. The venous drainage of the retina
viewed from the retinal side this region is is through small veins that correspond to
seen as a circular area called the optic disc. the branches of the central artery, but do
There are no photoreceptors here. The not accompany them closely. These small
optic disc is, therefore, insensitive to light veins end in two larger veins, superior and
and is called the blind spot. The optic disc inferior, that pierce the lamina cribrosa
is pierced, near its centre, by the central and join each other to form the central
artery and vein of retina (see below). vein of the retina.
The nerves (other than the optic nerve)
The Lens that supply the eyeball are the long and
short ciliary nerves.
The lens lies in front of the vitreous body
and behind the iris. It is surrounded by a
capsule. It has convex anterior and
posterior surfaces, and a peripheral margin Fig. 43.7. Scheme to show the
(or equator) to which the suspensory main elements of the retina.
ligament is attached. The anterior surface
is less convex than the posterior surface. It comes into contact
with the iris near the margin of the pupil. The posterior surface
of the lens lies in a depression in the vitreous body called the
hyaloid fossa.
The Suspensory Ligament
The suspensory ligament of the lens is also called the zonule

(Fig. 43.6). It is made up of fibres passing from the equator of
the lens to the ciliary processes.
Changes in the tension on the suspensory ligament, produced
by contraction of the ciliary muscle, produce alterations in the
convexity of the lens and enable it to focus objects at varying
distances from the eye.
Blood Vessels and Nerves

of the Eyeball
The arteries supplying the retina are the short ciliary arteries
and the long ciliary arteries. They are branches of the ophthalmic
artery. Fig. 43.8. Simplified scheme to show the arteries
supplying the eyeball.
407
408
THE EAR AND SOME RELATED STRUCTURES
Preliminary Remarks About The Ear
Anatomically speaking, the ear is made up of three main parts

called the external ear, the middle ear and the internal ear.
The external ear and the middle ear are concerned exclusively
with hearing. The internal ear has a cochlear part concerned
with hearing; and a vestibular part that provides information
to the brain regarding the position and movements of the head.
The main parts of the ear are shown in Figure 43.9. The part of
the ear that is seen on the surface of the body (i.e. the part that
the lay person calls the ear) is anatomically speaking the auricle
or pinna. Leading inwards from the auricle there is a tube called
the external acoustic meatus. The auricle and external acoustic
meatus together form the external ear. The inner end of the
external acoustic meatus is closed by a thin membranous
diaphragm called the tympanic membrane. This membrane Fig. 43.9. Scheme to show the main parts of the ear.
separates the external acoustic meatus from the middle ear. 1. Malleus; 2. Incus; 3. Stapes.
The middle ear is a small space placed deep within the petrous
part of the temporal bone. It is also called the tympanum (from The Auricle
which we get the adjective tympanic applied to structures
connected with the middle ear). Medially the middle ear is The auricle is made up of a skeleton of elastic cartilage and
closely related to parts of the internal ear. The cavity of the fibrous tissue, which is covered on both sides by a layer of
middle ear is continuous with that of the nasopharynx through thin skin. The cartilage of the auricle is continuous with that
a passage called the auditory tube. Within the cavity of the of the external acoustic meatus. The auricle has an external
middle ear there are three small bones that are collectively surface facing laterally, and an inner or cranial surface that
called the ossicles of the ear. The ossicles are called malleus lies against the side of the head.
(= like a hammer); the incus (= like an anvil, used by The auricle presents a number of elevations and
blacksmiths); and the stapes (= like a stirrup in which the foot depressions. These are given names that are shown in Figure
of a horse rider fits). The three ossicles form a chain that is 43.10. The lowest part of the auricle is soft. It does not contain
attached on one side to the tympanic membrane and at the cartilage and is composed only of a fold of skin with enclosed
other to a part of the internal ear. connective tissue. This part is called the lobule.
The internal ear is in the form of a cavity within the petrous
temporal bone having a very complex shape. This bony cavity
(or bony labyrinth) has a central part called the vestibule.
Continuous with the front of the vestibule there is a spiral
shaped cavity, the bony cochlea. Posteriorly, the vestibule is
continuous with three semicircular canals.
Sound waves traveling through air reach the ears. In many
lower animals in which the auricle is large and mobile it may
help in directing the sound waves into the external acoustic
meatus. The auricle is of doubtful functional significance in
man. Waves striking the tympanic membrane produce
vibrations in it. These vibrations are transmitted through the
chain of ossicles present in the middle ear to reach the internal
ear. Specialised end organs in the cochlea convert the
mechanical vibrations into nervous impulses. These impulses
travel through the cochlear part of the vestibulocochlear nerve
to reach the brain. Actual perception of sound takes place in
the auditory (or acoustic) areas in the cerebral cortex. Fig. 43.10. Named features to be seen on the external
aspect of the auricle.
ORBIT, EYE AND EAR
Blood vessels, lymphatics and nerves of the auricle:
The auricle is supplied by the posterior auricular branch of the
external carotid artery, the anterior auricular branch of the
superficial temporal artery, and branches from the occipital
artery. The veins accompany the arteries.
The sensory nerves supplying the auricle are the
auriculotemporal branch of the mandibular nerve, the great
auricular nerve, and the auricular branch of the vagus nerve.
External Acoustic Meatus
The external acoustic meatus is a tube passing medially from

the bottom of the concha of the auricle. It is closed medially by
the tympanic membrane. The total length of the tube is
approximately 24 mm. Of this, the wall of the outer 8 mm is
cartilaginous, while that of the inner 16 mm is bony (Fig. 43.9). Fig. 43.11. Scheme to show the direction of the
The cartilage or bone is lined by thin skin. This skin is external acoustic meatus.
continuous with that over the concha. The cartilage forming
the wall of the outer part of the meatus is continuous with the
cartilage of the auricle. Medially, the cartilage is firmly attached and through it of the tympanic membrane, the auricle is pulled
to the rough edge of the bony part of the tube. The wall of the upwards, backwards and somewhat laterally. This renders
bony part of the meatus is formed mainly by the tympanic plate the meatus straight (as shown in dotted lines in Figures
of the temporal bone. A small part is formed by the squamous 43.11 A, B). It then has a uniform medial, forward and
part of the temporal bone. downward direction.
The medial end of the meatus is closed by the tympanic The meatus shows a narrowing at the junction of the
membrane. The tympanic membrane is placed obliquely both cartilaginous and bony parts. It shows another narrowing
in the anteroposterior and vertical planes. As a result the floor called the isthmus about 4 mm from the tympanic membrane
and anterior wall are longer than the roof and posterior wall. (i.e. 20 mm from the floor of the concha). The floor of the
The external acoustic meatus is not straight, but follows an S- meatus shows a depression immediately lateral to the
shaped course. This is so because the cartilaginous part is not tympanic membrane. Foreign bodies entering the meatus can
in line with the bony part, and is also bent on itself. The curves get stuck here.
of the meatus are shown as seen from above in figure 43.11A, The skin lining the external acoustic meatus contains
and as seen from behind in Figure 43.11B. The cartilaginous numerous ceruminous glands. These are modified sweat
part first passes medially, forwards and upwards. It then passes glands that produce the wax of the ear, or cerumen.
medially, backwards and upwards. The bony part runs medially, Blood vessels, lymphatics and nerves
forwards and downwards. In clinical examination of the meatus, The external acoustic meatus is supplied by the posterior
auricular branch of the external carotid artery, the auricular
branches of the superficial temporal artery and by the deep
auricular branch of the maxillary artery.
The veins of the meatus drain into the external jugular vein,
the maxillary vein and veins of the pterygoid plexus.
The sensory nerve supply to the anterior wall and roof of
the meatus is by the auriculotemporal nerve, and that to the
posterior wall and floor is by the auricular branch of the
vagus nerve.
THE MIDDLE EAR
The middle ear is also called the tympanic cavity or

tympanum (Fig. 43.9). It is a space lying in the petrous
temporal bone. The middle ear is separated from the external
Fig. 43.12. Dimensions of the tympanic cavity. acoustic meatus by the tympanic membrane. From Figure
43.9 it will be seen that part of the tympanic cavity lies above
409
410
the level of the tympanic membrane: this part is
called the epitympanic recess. Three ossicles,
the malleus, the incus and the stapes lie within
the middle ear. The tympanic cavity
communicates with the cavity of the
nasopharynx through the auditory tube. It also
communicates with a large space in the petrous
part of the temporal bone, called the mastoid
antrum; and with smaller spaces within the
mastoid process called the mastoid air cells.
Because of their communication with the
nasopharynx these spaces are filled with air.
The tympanic cavity is shaped like a box (Fig.
43.12). It has six sides: a roof, a floor, and
anterior, posterior, medial and lateral walls. The
approximate dimensions of these walls are
shown in Figure 43.12. The anteroposterior and
vertical diameters are each about 15 mm. The
cavity is narrow from side to side. The distance
between the medial and lateral walls is about
6 mm near the roof; about 4 mm near the floor; Fig. 43.13. Ossicles of the ear as seen from the medial side.
and only about 2 mm in the middle of the cavity.
Lateral Wall of Middle Ear

Ossicles of the Ear The greater part of the lateral wall of the middle ear is formed
by the tympanic membrane. The part of the middle ear cavity
The Malleus: lying above the level of the tympanic membrane is the
The malleus is so called because it resembles a hammer (mallet epitympanic recess. The lateral wall of the epitympanic
= hammer) (Fig. 43.13). It has an upper rounded part called recess is formed by part of the temporal bone (Fig. 43.14).
the head to which is attached a relatively long handle (or The tympanic membrane
manubrium). At the junction of the head with the handle there This is an oval membrane about 8 to 9 mm in diameter. The
is a slight constriction called the neck. Just below the neck the long diameter passes downwards and forwards. The
bone gives off two processes, anterior and lateral. membrane is placed obliquely in the vertical plane so that
The Incus: the membrane forms an acute angle of about 55 with the
The incus (= anvil) has a main part or body and two processes, floor of the external acoustic meatus.
long and short. Structurally, the tympanic membrane has three layers. The
outer layer is continuous with the skin lining the external
The Stapes: acoustic meatus. The inner layer is formed by the mucous
The stapes is shaped like a stirrup (Fig. 43.13). It has a rounded membrane of the tympanic cavity. Between these two there
head, and a base (which is in the form of an oval plate). The is a layer of fibrous tissue.
head is connected to the base by two limbs, or crura (anterior With the exception of a small area in its anterosuperior part,
and posterior). The constricted part adjoining the head is called the circumference of the tympanic membrane is thickened
the neck. because of the presence here of fibrocartilage. This ring of
Roof of the Middle Ear fibrocartilage fits into a groove, the tympanic sulcus, present
The roof of the middle ear is formed by a plate of bone called at the medial end of the external acoustic meatus.
the tegmen tympani. The same plate of bone extends forwards The handle of the malleus is closely attached to the medial
to form the roof of the canal for the tensor tympani (see below), side of the tympanic membrane. A small area of the tympanic
and backwards to form the roof of the mastoid antrum. membrane, located in its anterosuperior region, is separated
from the rest of the membrane by two small folds. This part
Floor of Middle Ear of the membrane is not stretched like the rest of it; and is,
The floor of the middle ear is formed by a thin plate of bone therefore, called the pars flaccida. In contrast the rest of the
that separates it from the bulb of the internal jugular vein (Fig. membrane is called the pars tensa. The folds separating the
43.14). pars flaccida from the pars tensa are called the anterior and
posterior malleolar folds. On the whole the tympanic
membrane is convex medially. The point of greatest
ORBIT, EYE AND EAR
Fig. 43.14. Lateral wall of tympanic cavity. Parts of the roof, floor, anterior wall
and posterior wall (adjoining the lateral wall) are also seen. The position of the
upper part of the malleus, and of the incus is shown in dotted line.
convexity corresponds to the lower end of the handle of the the membrane and is referred to as the cone of light.
malleus and is called the umbo. It is sometimes necessary to incise the tympanic membrane
Relationship of chorda tympani to lateral wall to let out pus from the middle ear. Such an incision is always
The chorda tympani nerve has an intimate relationship to the made in the lower part to avoid damage to the chorda
tympanic membrane (Fig. 43.15.). The nerve passes forwards tympani. Another advantage of such an incision is that the
through the substance of the upper part of the tympanic lower part of the membrane is less vascular.
membrane, lying between the fibrous and mucosal layers. As it
does so it crosses medial to the handle of the malleus.
Blood vessels and nerves of tympanic membrane
Tympanic membrane as seen through the external The external surface is supplied by the deep auricular branch
acoustic meatus of the maxillary artery, and drains into the external jugular
Many features of the tympanic membrane can be seen in the vein. Nerves supplying it are the auriculotemporal nerve,
living through the external acoustic meatus (Fig. 43.16). The and the auricular branch of the vagus.
pars flaccida can be seen in the
anterosuperior corner of the
membrane, and the anterior and
posterior malleolar folds can also be
distinguished. The lateral process of
the malleus can be seen as a white
dot where these folds meet. Running
downwards and backwards from this
dot to the centre of the membrane
there is the handle of the malleus. A
little behind and parallel to the upper
part of the handle of the malleus the
long process of the incus may be
visible as a faint white streak.
The anteroinferior part of the
membrane (between the lower end
of the handle of the malleus and the
circumference of the membrane) Fig. 43.15. Relationship of the chorda tympani to the lateral wall
reflects light more than the rest of of the middle ear.
411
412
Fig. 43.16. Tympanic membrane as seen Fig. 43.17. Features to be seen on the posterior wall
through the external acoustic meatus. of the middle ear.
The internal surface of the tympanic membrane is supplied by Medial Wall of Middle Ear
the tympanic branches of the maxillary artery, and by the The medial wall of the middle ear is also the lateral wall of the
stylomastoid branch that arises either from the posterior internal ear. It can be properly understood only after
auricular artery or from the occipital artery. The nerves to the examining some features of the internal ear as follows:
internal surface are derived from the tympanic branch of the The most prominent feature to be seen on the medial wall is
glossopharyngeal nerve. the promontory. This is a large circular bulging produced
by the basal turn of the cochlea.
Anterior Wall of Middle Ear Posterosuperior to the promontory we see the fenestra
We have noted that the medial and lateral walls of the middle vestibuli that is also called the oval window. The base of the
ear are fairly close to each other. It follows that the anterior stapes fits into this opening and is attached to its margins by
and posterior walls are narrow. the annular ligament. Posteroinferior to the promontory there
The various structures to be seen on the anterior wall are is a round aperture called the fenestra cochleae (also called
shown in Figure 43.14. In the upper part of the wall there are the round window). This opening is continuous with part of
two openings. The upper opening leads into a canal in which the cavity of the cochlea. It is closed by the secondary
the tensor tympani muscle lies. The lower opening is that of tympanic membrane. Posterior to the promontory there is a
the auditory tube. Below the opening for the auditory tube the depression called the sinus tympani.
anterior wall of the middle ear is formed by a plate of bone The part of the medial wall above the promontory, and the
that separates the middle ear from the carotid canal. fenestra vestibuli, is marked by two rounded ridges that run
Posterior Wall of Middle Ear anteroposteriorly. The upper of these is produced by the
The features to be seen on the posterior wall of the middle ear lateral semicircular canal. The lower ridge is the wall of a
are shown in Figure 43.17. The upper part of the wall shows a canal through which the facial nerve runs backwards.
large round aperture through which the middle ear Muscles of the Middle Ear
communicates with the mastoid antrum. This aperture is called The stapedius is a small muscle lying in a bony canal that is
the aditus to the mastoid antrum. On the medial wall of the related to the posterior wall of the middle ear. The fibres of
aditus there is a bulging produced by the lateral semicircular the stapedius arise from the walls of this canal. They end in
canal. Anterior to the aditus we see a depression, the fossa a tendon that enters the middle ear through the pyramid and
incudis. runs forwards to be inserted into the posterior surface of the
Inferior to the aditus, the medial end of the posterior wall of neck of the stapes. The muscle is supplied by a branch from
the middle ear bears a conical elevation called the pyramid. the facial nerve.
The tip of the pyramid projects forwards, and has an opening The tensor tympani lies in a canal that opens into the anterior
that leads into a canal in which the stapedius muscle is lodged. wall of the middle ear. Muscle fibres arise from the wall of
The tendon of the stapedius emerges from the opening at the this canal and from adjoining structures. The muscle ends in
tip of the pyramid and runs forwards to be inserted into the a tendon that reaches the middle ear cavity near its medial
posterior surface of the neck of the stapes. wall. Here it bends sharply to the lateral side by passing
The facial nerve is closely related to the internal ear and to the around a hook-like projection, the processus
medial and posterior walls of the middle ear. Part of it runs trochleariformis. The muscle is inserted into the upper end
vertically downwards in a bony canal placed along the junction of the handle of the malleus.
of the medial and posterior walls.
ORBIT, EYE AND EAR
considerably. Infection can reach
the mastoid air cells though the
tympanic cavity and the mastoid
antrum.
The Auditory Tube
The auditory tube provides a
communication between the
nasopharynx and the middle ear
(Fig. 43.9). Because of the presence
of this communication air passes
from the nasopharynx into the
tympanic cavity (and into the
mastoid antrum and air cells). As a
result, air pressure on both sides of
the tympanic membrane is the same:
this is important for proper vibration
of the tympanic membrane.
However, the auditory tube is not
Fig. 43.18. Medial wall of middle ear. Parts of the anterior and posterior walls, patent all the time. It opens during
and of the mastoid antrum and mastoid air cells, are also seen. deglutition, or even during the
swallowing of saliva. The
communication between the
Both the tensor tympani and the stapedius protect the ear pharynx and the middle ear is also a path along which
against very loud sounds by restricting the vibrations of the infection frequently reaches the middle ear. Pus can
tympanic membrane and of the ossicles. accumulate in middle ear resulting in severe pain. The pus
The Mastoid Antrum may burst through the tympanic membrane leading to
The mastoid antrum is of considerable importance as it is a discharge from the ear, and to the formation of a perforation
frequent site of infection, which may be difficult to eradicate. in the membrane.
Furthermore, infection may spread from it to neighbouring The auditory tube is about 36 mm long. It consists of an
structures with serious consequences. outer bony part, that is about 12 mm long; and of an inner
The lateral wall of the mastoid antrum is related to the cartilaginous part that is about 24 mm long. The cartilaginous
suprameatal triangle (seen posterosuperior to the external part extends from the medial end of the bony part to the
acoustic meatus). This triangle is bounded above by an elevation lateral wall of the nasopharynx. The auditory tube is
called the supramastoid crest; anteroinferiorly by the narrowest at the junction of the bony and cartilaginous parts:
posterosuperior margin of the external acoustic meatus; and this part is called the isthmus.
posteriorly by a vertical line drawn as a tangent to the posterior The cartilaginous part of the auditory tube lies in close
margin of the meatus (Fig. 43.19). relation to the base of the skull in the groove between the
anterior margin of the petrous temporal bone and the
The Mastoid Air Cells posterior margin of the greater wing of the sphenoid bone.
These are a series of intercommunicating spaces of variable The interior of the auditory tube is lined by mucous
size present within the mastoid process. They communicate membrane continuous with that of the nasopharynx and of
above with the mastoid antrum. Their number varies the middle ear.
THE INTERNAL EAR
Preliminary Remarks
The internal ear is in the form of a complex system of cavities
within the petrous temporal bone. Because of the complex
shape of these intercommunicating cavities the internal ear
is referred to as the labyrinth. The wall of the bony labyrinth
is made up of dense bone. Lying within the bony labyrinth
Fig. 43.19. Boundaries of the suprameatal triangle. there is a system of ducts that constitute the membranous
413
414
labyrinth. The membranous labyrinth is filled by a fluid called
the endolymph. The space between the membranous labyrinth
and the bony labyrinth is filled by another fluid called the
perilymph.
The parts of the bony labyrinth are shown in Figure 43.20.
They are as follows.
(a) In the central part of the bony labyrinth there is a cavity
called the vestibule.
(b) Anterior to the vestibule we see the bony cochlea. The
cavity of the bony cochlea is divided into two parts. One part,
called the scala vestibuli (Fig. 43.22), is continuous posteriorly
with the cavity of the vestibule. The second part is called the
scala tympani. The scala tympani opens into the middle ear at
the fenestra cochleae (Fig. 43.22). At the apex of the cochlea
the scala vestibuli and the scala tympani become continuous.
The communication is called the helicotrema.
(c) Posteriorly, the cavity of the vestibule is continuous with Fig. 43.20. Bony labyrinth seen from the lateral side.
the three semicircular canals (Fig. 43.20).
The parts of the membranous labyrinth are shown in Figure
43.21. Within each semicircular canal the membranous
labyrinth is represented by a semicircular duct. The part of
the membranous labyrinth in the cochlea is called the duct of
the cochlea. In the vestibule the membranous labyrinth is
represented by two distinct membranous sacs called the saccule
and the utricle. For some details see Figure 43.21.
The Semicircular Canals

There are three semicircular canals, anterior (or superior),
posterior, and lateral (Fig. 43.20). One end of each canal is
dilated, and the dilatation is called an ampulla. The non-
ampullated ends of the anterior and posterior canals join to
form a common channel, the crus commune. As a result the
semicircular canals open into the vestibule through five (not
six) openings.
The most important facts about the semicircular canals concern Fig. 43.21. Scheme to show the parts of the
their orientation. The three canals lie in planes at right angles membranous labyrinth. Note the ampullated ends of
to one another). The anterior and posterior canals are both the semicircular ducts.
vertical, while the lateral canal is horizontal.
The Bony Cochlea Further details of the cochlea can be appreciated if we study
The cochlea is continuous with the anterior part of the vestibule. a transverse section through one turn of the cochlea (Fig.
From figure 43.20 it is seen that the cochlea is basically a tube 43.23).
that is coiled on itself for two and three quarter turns. The In this figure we see that the spiral lamina extends only
diameter of the tube is greatest at its junction with the vestibule, partially into the canal of the cochlea. The division of the
and this part is called the basal turn of the cochlea. The tube canal into the scala vestibuli and the scala tympani is
becomes progressively narrower towards the centre or apex completed by the basilar membrane that stretches from the
of the cochlea. The basal turn of the cochlea produces an free edge of the spiral lamina to the outer wall of the
elevation, the promontory, on the medial wall of the middle cochlear canal.
ear. The part of the membranous labyrinth in the cochlea is called
If we examine the basal turn of the cochlea shown in Figure the duct of the cochlea. This duct lies just above the basilar
43.22 we find that it is made up of an upper channel the scala membrane. It is separated from the scala vestibuli by a thin
vestibuli that is continuous with the vestibule; and of a lower vestibular membrane.
channel, the scala tympani, that opens into the middle ear Near the attached margin of the spiral lamina there is a canal.
through the fenestra cochleae. The fenestra cochleae is closed This canal is also shaped like a spiral and is called the spiral
by the secondary tympanic membrane. canal. It contains a collection of neurons that constitute the
The scala vestibuli and the scala tympani are partially separated spiral ganglion. Fibres arising from the ganglion pass
from each other by a shelf of bone. The shelf follows the coiling through the spiral lamina to supply the spiral organ (See
of the cochlea and is, therefore, called the spiral lamina. below).
ORBIT, EYE AND EAR
The end organ for hearing is the
spiral organ (of Corti). It lies in the
duct of the cochlea, just above the
basilar membrane (Fig. 43.23). We
have seen that sound waves
travelling through air produce
vibrations in the tympanic
membrane.
These are transmitted through the
malleus and incus to the stapes. The
base of the stapes (that fits into the
fenestra vestibuli) transmits these
vibrations to the perilymph of the
vestibule. From there the vibrations
pass into the scala vestibuli. Each
time the base of the stapes moves
Fig. 43.22. Interior of the bony labyrinth as seen from the lateral side. inwards into the vestibule it creates
a pressure wave that extends along
the perilymph filling the entire
Specialised End Organs in the Membranous Labyrinth length of the scala vestibuli. Reaching the helicotrema the
We have seen that the internal ear is a highly specialised end pressure wave passes into the perilymph filling the scala
organ that performs the dual functions of hearing and of tympani. Traversing the entire length of the scale tympani it
providing information about the position and movements of reaches the secondary tympanic membrane (that closes the
the head. fenestra cochleae) causing it to bulge into the middle ear.
A number of end organs are present in relation to the The process is reversed when the base of the stapes moves
membranous labyrinth. Their names and positions are given in outwards. These changes take place almost instantaneously.
Figure 43.24. In this way vibrations are set up in the perilymph. These in
turn produce vibrations of the basilar membrane and of
the spiral organ. The spiral organ contains highly
specialised hair cells. Distortions produced in these cells
as a result of vibrations generate nervous impulses. These
impulses travel along nerve fibres that are peripheral
processes of neurons located in the spiral ganglia. These
processes reach the hair cells through canals in the spiral
lamina.
Central processes arising from neurons of the spiral
ganglion constitute the cochlear nerve.
Fig. 43.23. Transverse section through one turn of the cochlea. Fig. 43.24. End organs in the membranous labyrinth.
415
416
Information about changes in the position of the head is of each semicircular duct. Each crista consists of hair cells
provided by end organs called maculae (singular = macula) (and supporting cells) that are surmounted by a gelatinous
present in the utricle and saccule. covering that forms a partition (cupola) within the ampulla.
Movements of the head produce currents in the endolymph
Each macula consists essentially of hair cells, surrounded by within the semicircular ducts. These cause the cupolae to
supporting cells. The hair of the hair cells are covered by a move resulting in deformation of hair cells and production
membrane that contains crystals of calcium carbonate of nerve impulses.
(otoliths). With changes in the position of the head the otoliths The nerve fibres innervating the cristae of the semicircular
are displaced leading to distortion of hair cells. Nervous ducts and the maculae of the utricle and saccule are peripheral
impulses are generated as a result of this distortion. processes of neurons located in the vestibular ganglion. This
Information about angular movements (acceleration) of the ganglion lies in the internal acoustic meatus. The central
head is provided by end organs called the ampullary crests processes of cells of the ganglion form the vestibular nerve.
(or cristae ampullae) one of which is present in the ampulla
44 : Oral Cavity, Nasal Cavity, Pharynx,

Larynx, Trachea, Oesophagus
THE ORAL CAVITY AND SOME

RELATED STRUCTURES
with the oral cavity proper through a space behind the last
THE ORAL CAVITY
tooth.
With the exception of the teeth all structures in the oral cavity
The layperson uses the word mouth loosely both for the are covered by mucous membrane. That over the alveolar
external opening and for the cavity it leads to. Strictly speaking, processes of the jaws is firmly attached to underlying bone
the term mouth should be applied only to the external opening, and is referred to as the gum.
which is also called the oral fissure. The cavity (containing The oral cavity proper communicates, posteriorly, with the
the tongue and teeth) is the mouth cavity or oral cavity. oral part of the pharynx. The communication between the
A basic idea of the boundaries of the oral cavity can be had two is called the oropharyngeal isthmus (Fig. 44.2). The
from Figure 44.1 that is a coronal section through it. Laterally roof of the oral cavity is formed by the palate (described
the cavity is bounded by the cheeks; above by the palate (which below). The chief structure in the floor is the tongue. The
separates it from the nasal cavity); and below it has a floor to rest of the floor is formed by mucous membrane passing
which the tongue is attached. Projecting into the cavity from from the sides of the tongue to the gum. The anterior part of
above and below, just medial to the each cheek, there are the the tongue is not attached to the floor and that is why it can
alveolar processes of the upper and lower jaws that bear the be protruded out of the mouth. This part of the tongue is
teeth. When the mouth is closed bringing the upper and lower connected to the floor by a median fold of mucosa called
teeth into apposition, the oral cavity is seen to consist of a part the frenulum linguae.
between the teeth of the two sides (the oral cavity proper); Three pairs of salivary glands are present near the oral cavity
and a part between the alveolar processes and the cheeks. The and pour their secretions into it. These are the parotid,
latter is called the vestibule. In Figure 44.1 the vestibule is submandibular and sublingual glands. The secretions of the
seen in two halves right and left, but when traced anteriorly parotid glands are poured into mouth through the right and
the two halves become continuous in the middle line in front left parotid ducts that open into the corresponding half of
of the teeth. Here the vestibule communicates with the exterior; the vestibule, on the inner side of the cheek, opposite the
and the external walls are formed by the upper and lower lips. crown of the second upper molar tooth. The duct for each
When the teeth are in apposition the vestibule communicates submandibular gland opens on the sublingual papilla located
ORAL CAVITY, NASAL CAVITY, PHARYNX, LARYNX, TRACHEA, OESOPHAGUS
to the wall of the pharynx and is called
the palatopharyngeal fold. (Also see
figure 38.6).
The soft palate consists of two layers
of mucous membrane (continuous with
those lining the upper and lower
surfaces of the hard palate). Between
these layers of mucosa there is a fibrous
sheet called the palatine aponeurosis
(see below). Several muscles are
present in the soft palate.
Muscles of the Soft Palate

These are the tensor palati, the levator
palati, the musculus uvulae, the
palatoglossus and the palato-
pharyngeus (Fig. 44.3). Details of their
attachments will not be considered.
Fig. 44.1. Schematic coronal section through the oral cavity.
just lateral to the frenulum linguae (Fig. 38.7). The sublingual

glands lie just below the mucosa on the floor of the mouth.
Each gland raises a ridge of mucosa that starts at the sublingual
papilla and runs laterally and backwards. This ridge is called
the sublingual fold.
Development
The oral cavity is developed partly from ectoderm of the
stomatodaeum, and partly from endoderm of the foregut.
THE PALATE
Fig. 44.2. Soft palate as seen through the mouth. The
The palate separates the oral cavity from the nasal cavity. It is dotted line indicates its upper and lateral limits.
divisible into an anterior, larger, part the hard palate, and a
posterior part the soft palate.
The hard palate has a skeletal basis formed by the palatal
processes of the right and left maxillae, and the horizontal plates
of the palatine bones. The bones are covered by periosteum.
The lower surface of the palate is lined by mucous membrane
of the mouth and its upper surface by the mucous membrane of
the nasal cavity.
The soft palate is shown as seen from the front (i.e. through the
mouth) in Figure 44.2, and as seen from behind in Figure 44.14.
The soft palate is attached to the posterior margin of the hard
palate. In its normal relaxed position it has one surface directed
upwards and backwards, and another surface directed forwards
and downwards (Fig. 44.6). Its median part is prolonged
downwards as a conical projection called the uvula (Fig. 44.2).
Its lateral margins are continuous with two folds of mucous
membrane. The anterior of these connects the palate to the
Fig. 44.3. Schematic coronal section to show
lateral margin of the posterior part of the tongue and is called
arrangement of muscles of the palate.
the palatoglossal fold. The posterior fold connects the palate
417
418
Nerve Supply of Muscles of the Palate incisor, a lateral incisor (i.e. two incisors); one canine; and
All muscles of the palate, except the tensor palati, are supplied two molars (distinguished from each other by being called
by the cranial part of the accessory nerve through the the first and second molars). There are, thus, five teeth in
pharyngeal branch of the vagus. The tensor palati is supplied each half of each jaw, i.e. twenty in all.
by the mandibular nerve. A set of permanent teeth consists of the following. Beginning
from the middle line there is a central incisor, a lateral incisor,
Actions of palatine muscles
a canine, two premolars (first and second, that replace the
The palatine muscles are responsible for movements of the
deciduous molars), and three molars (first, second and third).
palate associated with deglutition and with speech. The levator
Thus in each half of each jaw there are eight teeth, or
palati helps to close the pharyngeal isthmus (communication
thirtytwo in all.
between nasopharynx and oropharynx) by elevating the palate
There is considerable variation in the ages at which the
and bringing it into contact with the posterior wall of the
various teeth erupt. The following scheme gives the
pharynx. The tensor palati helps in deglutition by pressing the
approximate ages of appearance in a form easy to remember.
bolus between the palate and the tongue. The palatoglossus
closes the oropharyngeal isthmus. Deciduous teeth
Central incisor = 6 months
Nerve supply and blood supply of the palate
Lateral incisor = (+2) 8 months
The palate is supplied by the greater palatine branch of the
First molar = (+4) 12 months
maxillary artery (Fig. 41.16), the ascending palatine branch of
Canine = (+4) 16 months
the facial artery (Fig. 41.11), and by the palatine branch of the
Second molar = (+4) 20 months
ascending pharyngeal artery (Fig. 41.8). The veins from the
palate end in the pterygoid and tonsilar plexuses. The lymph
Note that the first deciduous molar appears before the canine.
vessels drain into the deep cervical lymph nodes.
The nerves supplying the palate
are the greater and lesser
palatine nerves and the
nasopalatine nerves.
Development
The palate is derived from
palatal processes arising from
the right and left maxillary
processes. The anterior part of
the palate (related to the incisor
teeth) is derived from the
premaxilla.
THE TEETH
There are two sets of teeth. The

teeth that appear in children and
fall off with time are called
deciduous (or milk) teeth. A
second set of permanent teeth
gradually replaces the
deciduous teeth.
The teeth are classified as
follows. Incisors have sharp
cutting edges. Canines are
sharp and pointed. Molars and
premolars have edges suitable
for a grinding function.
A set of deciduous teeth
consists of the following.
Beginning from the middle line
Fig. 44.4. Vertical section through a typical tooth.
(in front) there is a central
Permanent teeth white material, called the enamel. Over the root dentine is
First molar = 6 years covered by, a thin layer of, cement. The cement is united to
Central incisor = (+1) 7 years the wall of the bony socket in the jaw through a layer of
Lateral incisor = (+1) 8 years fibrous tissue called the periodontal ligament. The external
Canine = (+1) 9 years surface of the alveolar process is covered by the gum, which
Premolars = (+1) 10 years normally overlaps the lower edge of the crown. Within the
Second molar = (+1) 11 years dentine there is a pulp canal that contains pulp. Pulp is made
Third molar = 17 years + up of a mass of cells, blood vessels and nerves. The blood
Note that the first permanent tooth to appear is the first molar. vessels and nerves enter the pulp canal at the apex of the
Approximately one tooth appears every year from the 6th to root through an apical foramen.
11th years.
Blood Supply and Nerve Supply of Teeth
The lower teeth are supplied by branches from the inferior
The third molar teeth appear at the age of 17 years or later and
alveolar artery (branch of maxillary artery); and by the
are, therefore, called the wisdom teeth. Not infrequently one
inferior alveolar nerve (branch of mandibular nerve).
or more third molars may fail to erupt.
The upper teeth are supplied by the anterior and posterior
superior alveolar branches of the maxillary artery; and by
the anterior, middle and posterior superior alveolar nerves
Structure of a Typical Tooth (branches of the maxillary nerve and its infraorbital
continuation).
A tooth consists of an upper part, the crown, which is seen in
Development
the mouth; and of one or more roots that are embedded in
Teeth develop from ectoderm of the dental lamina (that is
sockets in the jaw bone (mandible or maxilla). The greater part
formed over the alveolar process).
of each tooth is formed by a bone like material called dentine.
In the region of the crown dentine is covered by, a much harder
THE NASAL CAVITY AND

PARANASAL SINUSES
Preliminary remarks
The nasal cavity is divided by a median
septum into right and left halves. Each
half of the nasal cavity opens to the
exterior through the external (or
anterior) nares, and posteriorly it opens
into the nasopharynx. A schematic
coronal section through the nasal
cavity is shown in Figure 44.5. It is seen
that each half of the cavity is triangular.
It has a vertical medial wall formed by
the nasal septum; a sloping lateral wall;
a relatively broad floor formed by the
palate (that separates it from the oral
cavity); and a narrow roof that lies at
the junction of the medial and lateral
walls.
These walls have a skeletal basis that
is made up predominantly of bone, but
is cartilaginous at some places. The
skeletal basis is covered (over most of
Fig. 44.5. Schematic coronal section through the nasal cavity to show some bones
the nasal cavity) by mucous membrane. forming its walls. The orbit is also shown.
419
420
Typically the mucosa is moist and
highly vascular. It serves to warm
inspired air and also helps to
remove dust (that sticks to the
moist wall). For these reasons the
mucosa is referred to as
respiratory. The mucosa lining the
uppermost part of the septum and
the adjoining part of the lateral wall
is characterised by the presence of
receptor cells that are sensitive to
smell: the mucosa in this region is,
therefore, called the olfactory
mucosa. Olfactory nerves arise
from this mucosa. A small area of
the nasal cavity (near the anterior
nares) is lined not by mucous
membrane, but by skin. This skin
bears hair that serve to trap dust Fig. 44.6. Lateral wall of the nasal cavity with the mucous membrane intact.
present in inspired air.
Medial Wall of Nasal Cavity:
Nasal Septum
The medial wall of the nasal cavity
is formed by the nasal septum. It
has a skeletal basis that is shown

in Figure 35.19. It is constituted
mainly by the perpendicular plate
of the ethmoid bone (postero-
superior part), the vomer
(posteroinferior part), and the
septal cartilage (anterior part).
As a point of practical importance
it may be remembered that the
septum is fairly often deflected to
one side so that one half of the
nasal cavity may be larger than the
other.
Fig. 44.7. Lateral wall of the nasal cavity afater cutting the conchae to reveal
structures deep to them.
Lateral Wall of Nasal Cavity meatuses respectively (2, 3, 4 in Figure 44.5). There is a
The skeletal basis of the lateral wall of the nasal cavity is triangular space above the superior concha (1 in Figure 44.5).
constituted by the maxilla (medial surface), the ethmoid bone, This is the sphenoethmoidal recess (Also see Figure 44.6).
the palatine bone, the inferior nasal concha and the lacrimal
Occasionally an additional concha (called the highest nasal
bone.
concha) may be present on the lateral wall of the
The lateral wall of the nasal cavity as seen with the mucous
sphenoethmoidal recess.
membrane intact is shown in Figure 44.6. The following points
The part of the nasal cavity just above the anterior nares is
may be noted. There are three anteroposterior elevations on
the lateral wall. These are the superior, middle and inferior called the vestibule. The vestibule is lined by skin. At the
nasal conchae. Each concha has a core of bone covered by upper limit of the vestibule (where skin meets mucous
mucous membrane. The bony core of the superior and middle membrane) there is a curved elevation called the limen nasi
conchae is formed by parts of the ethmoid bone, while that of (Fig. 44.6). Above the limen nasi there is a depression called
the inferior concha is independent (Fig. 44.5). Each concha the atrium. The atrium represents a forward continuation of
has an upper border attached to the rest of the lateral wall and the middle meatus beyond the anterior end of the middle
a free lower margin. The spaces deep to the superior, middle concha. The upper limit of the atrium is marked by another
and inferior conchae are called the superior, middle and inferior curved ridge called the aggar nasi.
Some structures in the lateral wall
of the nose can be seen only when
the conchae are cut away (Fig.
44.7). In the middle meatus we see
a rounded elevation called the
bulla ethmoidalis. Below and in
front of the bulla there is a curved
groove called the hiatus
semilunaris. The anterior end of
the hiatus is continuous with a
depression called the ethmoidal
infundibulum. The upper end of
the infundibulum is usually
continuous with the frontonasal
duct that connects the frontal sinus
to the nasal cavity.
Roof of Nasal Cavity
The roof of the nasal cavity lies at
the junction of the medial and
lateral walls (Fig. 44.5). It is
formed by the nasal, frontal,
ethmoid and sphenoid bones.
Floor of Nasal Cavity
The floor of the nasal cavity is
formed by the mucous membrane
covering the upper surface of the
hard palate. Each half of the hard
palate is formed in its anterior
three-fourths by the maxilla
(palatine process); and in its Fig. 44.8. Midline section through the neck, and part of head, to show some features
in the interior of the nose, the mouth, the pharynx and the larynx.
posterior one-fourth by the
palatine bone (horizontal plate).
Blood Supply and Nerve Supply of the Nasal Cavity

THE PARANASAL SINUSES
The chief artery to the mucous membrane of the nose is the
sphenopalatine branch of the maxillary artery. Smaller arteries
helping in the supply are the anterior and posterior ethmoidal These are spaces present in the substance of bones related
branches (of the ophthalmic artery); the terminal part of the to the nasal cavities. Each sinus opens into the nasal cavity,
greater palatine artery; and twigs from the superior labial branch and is lined by mucous membrane continuous with that of
of the facial artery. the latter. Because of this communication each sinus is
The veins accompany the arteries. normally filled with air.
The nerves innervating the nasal mucosal are as follows:
Frontal Sinuses
(1) The olfactory mucosa is innervated by the olfactory nerves.
The right and left frontal sinuses are present in the part of
(2) The posterior three-fourths of the cavity (including lateral
the frontal bone deep to the superciliary arches. Each sinus
wall, septum, roof and floor) are supplied by (a) the lateral and
lies deep to a triangular area the angles of which lie:
medial posterior superior nasal branches (including the
(a) at the nasion (meeting point of frontonasal and internasal
nasopalatine nerve) which arise directly from the
sutures), (b) at a point about 3 cm above the nasion, and
pterygopalatine ganglion; and (b) by the posterior inferior nasal
(c) at a point on the supraorbital margin at the junction of
branches of the greater palatine nerves.
the medial one-third with the lateral two-thirds.
(3) The upper and anterior part of the cavity is innervated by
The cavity of the frontal sinus extends for some distance
the anterior ethmoidal branch of the nasociliary nerve. The lower
into the orbital plate of the frontal bone between the roof of
and anterior part of the cavity is supplied by twigs from the
the orbit and the floor of the anterior cranial fossa.
anterior superior alveolar nerve.
Each frontal sinus usually opens into the middle meatus
Development through the frontonasal duct. This duct is usually continuous,
Nasal cavities are formed by great enlargement and extension below, with a funnel like space the ethmoidal infundibulum
of nasal pits formed on the frontonasal process.
421
422
(Fig. 44.7) that is continuous with the upper end of the hiatus by an opening in the lower part of the hiatus semilunaris
semilunaris. (Fig. 44.7). The opening lies just below the bulla ethmoidalis.
Sphenoidal Sinuses Ethmoidal Air Sinuses
The right and left sphenoidal sinuses are present in the body The ethmoidal air sinuses are located within the lateral part
of the sphenoid bone. Each sinus opens into the corresponding (or labyrinth) of the ethmoid bone. They can be divided into
half of the nasal cavity through an aperture on the anterior anterior, middle and posterior groups.
aspect of the body of the sphenoid. The part of the nasal cavity
into which the sinus opens lies above the superior nasal concha
Opening of nasolacrimal duct
and is called sphenoethmoidal recess (Fig. 44.7).
In addition to the openings of the paranasal sinuses, the lateral
Maxillary Sinuses wall of the nose shows the opening of the nasolacrimal duct.
Each maxillary sinus lies within the maxilla. On the medial This duct conveys lacrimal fluid from the conjunctival sac,
aspect of this bone there is a large maxillary hiatus. via the lacrimal sac. It opens into the anterior part of the
The sinus usually opens into middle meatus of the nasal cavity inferior meatus (Fig. 44.7).
THE PHARYNX
Preliminary Remarks salpingopalatine fold. The nasopharynx has a roof

The pharynx is a median passage that is common to the continuous with the posterior end of the roof of the nasal
alimentary and respiratory systems. It is divisible (from above cavity. The roof and posterior wall of the nasopharynx form
downwards) into a nasal part (or nasopharynx) into which a continuous curve that rests on the posterior part of the
the nasal cavities open; an oral part (or oropharynx) that is body of the sphenoid, the basilar part of the occipital bone,
continuous with the posterior end of the oral cavity; and a and the anterior arch of the atlas.
laryngeal part (or laryngopharynx) that is continuous in front The mucosa of the median part of the roof shows a bulging
with the larynx, and below with the oesophagus. produced by a mass of lymphoid tissue. This lymphoid tissue
The communication between the nasopharynx and the constitutes the pharyngeal tonsil. (When enlarged, the
oropharynx is called the pharyngeal isthmus. This isthmus pharyngeal tonsils are referred to as adenoids). Some
can be closed (e.g. during swallowing) by elevation of the soft lymphoid tissue is also present behind the opening of the
palate. auditory tube. This collection of lymphoid tissue is called
The communication between the oral cavity and the pharynx the tubal tonsil.
is called the oropharyngeal isthmus (Fig. 44.2). It is bounded
above by the soft palate, below by the posterior part of the The Oral Part of the Pharynx
tongue, and on either side by the palatoglossal arches. The The oropharynx lies in front of the second cervical vertebra
oropharyngeal isthmus can be closed by contraction of the and the upper part of the third. The only features to be noted
palatoglossus muscles. This closure plays an important part in on its lateral walls are the palatopharyngeal folds (or
deglutition. arches). These stretch from the uvula to the lateral wall of
The relationship of the laryngopharynx to the inlet of the larynx the pharynx and enclose the palatopharyngeus muscle. The
is shown in figure 44.14. This Figure also shows the anterior palatine tonsil lies between the palatoglossal and
wall of the nasopharynx and oropharynx. We may now proceed palatopharyngeal folds. The depression in which the palatine
to consider some further details about the features to be seen tonsil lies is called the tonsilar sinus.
in the three parts of the pharynx. Laryngeal Part of Pharynx
The Nasal Part of the Pharynx The laryngeal part of the pharynx lies in front of the third to
On each lateral wall of the nasopharynx there is an opening sixth cervical vertebrae. The level of the upper end of the
that leads into the auditory tube. This tube connects the laryngeal part of the pharynx corresponds to the upper end
nasopharynx to the middle ear. Above and behind the opening of the epiglottis; and its lower end lies at the caudal border
of the auditory tube the wall of the nasopharynx shows a of the cricoid cartilage. The anterior wall of the laryngeal
bulging called the tubal elevation. This elevation is produced part of the pharynx is shown in Figure 44.14. Its upper part is
by the medial end of the cartilaginous part of the auditory formed by the inlet of the larynx, and its lower part by the
tube. A fold of mucous membrane starting at the tubal elevation posterior surfaces of the arytenoid and cricoid cartilages.
passes down the pharyngeal wall. This is the Walls of the Pharynx
salpingopharyngeal fold. Another mucosal fold passes from The walls of the pharynx are constituted mainly by muscles.
the tubal elevation to the soft palate. This is the The layer of muscle is covered on the outside by the
fascia that is thickened in
this situation. The lower
edge of the inferior
constrictor becomes
continuous with the circular
muscle of the oesophagus.
Longitudinal muscles
1. The stylopharyngeus
arises from the styloid
process. It runs downwards
on the inner surface of the
middle and inferior
constrictors.
2. The fibres of the
palatopharyngeus descend
from the sides of the palate
and run longitudinally on
the inner aspect of the
constrictors.
3. The salpingopharyngeus
descends from the auditory
tube to merge with the
palatopharyngeus.
Actions of Muscles of
the Pharynx
The muscles of the pharynx
Fig. 44.9. Diagram showing details of origin of the constrictors of the pharynx. play an important part in
deglutition.
buccopharyngeal fascia. Between the mucous membrane and Food entering the oropharynx is carried downwards by
the layer of muscle there is the pharyngobasilar fascia. successive contraction of the superior, middle and inferior
constrictors. The stylopharyngeus, salpingopharyngeus and
the palatopharyngeus help by pulling the pharynx upwards
and by shortening it.
Muscles of the Pharynx
The inner surface of the superior constrictor is lined by a
band of muscle fibres arising from the sides of the palate.
Preliminary Remarks These fibres form the palatopharyngeal sphincter that
The muscular basis of the wall of the pharynx is formed mainly produces a ridge (of Passavant) on the pharyngeal wall at
by three pairs of constrictors, superior, middle and inferior. In the junction of nasopharynx with the oropharynx. Acting
addition to the constrictors, the pharynx has three muscles along with the soft palate the palatopharyngeal sphincter
which run longitudinally. These are the stylopharyngeus, the closes the pharyngeal isthmus preventing food from entering
palatopharyngeus and the salpingopharyngeus. the nasopharynx.
Constrictors of the Pharynx Nerve Supply of Muscles of Pharynx
The origins of the constrictors are situated anteriorly in relation The constrictors of the pharynx, and the salpingopharyngeus
to the posterior openings of the nose, mouth and larynx (from are supplied by the pharyngeal branch of the vagus, through
above downwards). (For details of origin see figure 44.9). From the pharyngeal plexus. The stylopharyngeus is supplied by
here their fibres pass into the lateral and posterior walls of the the glossopharyngeal nerve, and the palatopharyngeus by
pharynx, the fibres of the two sides meeting posteriorly, in the the cranial part of the accessory nerve.
middle line in a fibrous raphe. The three constrictors are so Blood Vessels, Lymphatics & Nerves of Pharynx
arranged that the inferior overlaps the middle, which in turn The pharynx receives numerous small branches that arise
overlaps the superior. The fibres of the superior constrictor from the ascending pharyngeal, lingual, facial and maxillary
reach the base of the skull posteriorly, in the middle line. On the arteries. The veins drain into a plexus that surrounds the
sides, however, there is a gap between the base of the skull and pharynx and drains into the internal jugular and facial veins.
the upper edge of the superior constrictor. Two small muscles, The lymph vessels of the pharynx drain into the deep cervical
the tensor palati and the levator palati are seen in relation to the lymph nodes. Some of the lymph passes through the
gap. The gap is filled by the upper part of the pharyngobasilar retropharyngeal nodes.
423
424
The nerve supply of the pharynx is through the pharyngeal
plexus that is formed by branches from the glossopharyngeal,
vagus and cranial accessory nerves; and from the sympathetic
trunk. The fibres of the cranial accessory nerve run through
the vagus and (as stated above) constitute the main supply of
the muscles of the pharynx, including that of the soft palate.
THE PALATINE TONSILS
The palatine tonsils are masses of lymphoid tissue. Each

palatine tonsil (right or left) lies in the tonsilar sinus on the
lateral wall of the oropharynx (Fig. 44.2). This sinus is bounded Fig. 44.10. Coronal section through the palatine tonsil.
by the palatoglossal fold in front and the palatopharyngeal fold
behind. Relative to the surface of the body the palatine tonsil
lies just in front of and above the angle of the mandible.
The medial surface of the palatine tonsil is covered by mucous The right and left palatine tonsils form the most conspicuous
membrane that is continuous with that of the palatoglossal parts of a ring of lymphoid tissue (Waldeyers ring) present
folds, and below with the mucous membrane on the tongue. near the oropharyngeal isthmus. The ring is completed below
Deep to the mucosa the lymphoid tissue of the tonsil extends by the lingual tonsil and above by the pharyngeal and tubal
upwards into the soft palate and downwards into the tongue. tonsils.
The mucosa over the upper part of the tonsil dips into the The chief artery to the tonsil the tonsilar branch of the facial
substance of the tonsil forming a deep intratonsillar cleft (Fig. artery. Veins from the tonsil end in the facial vein or in the
44.10). A number of smaller recesses called the tonsilar crypts pharyngeal plexus of veins.
are also present. The lateral surface of the tonsil is covered by The sensory nerves supplying the tonsil are derived from
fascia that forms a capsule for it and separates it from the the glossopharyngeal and lesser palatine nerves.
superior constrictor of the pharynx.
THE LARYNX
Introductory Remarks about the Larynx The larynx has a rigid framework made up of cartilages. The
The larynx is a space that communicates above with the cartilages are joined to one another by ligaments. A number
laryngeal part of the pharynx, and below with the trachea. Apart of muscles are attached to the cartilages. They produce
from being a respiratory passage the larynx is the organ where movements of the vocal folds that are necessary for speech.
voice is produced. Near the middle of the larynx there are a The cartilages, ligaments and muscles are covered on the
pair of vocal folds (one right and one left) that project into the inside by mucous membrane that is continuous above with
laryngeal cavity. Between these folds there is an interval called that of the laryngeal part of the pharynx and below with that
the rima glottidis. The rima is fairly wide in ordinary breathing. of the trachea.
When we wish to speak the two vocal folds come close together
Cartilages of the Larynx
narrowing the rima glottidis. Expired air passing through the
These are seen from the front in Figure 44.11; and from
narrow gap causes the vocal folds to vibrate resulting in the
behind in Figure 44.12. There are three unpaired cartilages:
production of sound. Variation in the loudness of sound is
these are the thyroid cartilage, the cricoid cartilage, and the
produced by the force with which air is expelled through the
cartilage of the epiglottis. The paired cartilages are the right
rima glottidis. Variation in pitch is achieved by stretching of
and left arytenoid cartilages; and the corniculate and
the vocal folds to different degrees. The difference in the voice
cuneiform cartilages that are small nodules.
of a man and that of a woman (or of a child) is due to the fact
that the vocal folds are considerably longer in the male adult. Thyroid Cartilage
The structure of the larynx has to be studied keeping these The thyroid cartilage consists of right and left laminae. Their
facts in view. posterior borders are far apart but the anterior borders
approach each other at an angle that is about 90 in the male
and about 120 in the female. The
lower parts of the anterior borders of
the right and left laminae fuse and form
a median projection called the
laryngeal prominence (Fig. 44.11).
The upper parts of the anterior borders
(of the laminae) do not meet: they are
separated by a notch. The posterior
margins of the laminae are prolonged
upwards to form a projection called the
superior cornu; and downwards to
form a smaller projection called the
inferior cornu. Each inferior cornu
articulates with the corresponding
lateral aspect of the cricoid cartilage.
The lateral surface of each lamina is
marked by an oblique line that runs
downwards and forwards.
Cricoid Cartilage
The cricoid cartilage is shaped like a
ring. The posterior part of the ring is
enlarged to form a roughly
quadrilateral lamina (Fig. 44.12). The Fig. 44.11. Cartilages of the larynx as seen from the front.
rest of the cartilage is called the arch.
The anterior part of the cricoid cartilage lies below the thyroid 3. The lower margin of the cricoid cartilage is attached to the
cartilage (Fig. 44.11). The posterior part of the cricoid cartilage trachea through the cricotracheal ligament (Fig. 44.11).
extends upwards into the interval between the laminae of the 4. The cartilage of the epiglottis is attached to the thyroid
thyroid cartilage (Fig. 44.12). cartilage by the thyroepiglottic ligament (Fig. 44.12).
Cartilage of Epiglottis
The cartilage of the epiglottis is tongue shaped, having a broad
upper part, and a narrow lower end.
Arytenoid Cartilage
Each arytenoid cartilage (right or left) is pyramidal.
It has a base (below) that articulates with the cricoid
cartilage; an apex that is directed upwards; and three
surfaces, medial, posterior and anterolateral. The
anteroinferior angle of the cartilage is prolonged
forwards to form the vocal process. The
inferolateral angle is enlarged to form the muscular
process.
Corniculate and Cuneiform Cartilages
The corniculate cartilage is small and is present
near the apex of the corresponding arytenoid
cartilage.
The cuneiform cartilages are small nodules present
within the aryepiglottic folds.
Ligaments and Membranes of Larynx
1. The thyroid cartilage (upper border) is connected
to the hyoid bone (body and greater cornu) by the
thyrohyoid membrane (Figs. 44.11).
2. Near the middle line, in front, the lower border of
the thyroid cartilage is attached to the arch of the
cricoid cartilage by the anterior cricothyroid Fig. 44.12. Cartilages of the larynx seen from behind.
ligament (Fig. 44.11).
425
426
INTERIOR OF THE LARYNX
The essential features to be seen in the interior

of the larynx are best appreciated by examining
a coronal section (Fig. 44.13). Almost midway
between the upper and lower ends of the larynx,
two pairs of mucosal folds project into its
cavity. The upper pair are the right and left
vestibular folds. The lower pair are the right
and left vocal folds. The part of the laryngeal
cavity lying above the vestibular folds is called
the vestibule. The narrow recess between the
levels of the vestibular and vocal folds (on
either side) is called the sinus or ventricle of
the larynx.
The upper aperture of the larynx is called its
inlet, or aditus. The aperture is directed
backwards and a little upwards. It is bounded
(Fig. 44.14) in front by the mucous membrane
covering the epiglottis; behind by a fold of
mucous membrane that covers the two
arytenoid cartilages; and on either side by the
aryepiglottic folds. These folds are made of
mucous membrane. They pass from the sides Fig. 44.13. Coronal section through the larynx viewed from behind.
of the epiglottis (in front) to the arytenoid

cartilages. The corniculate and cuneiform
cartilages lie within the aryepiglottic folds.
Each vestibular fold encloses a bundle of fibres
that constitute the vestibular ligament (Fig.
44.13).
Each vocal fold contains a bundle of elastic
fibres that constitute the vocal ligament (Fig.
44.13). The ligament is attached in front to the
angle of the thyroid cartilage (below the
attachment of the vestibular ligament); and
behind to the vocal process of the arytenoid
cartilage.
The function of voice production (by
vibration) demands that the vocal folds be firm
and of uniform thickness. This aim is achieved
by close adherence of the lining epithelium to
the vocal ligaments, and by the absence of
blood vessels. As a result the vocal folds
withstand the stress of repeated and intense
vibration.
The right and left vocal folds are separated by
the anterior or intermembranous part of a
fissure called the rima glottidis. The posterior
part of the fissure lies between the two
arytenoid cartilages and is, therefore, called the
intercartilaginous part (Fig. 44.15). The shape Fig. 44.14. Openings in the anterior wall of the larynx seen from behind.
of the rima varies in different phases of
respiration and of phonation.
Fig. 44.15. Scheme to show the intermembranous (x)
and intercartilaginous (y) parts of the rima glottidis. Fig. 44.17. Scheme to show attachments of the
cricothyroid muscle.
Fig. 44.18. Attachments of the posterior

Fig. 44.16. Some features of the larynx as seen through a cricoarytenoid muscle.
laryngoscope (i.e. from above). The gap between the two
vestibular folds is the rima vestibuli.
Muscles of the Larynx
The muscles of the larynx are extrinsic and intrinsic. The

extrinsic muscles are those in which one end of the muscle is
attached to a cartilage of the larynx whereas the other end is
attached elsewhere. These muscles raise or lower the larynx as
a whole during deglutition. The extrinsic muscles include the
sternothyroid and thyrohyoid muscles and the inferior
constrictor of the pharynx. Some muscles attached to the hyoid
bone can raise the larynx indirectly. Fig. 44.19. Attachments of the lateral
The intrinsic muscles are confined to the larynx. They may be cricoarytenoid muscle.
classified in accordance with their actions as follows.
Muscles that open or close the glottis:
Muscles that increase or decrease tension of the vocal folds: 1. The posterior cricoarytenoid muscle arises from the
1. The cricothyroid is the only intrinsic muscle of the larynx posterior aspect of the lamina of the cricoid cartilage. It is
that is seen on its outer aspect. It passes upwards and backwards inserted into the muscular process of the arytenoid cartilage
from the outer aspect of the cricoid cartilage to the lamina of (Fig. 44.8).
the thyroid cartilage (Fig. 44.17). 2. The lateral cricoarytenoid muscle arises from the arch of
2. The thyroarytenoid passes from the thyroid cartilage to the the cricoid cartilage. It runs backwards to the muscular
arytenoid cartilage. process of the arytenoids cartilage.
The cricothyroid lengthens the vocal folds and make them more 3. The transverse arytenoid passes from one arytenoids
tense. The thyroarytenoid has the opposite action. cartilage to the other.
427
428
Actions of Posterior and Lateral cricoarytenoid muscles,
and of Transverse arytenoid
The two vocal folds are separated by an aperture called the
glottis (or rima glottidis). The glottis has an anterior
(membranous) part placed between the two vocal folds, and a
posterior (cartilaginous) part placed between the medial
surfaces of the two arytenoid cartilages. The size and shape of
the glottis undergoes changes during different phases of
respiration and of speech. The changes are produced by
movements at the joints between the arytenoid and cricoid
cartilages.
The posterior cricoarytenoid abducts the vocal fold, while the
lateral cricoarytenoid adducts it.
Muscles that open or close the inlet of the larynx.
These are the oblique arytenoids, the aryepiglottic and Fig. 44.20. Attachments of the oblique arytenoid
thyroepiglottic muscles (Fig. 44.20). and aryepiglotticus muscles.
1. The oblique arytenoids pass from one arytenoid cartilage
to the other.
2. The aryepiglotticus is made of some fibres that connect the Some Relations of the Trachea in the Neck
arytenoid cartilage to the epiglottis. 1. Posteriorly the trachea is related to the oesophagus that
3. The thyroepiglotticus is made up of some fibres that enter runs vertically behind it, and separates it from the bodies of
the aryepiglottic fold to reach the lateral margin of the epiglottis. vertebrae C6 and C7.
The oblique arytenoids and the aryepiglottic muscles close 2. Near its upper end (over the 2nd, 3rd and 4th rings) the
the inlet of the larynx by drawing the two aryepiglottic folds trachea is covered anteriorly by the isthmus of the thyroid
together. The thyroepiglottic muscles pull the aryepiglottic gland. The right and left lobes of the gland overlap the
folds apart to open the inlet. corresponding sides of the trachea.
3. The right and left common carotid arteries ascend along
Vessels and Nerves of Larynx
the corresponding side of the cervical part of the trachea.
The arteries supplying the larynx are branches from the
4. On either side the recurrent laryngeal nerve lies in the
superior and inferior thyroid arteries. The veins accompany
groove between the trachea and the oesophagus.
the arteries.
The sensory innervation of the part of the larynx above the
vocal folds is by the internal laryngeal nerve. The part of the
larynx below the vocal folds receives its sensory innervation
through branches of the recurrent laryngeal nerve. Most of THE OESOPHAGUS
the intrinsic muscles of the larynx are supplied by the recurrent
laryngeal nerve. The only exception is the cricothyroid that is The oesophagus is a tubular structure that starts at the lower
supplied by the external laryngeal nerve. end of the oropharynx (i.e. in front of the sixth cervical
vertebra). It descends through the lower part of the neck,
and enters the thorax through its inlet. After passing through
the thorax the oesophagus enters the abdomen and ends by
joining the cardiac end of the stomach.
THE TRACHEA
Relations of Oesophagus in the Neck
Posteriorly, the oesophagus is related to the sixth and
The trachea is a wide tube lying on the front of the neck more
seventh cervical vertebrae. Anteriorly it is related to the
or less in the middle line. The upper end of the trachea is
trachea. Laterally the oesophagus is related to the
continuous with the lower end of the larynx. The junction lies
corresponding common carotid artery.
opposite the lower part of the body of the sixth cervical vertebra. The upper part of the oesophagus is overlapped laterally by
At the root of the neck the trachea passes into the superior the corresponding lobe of the thyroid gland. The right and
mediastinum of the thorax where it has been described. Here left recurrent laryngeal nerves lie anterolateral to the
we will consider the relations of the trachea in the neck. oesophagus
ENDOCRINE GLANDS
45 : Endocrine Glands of Head and Neck
The endocrine glands that lie in the head and neck are the On the right and left sides the hypophysis cerebri is related
hypophysis cerebri, the pineal gland, the thyroid gland, and the to the corresponding cavernous sinus (and to structures in
parathyroid glands. its wall).
Some endocrine functions are also ascribed to the carotid body.
The carotid body, and the carotid sinus, will also be considered. Subdivisions of the Hypophysis Cerebri
The hypophysis cerebri has, in the past, been usually divided
into an anterior part, the pars anterior; an intermediate part,
the pars intermedia; and a posterior part, the pars posterior
(or pars nervosa). The pars posterior is directly continuous
THE HYPOPHYSIS CEREBRI with the central core of the infundibulum, that is made up of
nervous tissue. These two parts are together referred to as
The hypophysis cerebri is also called the pituitary gland. It is the neurohypophysis.
placed in the cranial cavity, in the floor of the middle cranial The pars anterior (that is also called the pars distalis) and
fossa. It lies in a depression on the superior surface of the body the pars intermedia are both made up of cells having a direct
of the sphenoid bone called the hypophyseal fossa or sella secretory function and are collectively referred to as the
turcica. The hypophysis is suspended from the floor of the third adenohypophysis. An extension of the pars anterior
ventricle of the brain by a narrow funnel shaped stalk called surrounds the central nervous core of the infundibulum.
the infundibulum. Because of the tubular shape of this extension it is called
The hypophysis cerebri is a small ovoid structure measuring the pars tubularis. The pars tubularis is part of the
about 13 mm from side to side, about 10 mm from front to back, adenohypophysis.
and about 8 mm in vertical diameter.
The relations of the hypophysis cerebri are shown in Figure
45.1. The hypophyseal fossa is lined by dura mater that is
adherent to the lower part of the hypophysis. Superior to the
hypophysis the dura mater is folded on itself to form the
diaphragma sellae. The infundibulum passes through an
aperture in the diaphragma to join the inferior wall of the third
ventricle. The optic chiasma lies anterosuperior to the
hypophysis cerebri being separated from it by the anterior part
of the diaphragma. It lies anterior to the infundibulum. Inferiorly,
the hypophysis cerebri is related to the sphenoidal air sinuses.
Fig. 45.1. Coronal section through hypophysis cerebri to show some of its relations.
429
430
Fig. 45.2. Scheme to show the hypothalamo-hypophyseal portal circulation, and the control of secretions
of the adenohypophysis by the hypothalamus.
Blood Supply of the Hypophysis Cerebri Development

The hypophysis cerebri is supplied by branches arising from The pars anterior and intermedia are derived from Rathkes
the internal carotid arteries and from the anterior and posterior pouch that arises from the stomatodaeum. The
cerebral arteries. Some vessels end in a set of capillaries in the neurohypophysis is derived as a downgrowth from the
hypothalamus which drain into a second set of capillaries in diencephalon.
the pars anterior. These two sets of capillaries constitute the
hypothalamo-hypophyseal portal system. Releasing factors
produced in parts of the hypothalamus travel to the pars anterior
through the portal system and stimulate release of hormones.
Fig. 45.3. Diagram to show the position of the hypophysis cerebri and of the pineal body relative to the third
ventricle of the brain.
ENDOCRINE GLANDS
THE PINEAL BODY
The pineal body is a small piriform structure

present in relation to the posterior wall of the
third ventricle of the brain. It is also called the
epiphysis cerebri. It is about 8 mm in length,
and about 4 cm in width and in thickness. It is
situated in the median plane just below the
splenium of the corpus callosum, and just above
the superior colliculi of the midbrain (Fig. 45.3).
The pineal body is made up mainly of cells called
pinealocytes. Neuroglial cells, sympathetic
nerve fibres and a rich network of capillaries are
also present. In the adult, sections of the pineal
gland show aggregations of salts containing
calcium. These are referred to as corpora
arenacea, or brain sand.
Recent investigations have shown that the pineal
body is an endocrine gland of great importance.
It produces hormones that may have an important
regulatory influence on many other endocrine
organs (including the adenohypophysis, the
neurohypophysis, the thyroid, the parathyroids, Fig. 45.4. Outline of the thyroid gland as seen from the front, and
the adrenal cortex and medulla, and the gonads). its relationship to the larynx and trachea.
Development
The pineal body is formed as a diverticulum arising from the between the trachea and oesophagus; and the external
diencephalon. laryngeal nerve as it descends to reach the cricothyroid
(Fig. 45.6).
The posterior surface of the lobe is directed posterolaterally.
It is in contact with the carotid sheath and its contents.
The lateral and medial surfaces are separated by a sharp
THE THYROID GLAND anterior border. A branch of the superior thyroid artery
descends along this border. The posterior and medial surfaces
The thyroid gland lies in the front of the neck, in front of the are separated by the posterior border which is rounded. It is
lower part of the larynx and the upper part of the trachea. It related to the inferior thyroid artery, and to the parathyroid
consists of right and left lobes that are joined, across the midline, glands.
by an isthmus (Fig. 45.4).
When seen in cross section each lobe of
the thyroid is seen to have three surfaces,
lateral (or superficial); medial and
posterior. The lateral surface is directed
forwards and laterally (Fig. 45.5). It is
covered by skin and fascia; by the
sternothyroid and sternohyoid muscles; by
the superior belly of the omohyoid muscle;
and by the anterior part of the
sternocleidomastoid muscle. The medial
surface lies over the thyroid and cricoid
cartilages of the larynx, and the uppermost
parts of the trachea and oesophagus. Parts
of two muscles, the inferior constrictor of
the pharynx, and the cricothyroid, are deep
to it. Two important nerves lie deep to the
medial surface. These are recurrent
Fig. 45.5. Transverse section across the thyroid gland and related structures.
laryngeal nerve as it ascends in the groove
431
432
The upper end of each lobe extends up to the oblique line of
the thyroid cartilage (Fig. 45.4). The lower end of the lobe lies
at the level of the fifth or sixth tracheal ring.
The isthmus of the thyroid glands lies in front of the second,
third and fourth rings of the trachea.
A finger like projection of thyroid tissue frequently arises from
the upper border of the isthmus. This is called the pyramidal
lobe (Fig. 45.4). Its upper end is attached to the hyoid bone by
fibrous tissue or muscle (levator of the thyroid gland).
The thyroid is surrounded by a capsule of connective tissue.
Outside this capsule the thyroid has another sheath (or false
capsule) formed by the pretracheal fascia.
The thyroid has a rich blood supply. The arteries supplying it
are the superior thyroid branch of the external carotid artery;
the inferior thyroid branch of the thyrocervical trunk; a small
artery the thyroidea ima arising from the brachiocephalic trunk;
and accessory thyroid arteries derived from those supplying
the trachea and oesophagus.
The thyroid gland is drained by three veins, superior, middle
and inferior. The veins form a plexus deep to the capsule of
the gland.
The lymphatic drainage of the thyroid gland is described in
Chapter 46.
The thyroid gland is covered by a fibrous capsule. Septa
extending into the gland from the capsule divide it into lobules.
On microscopic examination each lobule is seen to be made

up of an aggregation of follicles. Each follicle is lined by
follicular cells that are typically cubical. It has a cavity that is
filled by a homogeneous material called colloid. At some places
cells of a different type intervene between the follicular cells Fig. 45.6. Medial relations of the thyroid gland. The
and the basement membrane. These are called the outline of the gland is shown in thick magenta line.
parafollicular cells.
The follicular cells secrete the hormones triiodothyronine (or
T3) and tetraiodothyronine (or T4). The parafollicular cells thyroid arteries. The inferior gland receives a branch from
produce a hormone called calcitonin. the inferior thyroid artery.
Development The large majority of cells are called chief cells or principal
The thyroid develops mainly from the thyroglosssal duct (a cells. The second variety of cells are called oxyphil or
diverticulum of the foregut). eosinophil cells.
The parathyroid glands produce a hormone called the
parathyroid hormone (PTH) or parathormone.
Development
THE PARATHYROID GLANDS The inferior parathyroid glands develop from the third
pharyngeal pouch. The superior parathyroid glands develop
from the fourth pouch.
The parathyroid glands are so called because they lie in close
relationship to the thyroid gland. Normally there are two glands,
one superior and one inferior, on either side, there being four
glands in all. However, the number can be more or less. THE CAROTID SINUS
On each side, the superior parathyroid gland lies near the
middle of the posterior border of the thyroid gland. It is The term carotid sinus is applied to a dilated segment of the
relatively constant in position. common carotid body at its bifurcation. Afferent nerve
The inferior parathyroid gland lies near the lower end of the terminals present over the carotid sinus are stimulated by
posterior border of the thyroid gland. Its position is variable. alterations in blood pressure. Afferent impulses arising from
The superior parathyroid gland receives a branch from the the sinus play an important role in reflex control of blood
anastomotic channel connecting the superior and inferior pressure.
LYMPHATICS OF HEAD AND NECK
THE CAROTID BODIES carbon dioxide levels in blood. They reflexly control the
These are small oval structures, present one on each side of the rate and depth of respiration through respiratory centres
neck, at the bifurcation of the common carotid artery (i.e. near located in the brainstem. In addition to this function the
the carotid sinus). The main function of the carotid bodies is carotid bodies are also believed to have an endocrine
that they act as chemoreceptors that monitor the oxygen and function.
46 : Lymphatics of Head and Neck
LYMPH NODES OF HEAD AND NECK Deep Cervical Nodes
Lymph from all the superficial nodes described above drains

Superficial Lymph Nodes into the deep cervical lymph nodes that lie along the internal
jugular vein (Fig. 46.2). Most of the deep cervical nodes lie
The lymph nodes that drain the superficial tissues of the head deep to the sternocleidomastoid muscle. They are divided
and neck are shown in Figure 46.1. They are as follows. (rather arbitrarily) into a superior group and an inferior
1. The nodes of the occipital group lie along the attachment of group. Some nodes of the superior group lie in a triangle
the trapezius to the occipital bone. bounded behind by the internal jugular vein, above and in
2. The nodes of the retroauricular group (or mastoid group) front by the posterior belly of the digastric muscle, and below
lie superficial to the upper attachment of the and in front by the facial vein. These are called the
sternocleidomastoid muscle. jugulodigastric nodes. One node of the inferior group lies
3. The parotid lymph nodes are in two groups, superficial and just above the intermediate tendon of the omohyoid muscle.
deep. The nodes of the superficial parotid group lie over the This is the jugulo-omohyoid node.
parotid gland. Those of the deep
parotid group (shown in dots in
Figure 46.1) are embedded in the
gland.
4. The nodes of the submandibular
group lie over the submandibular
gland. Some of them are embedded
within the gland.
5. The submental nodes lie below
the chin overlying the mylohyoid
muscle, between the anterior bellies
of the right and left digastric
muscles.
6. The buccal nodes lie along the
facial vein.
7. The superficial cervical nodes lie
along the external jugular vein,
superficial to the sterno-
cleidomastoid muscle.
8. The anterior cervical nodes lie
along the anterior jugular vein.
Fig. 46.1. Lymph nodes draining superficial tissues of the head and neck.
433
434
LYMPHATIC DRAINAGE OF SOME
REGIONS OF THE HEAD AND NECK
The Scalp
From behind forwards lymph vessels from the scalp end in
the occipital, retroauricular and superficial parotid nodes
(Fig. 46.1). The part of the forehead just above the root of
the nose drains into the submandibular nodes.
The Ear
The lymphatic drainage of the auricle is easily visualized if
the auricle is imagined as being pulled laterally. The lateral
surface is then anterior and the medial surface is posterior.
The drainage is shown in Figure 46.4.
Fig. 46.2. Scheme to show the deep cervical lymph nodes.

The deeper tissues of the head and neck drain into the deep
cervical nodes. Some of these vessels pass through outlying
groups of lymph nodes. These are the lingual, infrahyoid,
retropharyngeal, prelaryngeal, pretracheal and paratracheal
nodes. They are shown, and are briefly described in Figure
46.3.
Fig. 46.4. Lymphatic drainage of the auricle.
The lymphatic drainage of the external acoustic

meatus is similar to that of the upper half of the auricle.
It is shown in Figure 46.5.
(Please do not skip these and other figures in this
chapter. Details shown in them are not repeated in
the text. It is easier to appreciate them in diagrams).
The Face
The lymphatic drainage of the face is shown in Figure
46.6.
The forehead, the lateral parts of the eyelids, the
whole of the conjunctiva, and the lateral part of the
cheek drain into the superficial and deep parotid
lymph nodes.
The central part of the face (shaded in dots in figure
46.6) including the lower part of the forehead, the
medial parts of the eyelids, the nose, the medial parts
of the cheeks, the upper lip and the lateral parts of
Fig. 46.3. Outlying members of the deep cervical group the lower lip drain into the submandibular lymph
of lymph nodes.
LYMPHATICS OF HEAD AND NECK
Fig. 46.5. Scheme to show the lymphatic drainage of the Fig. 46.8. Lymphatic drainage of the palate.
external acoustic meatus.
nodes. Some of these vessels pass through the buccal
nodes.
The median part of the lower lip, the chin, and the floor of
the mouth drain into the submental nodes, and through
them into the submandibular nodes.
The Nasal Cavity
The lymphatic drainage of the nasal cavity is shown in
Figure 46.7. Most of the nasal cavity, the paranasal sinuses
and the nasopharynx drain directly into the deep cervical
lymph nodes.
Some lymphatics from the upper part of the nasal cavity
reach the skin covering the nose and drain (as shown in
Figure 46.6) to the submandibular nodes. Some lymphatics
of the nasopharynx drain into the retropharyngeal nodes.
Fig. 46.6. Scheme to show the lymphatic drainage of the face.
Fig. 46.9. Scheme to show the lymph nodes receiving

Fig. 46.7. Lymphatic drainage of nasal cavity. lymph from different areas of the tongue.
435
436
Fig. 46.11. Lymphatic drainagae of the thyroid gland.

Fig. 46.10. Lymphatic drainage of the larynx.
The Palate into the submandibular and deep cervical nodes. In Figure
Lymph from the hard palate, the soft palate and the nasopharynx 46.9 note particularly that lymph from areas of the tongue
drains into the retropharyngeal nodes, and through them, or near the middle line can pass to lymph nodes of either the
directly, to the deep cervical lymph nodes (Fig. 46.8). right or left side.
Floor of Mouth Lymphatic Drainage of the Neck
Lymphatic vessels from the floor of the mouth, gums and teeth Some of the superficial tissues of the neck drain directly into
drain into the submandibular nodes, and through them into the deep cervical lymph nodes. Lymph from areas close to
the deep cervical nodes. Some vessels from the anterior part of the occipital nodes, the superficial cervical nodes, the
the floor of the mouth pass to the submental nodes. Some
submandibular nodes and the anterior cervical nodes drains
lymph vessels from the mouth go directly to the deep cervical
first into these nodes and through them to the deep cervical
lymph nodes.
nodes. Lymph from the anterior cervical nodes passes to the
The Tonsil infrahyoid, prelaryngeal and pretracheal nodes. (See Figures
Lymph vessels pass through the superior constrictor of the 46.3, 46.10 and 46.11).
pharynx to reach the jugulodigastric nodes and some other Deeper tissues in the neck mostly drain direct into the deep
nodes of the upper deep cervical group. cervical nodes. Some of this lymph reaches them through
the infrahyoid, prelaryngeal, pretracheal, para-tracheal,
lingual and retropharyngeal lymph nodes.
Lymphatic Drainage of the Tongue The pharynx, the cervical part of the trachea and the cervical
part of the oesophagus all drain into the deep cervical nodes.
The tongue is a frequent site of carcinoma and hence Some of the lymph reaches these nodes after passing through
knowledge of its lymphatic drainage is of special importance. outlying groups. That from the pharynx passes through the
From this point of view the tongue may be divided into a part retropharyngeal nodes; that from the trachea through the
behind the vallate papillae (a in figure 46.9); and a part in front pretracheal and paratracheal nodes; and that from the
of them. The latter is further divided into a central area (b) and oesophagus through the paratracheal nodes.
a marginal area (c) that includes the tip (d). Lymph from area a,
area b, and the posterior part of area c drains directly into the Lymphatic Drainage of Larynx
jugulodigastric, jugulo-omohyoid and other deep cervical The lymph vessels of the larynx are in two sets: those above
nodes. Lymph from the anterior part of area c and from the tip the vocal folds and those below them. The vessels of the
of the tongue (area d) reaches the same nodes after passing upper part pierce the thyrohyoid membrane to reach the upper
through the submandibular nodes. Lymph from the tip of the deep cervical nodes (Fig. 46.10). These lymphatics travel
tongue also passes into the submental nodes, and from them along the superior laryngeal vessels.
SURFACE MARKING AND SOME CLINICAL CORRELATIONS
Some of the vessels from the lower part of the larynx pass divided into distinct parts draining in different directions.
through the cricovocal membrane to reach the prelaryngeal and However, it must be noted that in the thyroid (and for that
pretracheal nodes. From here they pass to the deep cervical matter in most other organs) lymph vessels form a plexus
nodes. Some vessels pass below the cricoid cartilage and reach through which lymph may pass in any direction. Such
the lower deep cervical nodes directly. divisions are, therefore, artificial and misleading. The arrows
in the figure only indicate the predominant direction of flow.
Lymph from the upper part of the gland reaches the upper
Lymphatic Drainage of Thyroid Gland
deep cervical nodes either directly or through the
prelaryngeal nodes. Lymph from the lower part of the gland
The lymph vessels draining the thyroid gland are shown in
drains to the lower deep cervical nodes directly, and also
Figure 46.11. The thyroid is sometimes described as being
through the pretracheal and paratracheal nodes.
47 : Surface Marking and Some

Clinical Correlations
SURFACE MARKING OF SOME STRUCTURES

IN THE HEAD AND NECK
Parotid Gland To complete the marking of the lobe, join the lower end of
1. To mark the anterior border, begin at the upper border of the posterior border to the lateral end of the lower border of
the head of the mandible. Draw a line downwards and forwards the isthmus by a broad line convex downwards.
to reach the centre of the masseter muscle. Now carry the line
Submandibular gland
downwards and backwards to reach a point just posteroinferior
The outline of this gland is oval. To draw the upper margin
to the angle of the mandible.
of the gland draw a line convex upwards, starting at the angle
2. To mark the posterior border begin at the lower end of the
of the mandible and reaching the middle of the base of the
anterior border. Draw a line upwards to the reach the anterior
mandible. To mark the lower margin of the gland join the
border of the mastoid process, near its upper end.
two ends of the upper margin (drawn as described above)
3. To mark the superior border join the upper ends of the
by a line convex downwards. The curve should extend below
posterior and anterior borders by a line that is convex
to the level of the greater cornu of the hyoid bone.
downwards.
Palatine tonsil
Thyroid gland
To mark it draw a small oval just in front of, and above, the
1. To mark the isthmus of the gland begin by feeling the lower
angle of the mandible. The marking will lie over the masseter
border of the arch of the cricoid cartilage. Take one point half
muscle.
an inch below this border, and another point one inch below
the border. At each of these levels draw transverse lines, half Frontal air sinus
an inch long. These lines represent the upper and lower borders The projection of this sinus lies above the medial part of the
of the isthmus. orbit. It is triangular. To mark the medial border of the sinus
2. Each lobe of the thyroid gland is marked as follows. draw a vertical line one inch (2.5 cm) long over the lower
To mark the anterior border start at the lateral end of the upper part of the forehead, in the middle line. The lower end of
border of the isthmus (marked above). Carry the line upwards the line should be just above the depression between the
and slightly backwards to reach the anterior border of the forehead and the upper end of the nose. (The point
sternocleidomastoid muscle, at the level of the middle of the corresponds to the nasion that is the point at which the
thyroid cartilage. internasal and frontonasal sutures meet).
To mark the posterior border begin at the upper end of the To mark the lower border of the sinus draw a line starting at
anterior border. Draw a line running downwards (with a slight the lower end of the medial border, and passing laterally
backward convexity) to reach the clavicle. and slightly upwards to reach the upper margin of the orbit.
437
438
The line should lie just above the medial one-third of the Subclavian vein
superior orbital margin. Its lateral end lies behind the clavicle a little medial to its
The third border (above and laterally) is drawn by joining the midpoint. Its medial end lies behind the medial end of the
upper end of the medial border with the lateral end of the lower clavicle. The vein can be marked by a broad line over the
border. clavicle joining these points.
Maxillary sinus External jugular vein
The outline of this sinus is irregular. It can be marked on the Its upper end lies a little behind and below the angle of the
face following the outline of the maxilla. Above, the line is mandible. The vein runs downwards across the sternocleido-
just below the orbit. Below, the line lies just above the alveolar mastoid and ends deep to the clavicle immediately behind
process of the maxilla. Medially it reaches the lateral wall of the sternocleidomastoid muscle. The vein can be marked by
the nose. Laterally it reaches the zygomatic process of the drawing a line joining these points. The vein can often be
maxilla seen in the living subject.
Common carotid artery Some Branches of Trigeminal Nerve
To mark the artery in the neck draw a broad line starting over The main stem of the mandibular nerve can be marked on
the sternoclavicular joint, passing upwards along the anterior the surface as a short vertical line just in front of the head of
border of the sternocleidomastoid muscle, and ending at the the mandible.
level of the upper border of the thyroid cartilage. The auriculotemporal nerve can be marked by a line that
runs backwards from the mainstem of the mandibular nerve,
Internal carotid artery
across the neck of the mandible. The nerve then turns
The lower end of this artery corresponds to the termination of
upwards passing immediately in front of the tragus
the common carotid artery. It lies over the anterior border of
(preauricular point).
the sternocleidomastoid muscle at the level of the upper border
The lingual nerve is marked by a line continuous with the
of the thyroid cartilage. From this level draw a broad line
main stem of the mandibular nerve (see above). It is
running upwards and ending just behind the condyle of the
represented by a line that runs downwards and forwards to
mandible.
reach opposite the lower third molar tooth. It then runs
External carotid artery forwards in relation to the mandible up to the level of the
The lower end of this artery corresponds to the termination of first molar tooth.
the common carotid artery. It lies over the anterior border of
Facial nerve
the sternocleidomastoid muscle at the level of the thyroid
It is useful only to mark the extracranial part of the nerve,
cartilage. From here draw a line upwards to end just behind
before it divides into several branches. Remember that the
the neck of the mandible.
nerve emerges from the skull through the stylomastoid
Subclavian artery foramen. This foramen lies deep to the middle of the anterior
The artery can be marked in the neck by drawing a broad line border of the mastoid process.From here draw a horizontal
beginning over the sternoclavicular joint, and passing laterally line that runs forwards to end just behind the neck of the
with an upward convexity to a point over the middle of the mandible.
clavicle. The highest point of the upward convexity rises 2 cm
Glossopharyngeal nerve
above the clavicle.
This nerve is marked by a line that runs downwards and
Facial artery forwards with a downward convexity. The line begins over
Ask the subject to clench his teeth. This makes the masseter the tragus and runs to the angle of the mandible. It then runs
prominent and its anterior border can be felt. The facial artery for a short distance along the lower border of the mandible.
enters the face where the anterior border of the masseter cuts
Vagus nerve
the lower border of the mandible. The pulsations of the artery
It can be represented by a straight line running down the
can be felt here.
entire length of the neck. The upper end of the line should
From here the artery runs upwards and forwards to reach a
lie over the anterior part of the tragus. The lower end should
point half an inch (1.2 cm) lateral to the angle of the mouth. It
lie over the medial end of the clavicle.
then bends more sharply upwards to reach the medial angle of
the eye. Spinal accessory nerve
Its upper end lies over the same point as for the vagus (i.e.
Internal jugular vein
over the anterior part of the tragus). From here draw a line
The upper end of the vein lies on the neck just deep to the
downwards and backwards to reach a point midway between
lobule of the ear. Its lower end lies deep to the medial end of
the mastoid process and the angle of the mandible. From
the clavicle. The vein can be marked by drawing a broad line
this point carry the line further downwards and backwards
joining these points.
to reach the middle of the posterior border of the
sternocleidomastoid muscle. The nerve then runs across the
posterior triangle to reach the anterior border of the trapezius Sympathetic chain in the neck
about two inches above the clavicle. To mark this chain remember that it runs vertically
immediately behind the carotid sheath. Its upper end lies
Phrenic Nerve
just behind the condyle of the mandible. Its lower end lies
To mark this nerve first feel for the upper border of the thyroid
over the sternoclavicular joint.
cartilage. At this level take a point 3.5 cm from the anterior
midline of the neck. This is the upper end of the nerve. From
here draw a line downwards and medially to reach the medial
end of the clavicle.
OF THE HEAD AND NECK
Dangerous area of face Optic nerve and visual pathway

Near the medial angle of the eye the supraorbital vein, which is
a tributary of the facial vein, communicates with the superior Testing the optic nerve:
ophthalmic vein (lying in the orbit). The superior ophthalmic To test the optic nerve first ask the patient if his vision is
vein drains into the cavernous sinus. In this way the facial vein normal. Acuity (sharpness) of vision can be tested by making
is brought into communication with the cavernous sinus. The the patient read letters of various sizes printed on a chart
facial vein also communicates with the cavernous sinus through from a fixed distance. It must of course be remembered that
the deep facial vein and the pterygoid plexus. Because of these loss of acuity of vision can be caused by errors of refraction,
communications an infection in the face can spread to the or by the presence of opacities in the cornea or the lens
cavernous sinus leading to cavernous sinus thrombosis (see (cataract).
below). It has been observed that such spread of infection is If there is any doubt about the integrity of optic nerve the
most likely to take place if the infection is over the upper lip or retina is examined using an ophthalmoscope. With this
the lower part of the nose. That is why this region is called the instrument we can see the interior of the eye through the
dangerous area of the face. pupil of the eye. The optic disc and blood vessels radiating
from it can be seen.
Thrombosis in the cavernous sinus:
The cavernous sinus can be infected by spread of infection from Effects of injury to visual pathway
the dangerous area of the face (see above). Infection can also Injuries to different parts of the visual pathway can produce
reach it from the nose and paranasal sinuses. various kinds of defects. Loss of vision in one half (right or
Symptoms can be produced by (a) blockage to blood flow, (b) left) of the visual field is called hemianopia. If the same
involvement of cranial nerves. half of the visual field is lost in both eyes the defect is said
As veins of the orbit drain into the cavernous sinus they become to be homonymous and if different halves are lost the defect
congested. Accumulation of fluid in the orbit pushes the eyeball is said to be heteronymous. Note that the hemianopia is
forwards (exophthalmos). The eyelids and the root of the nose named in relation to the visual field and not to the retina.
show swelling. Injury to the optic nerve will obviously produce total
Involvement of the ophthalmic nerve leads to severe pain in blindness in the eye concerned. Damage to the central part
the region of distribution of the nerve (eye and over the of the optic chiasma (e.g. by pressure from an enlarged
forehead). Involvement of the oculomotor, trochlear and hypophysis) interrupts the crossing fibres derived from the
abducent nerves can lead to paralysis of extraocular muscles. nasal halves of the two retinae resulting in bitemporal
heteronymous hemianopia. It has been claimed that macular
Olfactory nerve fibres are more susceptible to damage by pressure than
The olfactory nerve is tested by asking the patient to recognize peripheral fibres and are affected first. When the lateral part
various odours. The right and left nerves can be tested separately of the chiasma is affected a nasal hemianopia results. This
by closing one nostril and putting the substance near the open may be unilateral or bilateral. Complete destruction of the
nostril. optic tract, the lateral geniculate body, the optic radiation or
the visual cortex of one side, results in loss of the opposite
half of the field of vision. A lesion on the right side leads to
left homonymous hemianopia. Lesions anterior to the lateral
439
440
geniculate body also interrupt fibres responsible for the (a) Caries of a tooth in the lower jaw (supplied by the inferior
pupillary light reflex (See below). alveolar nerve) may cause pain in the ear (auriculotemporal).
(b) If there is an ulcer or cancer on the tongue (lingual nerve)
Paralysis of oculomotor nerve
the pain may again be felt over the ear and temple
All movements of the eyeball are lost in the affected eye.
(auriculotemporal).
When the patient is asked to look directly forwards the
(c) In frontal sinusitis (sinus supplied by a branch from the
affected eye is directed laterally (by the lateral rectus) and
supraorbital nerve) the pain is referred to the forehead (skin
downwards (by the superior oblique). There is lateral quint
supplied by supraorbital nerve). In fact headache is a
(external strabismus) and diplopia.
common symptom when any structure supplied by the
As the levator palpebrae superioris is paralysed there is
trigeminal nerve is involved (e.g. eyes, ears, teeth).
drooping of the upper eyelid (ptosis). As parasympathetic
4. A source of irritation in the distribution of the nerve may
fibres to the sphincter pupillae pass through the oculomotor
cause severe persistent pain (trigeminal neuralgia).
nerve, the sphincter pupillae is paralysed. Unopposed action
Removal of the cause can cure the pain. However, in some
of sympathetic nerves produces a fixed and dilated pupil.
cases no cause can be found. In such cases pain can be
Normally the pupil contracts when exposed to light (light
relieved by injection of alcohol into the trigeminal ganglion,
reflex). It also contracts when the relaxed eye is made to
into one of the divisions of the nerve, or into its sensory
concentrate on a near object (accommodation reflex). Both
root.
these reflexes are lost. The power of accommodation is lost
because of paralysis of the ciliaris muscle. Facial nerve
The facial nerve supplies the muscles of the face including
Paralysis of trochlear nerve
the muscles that close the eyelids, and the mouth. The nerve
The superior oblique muscle (supplied by the trochlear nerve)
is tested as follows.
moves the eyeball downwards and laterally, and the inferior
1. Ask the patient to close his eyes firmly. In complete
rectus (supplied by the oculomotor nerve) moves it
paralysis of the facial nerve the patient will not be able to
downwards and medially. For direct downward movement
close the eye on the affected side. In partial paralysis the
synchronized action of both muscles is required. When the
closure is weak and the examiner can easily open the closed
superior oblique muscle is paralysed the eyeball deviates
eye with his fingers (which is very difficult in a normal
medially when trying to look downwards.
person).
Paralysis of abducent nerve 2. Ask the person to smile. In smiling the normal mouth is
This nerve supplies the lateral rectus muscle which moves more or less symmetrical, the two angles moving upwards
the eyeball laterally. In looking forwards the lateral pull of and outwards. In facial paralysis the angle fails to move on
the lateral rectus is counteracted by the medial pull of the the paralysed side.
medial rectus and so the eye is maintained in the centre. When 3. Ask the patient to fill his mouth with air. Press the cheek
the lateral rectus is paralysed the affected eye deviates with your finger and compare the resistance (by the
medially (medial squint, or internal strabismus). buccinator muscle) on the two sides. The resistance is less
on the paralysed side. On pressing the cheek air may leak
Trigeminal nerve
out of the mouth because the muscles closing the mouth are
Motor function is tested by asking the patient to clench his
weak.
teeth firmly. Contraction of the masseter can be felt by
4. The sensation of taste should be tested on the anterior
palpation when the teeth are clenched.
two-thirds of the tongue (as described under
Effects of injury or disease glossopharyngeal nerve).
Injury to the trigeminal nerve causes paralysis of the muscles
Paralysis of facial nerve
supplied and loss of sensations in the area of supply. Some
The effects of paralysis are due to the failure of the muscles
features of special importance are as follows:
concerned to perform their normal actions. Some effects are
1. In paralysis of the pterygoid muscles of one side the chin
as follows:
is pushed to the paralysed side by muscles of the opposite
1. The normal face is more or less symmetrical. When the
side.
facial nerve is paralysed on one side the most noticeable
2. Loss of sensation in the ophthalmic division (specially the
feature is the loss of symmetry. (Also see para 4 in this
nasociliary nerve) is of great importance. Normally the eyelids
regard).
close as soon as the cornea is touched (corneal reflex). Loss
2. Normal furrows on the forehead are lost because of
of sensation in the cornea abolishes this reflex leaving the
paralysis of the occipitofrontalis.
cornea unprotected. This can lead to the formation of ulcers
3. There is drooping of the eyelid and the palpebral fissure
on the cornea which can in turn lead to blindness.
is wider on the paralysed side because of paralysis of the
3. Pain arising in a structure supplied by one branch of the
orbicularis oculi. The conjunctival reflex is lost for the same
nerve may be felt in an area of skin supplied by another
reason.
branch: this is called referred pain. Some examples are as
4. There is marked asymmetry of the mouth because of
follows:
paralysis of the orbicularis oris and of muscles inserted into
the angle of the mouth. This is most obvious when a smile is Hypoglossal nerve
attempted. As a result of asymmetry the protruded tongue This nerve supplies muscles of the tongue. To test the nerve
appears to deviate to one side, but is in fact in the midline. ask the patient to protrude the tongue. In a normal person
5. During mastication food tends to accumulate between the the protruded tongue lies in the midline. If the nerve is
cheek and the teeth. (This is normally prevented by the paralysed the tongue deviates to the paralysed side.
buccinator).
Sympathetic Nerves of Head and Neck
Vestibulocochlear nerve Interruption of sympathetic supply to the head and neck
This nerve is responsible for hearing (cochlear part) and for results in Horners syndrome. The features of this syndrome
equilibrium (vestibular part). Normally we test only the cochlear are as follows.
part. 1. There is constriction of the pupil because of paralysis of
The hearing of the patient can be tested by using a watch. First the dilator pupillae. Unopposed action of the sphincter
place the watch near one ear so that the patient knows what he pupillae leads to constriction.
is expected to hear. Next ask him to close his eyes and say so 2. There is drooping of the upper eyelid (ptosis) because of
when he hears the ticking of the watch. The watch should be paralysis of smooth muscle fibres present in the levator
held away from the ear and then gradually brought towards it. palpebrae superioris.
The distance at which the sounds are first heard should be 3. The eyeball is less prominent than normal (enophthalmos).
compared with the other ear. 4. There is absence of sweating on the affected side of the
face. (Remember that secretomotor supply to sweat glands
Glossopharyngeal nerve
is through sympathetic nerves).
Testing of this nerve is based on the fact that (a) the nerve carries
fibres of taste from the posterior one-third of the tongue; and Thyroid Gland
(b) that it provides sensory innervation to the pharynx. 1. Deficient intake of iodine (common in areas where drinking
1. Sensations of taste can be tested by applying substances water does not contain iodine) can lead to benign
that are salty (salt), sweet (sugar), sour (lemon), or bitter (quinine) enlargement of the thyroid gland. The enlarged thyroid is
to the posterior one-third of the tongue. The mouth should be referred to as goitre. The symptoms are those of
rinsed and the tongue dried before the substance is applied. hypothyroidism.
2. Touching the pharyngeal mucosa causes reflex constriction 2. Hypothyroidism in infants leads to cretinism. A child
of pharyngeal muscles. The glossopharyngeal nerve provides with cretinism has a puffed face with a protruding tongue, a
the afferent part of the pathway for this reflex. bulky belly, and sometimes an umbilical hernia.
Hypothyroidism in adults is manifested by symptoms
Vagus nerve (and cranial part of accessory nerve)
including a slow pulse, cold intolerance, mental and physical
This nerve has an extensive distribution but testing is based on
lethargy, and a hoarse voice. In advanced cases the condition
its motor supply to the soft palate and to the larynx.
is called myxoedema.
1. Ask the patient to open the mouth wide and say aah.
3. Hyperthyroidism is also referred to as thyrotoxicosis, or
Observe the movement of the soft palate. In a normal person
toxic goitre. The condition is much more common in women
the soft palate is elevated. When one vagus nerve is paralysed
than in men. The condition is marked by nervousness, loss
the palate is pulled towards the normal side. When the nerve is
of weight, tachycardia and palpitation, excitability, tremors
paralysed on both sides the soft palate does not move at all.
of the outstretched hands, and exophthalmos.
2. Injury to the recurrent laryngeal nerve also leads to
4. Tumours of the thyroid may be benign or malignant. A
hoarseness, but this hoarseness is permanent. On examining
tumour can press upon or involve the trachea, or carotid
the larynx through a laryngoscope it is seen that on the affected
sheath. Involvement of the recurrent laryngeal nerve may
side the vocal fold does not move. It is fixed in a position
occur.
midway between adduction and abduction. In cases where the
5. An operation for removal of the thyroid gland is called
recurrent laryngeal nerve is pressed upon by a tumour it is
thyroidectomy.
observed that nerve fibres that supply abductors are lost first.
3. In paralysis of both recurrent laryngeal nerves voice is lost Parathyroid Glands
as both vocal folds are immobile.
Hyperparathyroidism
Accessory nerve (spinal part) Excessive amounts of circulating parathormone can be
This nerve is tested as follows. present in tumours of the parathyroid gland (parathyroid
1. Put your hands on the right and left shoulders of the patient adenoma). As a result calcium is depleted from bones which
and ask him to elevate (shrug) his shoulders. In paralysis the become weak (and can fracture). Increased urinary excretion
movement will be weak on one side (due to paralysis of the of calcium may lead to formation of urinary calculi.
trapezius).
Hypoparathyroidism
2. Ask the patient to turn his face to the opposite side (against
Calcium levels in blood fall leading to muscular irritability
resistance offered by your hand). In paralysis the movement is
and convulsions. The condition may be spontaneous or may
weak on the affected side (due to paralysis of the
sternocleidomastoid muscle).
441
442
occur following accidental removal of parathyroid glands
during thyroidectomy.
Harelip and Cleft Palate
Embryologically, both the upper lip and the palate are derived
from three elements. These are the right and left maxillary
processes, and the frontonasal process that is a median
structure.
Harelip
The frontonasal process forms the median part of the upper
lip. This part is called the philtrum. On each side the frontonasal
process fuses with the corresponding maxillary process.
Abnormalities in fusion of these processes lead to clefts in the
upper lip (called hare lip because the hare normally has an
upper lip with a cleft). The defect may be unilateral or bilateral.
Cleft palate
As stated above the palate is derived from the frontonasal
process and the right and left maxillary processes. The
frontonasal process forms the part of the palate that bears the
incisor teeth. This part of the palate is also called the premaxilla.
It is triangular in shape, the apex of the triangle pointing
backwards, and lying in the midline. The rest of the palate is

formed by shelf like projections of the right and left maxillary
Fig. 47.2. Varieties of cleft palate. A. Complete non-
fusion leading to a Y-shaped cleft accompanied by
bilateral harelip. B. The left maxillary process has fused
with the premaxilla, but not with the right maxillary
process. The cleft is accompanied by unilateral harelip.
C. Midline cleft involving both hard and soft palate.
D. Cleft involving soft palate only.
process. These processes grow towards the midline.

Anteriorly, each maxillary process fuses with the
corresponding edge of the premaxilla. Behind the level of
the premaxilla the two maxillary processes fuse with each
other. From the manner of fusion it will be clear that the line
of union of the three elements forming the palate is Y shaped
Defects in the process of union lead to the formation of
different varieties of cleft palate as follows. Remember that
fusion of components of the palate starts anteriorly and
proceeds posteriorly.
a. Complete non-union gives rise to a Y-shaped cleft.
Anteriorly the limbs of the Y become continuous with a
cleft in the upper lip. There will also be bilateral hare lip.
b. The premaxilla may fuse with the maxillary process on one
side, but not on the other side. At the same time the two
maxillary processes do not fuse with each other. This results
in a defect that is oblique anteriorly and median posteriorly.
It will be associated with a unilateral harelip.
c. Both the maxillary processes fuse with the premaxilla
Fig. 47.1. Varieties of harelip. A to C. Different but their fusion to each other is deficient. This can give rise
degrees of unilateral harelip. D. Bilateral harelip. to median defects of varying extent. The cleft may involve
E. Median harelip.F. Median cleft in lower lip.
both the hard palate and the soft palate, may be confined to
the soft palate, or may be represented only by a cleft in the Pain originating in the paranasal sinuses may be referred to
uvula. other sites. The frontal sinus is supplied by the supraorbital
nerve that also supplies the skin of the forehead and anterior
part of the scalp. Therefore frontal headache is almost always
present in frontal sinusitis. In maxillary sinusitis pain may
Palatine Tonsils
be felt in the upper jaw and teeth.
When we talk of tonsils we are really referring to palatine tonsils.
Infections of the tonsils is common and is referred to as Larynx
tonsillitis. Infection can spread from them to peritonsillar tissues
leading to a peritonsillar abscess (also called quinsy). Infected 1. Inflammation of the mucous membrane of the larynx
tonsils can be responsible for spread of infection to the nasal (laryngitis) can cause hoarseness of voice, or even complete
cavities, the ears, and the respiratory passages. loss of voice, because of oedema above the level of the vocal
An operation for surgical removal of the tonsils is called folds. [Note that laryngeal mucous membrane is firmly
tonsillectomy. The main danger during the operation is bleeding adherent to the vocal folds and that is why fluid accumulates
(from the external palatine (peritonsillar) vein. The ascending above this level].
branch of the facial artery (and sometimes the facial artery itself) In the presence of severe inflammation or irritation the
are separated from the tonsil only by the superior constrictor oedema may be of such a degree as to lead to suffocation. In
muscle, and can in injured in a crudely performed tonsillectomy. such cases it may become necessary to create an artificial
Palatine tonsils are best developed in children. Like other opening in the trachea (tracheostomy) to save the life of the
lymphoid tissue they undergo retrogression after puberty. person.
2. Paralysis of one or more muscles of the larynx leads to
The Pharyngeal Tonsil
hoarseness of voice. The hoarseness is temporary in case of
This is a collection of lymphoid tissue present in relation to the
injury to the external laryngeal nerve (as the function of the
roof of the nasopharynx. Hence it is also called the
paralysed cricothyroid is gradually taken up by the muscle
nasopharyngeal tonsil. When enlarged (because of chronic
of the normal side). When the recurrent laryngeal nerve is
infection) the pharyngeal tonsils are referred to as adenoids.
injured hoarseness is permanent.
Adenoids lead to obstruction in the nasopharynx forcing the
child to breathe through the mouth. A constantly open mouth
The interior of the larynx can be examined in a living person
can lead to deformities of the teeth and palate (as normal
using an instrument called a laryngoscope. The procedure
pressure of the tongue on the palate is not present). Infection
is called laryngoscopy.
frequently spreads to the middle ear (through the auditory tube).
Removal of adenoids is called adenoidectomy.
Neck
Paranasal Sinuses
Midline swellings
Common causes of swellings to be seen in the midline on
Sinusitis
the front of the neck include enlarged submental lymph
Paranasal sinuses are frequently sites of infection (sinusitis).
nodes, cysts arising from remnants of the thyroglossal duct
The infection usually reaches them from the nasal cavity. As
(thyroglossal cyst), enlargements of the thyroid gland,
the sinuses open into the nasal cavity through narrow openings,
carcinoma of the larynx, and enlarged suprasternal lymph
slight swelling of the mucosa, or presence of thick secretions
nodes.
at the orifice, can block outflow of secretions that accumulate
within the sinus. This is one reason why sinusitis so often
becomes chronic. Branchial cysts and fistulae
This is specially true in the case of the maxillary sinus because A series of branchial arches develop in the embryo in the
the level of the opening of the maxillary air sinus into the nose region of the neck. The arches are separated (superficially)
is placed at a higher level than the floor of the sinus, so that by ectodermal clefts. The first ectodermal cleft takes part in
natural drainage is difficult. To facilitate drainage it is sometimes forming the external acoustic meatus. The second cleft is
necessary to make an artificial opening into the sinus through normally obliterated but sometimes remnants of it may form
the inferior meatus of the nose. branchial cysts. Such a cyst forms a swelling near the
Infection in the maxillary sinus can spread to the orbit. anterior border of the sternocleidomastoid muscle. If the
[Remember that the plate of bone that forms the roof of the cyst ruptures on to the surface it results in a branchial fistula.
maxillary sinus also forms the floor of the orbit]. For treatment it is necessary to excise the tract of the fistula.
443
444
PART 6:CENTRAL NERVOUS SYSTEM
48 : Gross Anatomy of the Brain
GROSS ANATOMY OF THE BRAINSTEM fourth ventricle. The surface of the medulla is marked by a
series of fissures or sulci that divide it into a number of
ESSENTIALS OF ANATOMY : CENTRAL NERVOUS SYSTEM
regions. The anterior median fissure and the posterior

The brainstem consists (from above downwards) of the median sulcus are upward continuations of the
midbrain, the pons and the medulla (Figs 48.1 and 48.2). The corresponding features seen on the spinal cord. On each side
midbrain is continuous, above, with the cerebral hemispheres. the anterolateral sulcus lies in line with the ventral roots of
The medulla is continuous, below, with the spinal cord. spinal nerves. The rootlets of the hypoglossal nerve emerge
Posteriorly, the pons and medulla are separated from the from this sulcus. The posterolateral sulcus lies in line with
cerebellum by the fourth ventricle. The ventricle is continuous, the dorsal nerve roots of spinal nerves, and gives attachment
below, with the central canal, which traverses the lower part to rootlets of the glossopharyngeal, vagus and accessory
of the medulla, and becomes continuous with the central canal nerves. The region between the anterior median sulcus and
of the spinal cord. Cranially, the fourth ventricle is continuous the anterolateral sulcus is occupied (on either side of the
with the aqueduct, which passes through the midbrain. The midline) by an elevation called the pyramid. The elevation
midbrain, pons and medulla are connected to the cerebellum is caused by a large bundle of fibres that descend from the
by the superior, middle and inferior cerebellar peduncles, cerebral cortex to the spinal cord. Some of these fibres cross
respectively. from one side to the other in the lower part of the medulla,
A number of cranial nerves are attached to the brainstem. The obliterating the anterior median fissure. These crossing fibres
third and fourth nerves emerge from the surface of the midbrain; constitute the decussation of the pyramids. Some other fibres
and the fifth from the pons. The sixth, seventh and eighth nerves emerge from the anterior median fissure, above the
emerge at the junction of the pons and medulla. The ninth, decussation, and wind laterally over the surface of the
tenth, eleventh and twelfth cranial
nerves emerge from the surface of
the medulla.
Gross Anatomy
of the Medulla
The medulla is broad above, where

it joins the pons; and narrows down
below, where it becomes
continuous with the spinal cord.
The junction of the medulla and
cord is usually described as lying
at the level of the upper border of
the atlas vertebra. The transition is,
in fact, not abrupt but occurs over
a certain distance. The medulla is
divided into a lower closed part,
which surrounds the central canal;
and an upper open part, that is
related to the lower part of the Fig. 48.1. Ventral aspect of the brainstem.
GROSS ANATOMY OF BRAIN
Gross Anatomy of the Pons
The pons shows a convex anterior

surface, marked by prominent
transversely running fibres. Laterally,
these fibres collect to form a bundle,
the middle cerebellar peduncle. The
trigeminal nerve emerges from the
anterior surface, and the point of its
emergence is taken as a landmark to
define the plane of junction between
the pons and the middle cerebellar
peduncle. The anterior surface of the
pons is marked, in the midline, by a
shallow groove, the sulcus basilaris,
that lodges the basilar artery. The line
of junction between the pons and the
medulla is marked by a groove
through which a number of cranial
nerves emerge. The abducent nerve
emerges just above the pyramid and
Fig. 48.2. Dorsal aspect of the brainstem. Letters G to A represent levels at
runs upwards in close relation to the
which transverse sections are shown in Figures 48.3 to 48.9. anterior surface of the pons. The
facial and vestibulo-cochlear nerves emerge in the interval

medulla. These are the anterior external arcuate fibres. In the between the olive and the pons. The posterior aspect of the
upper part of the medulla, the region between the anterolateral pons forms the upper part of the floor of the fourth ventricle.
and posterolateral sulci shows a prominent, elongated, oval
swelling named the olive. It is produced by a large mass of grey
matter called the inferior olivary nucleus. The posterior part
of the medulla, between the posterior median sulcus and the Gross Anatomy of the Midbrain
posterolateral sulcus, contains tracts that enter the medulla from
the posterior funiculus of the spinal cord. These are the When the midbrain is viewed from the anterior aspect, we
fasciculus gracilis lying medially, next to the middle line, and see two large bundles of fibres, one on each side of the
the fasciculus cuneatus lying laterally. These fasciculi end in middle line. These are the crura of the midbrain. The right
rounded elevations called the gracile and cuneate tubercles. and left crura are separated by a deep fissure. Near the pons
These tubercles are produced by masses of grey matter called the fissure is narrow, but broadens as the crura diverge to
the nucleus gracilis and the nucleus cuneatus respectively. enter the corresponding cerebral hemispheres. The parts of
the crura just below the cerebrum form the posterior
Just above these tubercles the posterior
aspect of the medulla is occupied by a
triangular fossa that forms the lower part
of the floor of the fourth ventricle. This
fossa is bounded on either side by the
inferior cerebellar peduncle. The lower
part of the medulla, immediately lateral
to the fasciculus cuneatus, is marked by
another longitudinal elevation called the
tuberculum cinereum. This elevation is
produced by an underlying collection of
grey matter called the spinal nucleus of
the trigeminal nerve. The grey matter of
this nucleus is covered by a layer of nerve
fibres that form the spinal tract of the
trigeminal nerve.
Fig. 48.3. Main features to be seen in a transverse section through the
medulla at the level of the pyramidal decussation.
445
446
boundary of a space called the
interpeduncular fossa (Fig. 48.18). The
oculomotor nerve emerges from the medial
aspect of the crus (singular of crura) of the
same side.
The posterior aspect of the midbrain is
marked by four rounded swellings. These
are the colliculi, one superior and one
inferior on each side. Each colliculus is
related laterally to a ridge called the
brachium. The superior brachium
connects the superior colliculus to the
lateral geniculate body, while the inferior
brachium connects the inferior colliculus
to the medial geniculate body. Just below
the colliculi, there is the uppermost part of Fig. 48.4. Transverse section through the medulla to show the main features
a membrane, the superior medullary seen at the level of the sensory decussation.
velum, that stretches between the two
superior cerebellar peduncles, and helps to
form the roof of the fourth ventricle. The
trochlear nerve emerges from the velum,
and then winds round the side of the
midbrain to reach its ventral aspect.
In the description of the surface features
of the brainstem, given above, reference
has been made to the floor of the fourth
ventricle. It is important that this
description be read at this stage, so as to
obtain a complete idea of the posterior
aspect of the pons and medulla.
Fig. 48.5. Main features to be seen in a transverse section through the

medulla at the level of the olive.
PRELIMINARY REVIEW OF THE INTERNAL medially; and by the fasciculus cuneatus laterally. Closely
STRUCTURE OF THE BRAINSTEM related to these fasciculi there are two tongue-shaped
extensions of the central grey matter. The medial of these
extensions is the nucleus gracilis, and the lateral is the
The following description is confined to those features of
nucleus cuneatus. More laterally, there is the spinal nucleus
internal structure that can be seen with the naked eye. The
of the trigeminal nerve. When traced inferiorly, this nucleus
main features of the internal structure of the brainstem are most
reaches the second cervical segment of the spinal cord, where
easily reviewed by examining transverse sections at various
it becomes continuous with the substantia gelatinosa.
levels. These are illustrated in Figures 48.3 to 48.7. The levels
Superiorly, the nucleus extends as far as the upper part of
represented in these figures are indicated in Figure 48.2.
the pons. The spinal nucleus of the trigeminal nerve is related
superficially to the spinal tract of the nerve. The ventral
part of the medulla is occupied, on either side of the middle
Internal Structure of the Medulla line, by a prominent bundle of fibres: these fibres form the
pyramid. The fibres of the pyramids are corticospinal fibres
A section at the level of the pyramidal decussation (Fig. 48.3) on their way from the cerebral cortex to the spinal cord. At
shows some similarity to sections through the spinal cord. The this level in the medulla many of these fibres run backwards
central canal is surrounded by central grey matter. The ventral and medially to cross in the middle line. These crossing fibres
grey columns are present, but are separated from the central constitute the decussation of the pyramids. Having crossed
grey matter by decussating pyramidal fibres. The region behind the middle line, the corticospinal fibres turn downwards to
the central grey matter is occupied by the fasciculus gracilis, enter the lateral white column of the spinal cord. The
nucleus and tract of the trigeminal
nerve, and the reticular formation are
present in the same relative position as
at lower levels. The medial lemniscus
is, however, much more prominent and
is somewhat expanded anteriorly.
Lateral to the spinal nucleus (and tract)
of the trigeminal nerve we see a large
compact bundle of fibres. This is the
inferior cerebellar peduncle that
connects the medulla to the cerebellum.
Posteriorly, the medulla forms the floor
of the fourth ventricle. Here it is lined
by a layer of grey matter in which are
located several important cranial nerve
Fig. 48.6. Main features to be seen in a transverse section through the upper
part of the pons.
nuclei. The inferior olivary nucleus
forms a prominent feature in the
anterolateral part of the medulla at this
level. It is made up of a thin lamina of
grey matter that is folded on itself like
a crumpled purse. The nucleus has a
hilum that is directed medially.
Internal Structure of the Pons
The pons is divisible into a ventral part

and a dorsal part (Fig. 48.6).
The ventral (or basilar) part consists
of transverse and vertical fibres.
Amongst the fibres are groups of cells
Fig. 48.7. Main features to be seen in a transverse section through that constitute the pontine nuclei.
the lower part of the pons.
When traced laterally the transverse
fibres form the middle cerebellar
anterolateral region of the medulla is continuous with the peduncle. The vertical fibres are of two types. Some of them
anterior and lateral funiculi of the spinal cord. descend from the cerebral cortex to end in the pontine nuclei.
A section through the medulla at a somewhat higher level is Others are corticospinal fibres that descend through the pons
shown in Figure 48.4. The central canal surrounded by central into the medulla where they form the pyramids.
grey matter, the nucleus gracilis, the nucleus cuneatus, the spinal The dorsal part (or tegmentum) of the pons may be regarded
nucleus of the trigeminal nerve, and the pyramids occupy the as an upward continuation of the part of the medulla behind
same positions as at lower levels. The nucleus gracilis and the the pyramids. Superiorly, it is continuous with the tegmentum
nucleus cuneatus are, however, much larger and are no longer of the midbrain. It is bounded posteriorly by the fourth
continuous with the central grey matter. The fasciculus gracilis ventricle. Laterally, it is related to the superior cerebellar
and the fasciculus cuneatus are less prominent. The region just peduncles in its upper part (Fig. 48.6); and to the inferior
behind the pyramids is occupied by a prominent bundle of fibres, cerebellar peduncles in its lower part (Fig. 48.7). The spinal
the medial lemniscus, on either side of the middle line. The nucleus and tract of the trigeminal nerve lie just medial to
medial lemniscus is formed by fibres arising in the nucleus these peduncles. The medial lemniscus forms a transversely
gracilis and the nucleus cuneatus. These fibres cross the middle elongated band of fibres just behind the ventral part of the
line and turn upwards in the lemniscus of the opposite side. pons.
Crossing fibres of the two sides constitute the sensory
decussation. The region lateral to the medial lemniscus contains
scattered neurons and nerve fibres. This region is the reticular Internal Structure of the Midbrain
formation. More laterally there is a mass of white matter
containing various tracts. For convenience of description, the midbrain may be divided
A section through the medulla at the level of the olive is shown as follows (Fig. 48.8).
in Figure 48.5. The pyramids, the medial lemniscus, the spinal
447
448
a. The part lying behind a
transverse line drawn through the
cerebral aqueduct is called the
tectum. It consists of the superior
and inferior colliculi of the two
sides.
b. The part lying in front of the
transverse line is made up of right
and left halves called the cerebral
peduncles. Each peduncle consists
of three parts. From anterior to
posterior side these are the crus
cerebri (or basis pedunculi), the
substantia nigra and the
tegmentum.
The crus cerebri consists of a large
mass of vertically running fibres.

These fibres descend from the Fig. 48.8. Main features to be seen in a transverse section through the lower part
cerebral cortex. Some of these pass of the midbrain.
through the midbrain to reach the
pons, while others reach the spinal
cord. The two crura are separated
by a notch seen on the anterior
aspect of the midbrain.
The substantia nigra is made up of
pigmented grey matter and,
therefore, appears dark in colour.
The tegmentum of the two sides is
continuous across the middle line.
It contains important masses of grey
matter as well as fibre bundles. The
largest of the nuclei is the red
nucleus (Fig. 48.9) present in the
upper half of the midbrain. The
tegmentum also contains the
reticular formation that is Fig. 48.9. Main features to be seen in a transverse section through the upper
continuous below with that of the part of the midbrain.
pons and medulla. The fibre bundles
of the tegmentum include the medial
lemniscus that lies just behind the substantia nigra, lateral to GROSS ANATOMY OF THE
the red nucleus. The lower part of the tegmentum is traversed CEREBELLUM
by a large number of fibres that cross the middle line from one
side to the other. These are the fibres of the superior cerebellar
peduncles that have their origin in the cerebellum and decussate Subdivisions of the Cerebellum
before ending in the red nucleus (and in some other centres).
It may be noted that some authorities describe the The cerebellum lies in the posterior cranial fossa, behind
corresponding half of the tectum as part of the cerebral the pons and the medulla. It is separated from the cerebrum
peduncle. by a fold of dura mater called the tentorium cerebelli.
The cerebellum consists of a part lying near the middle line
called the vermis, and of two lateral hemispheres. It has
two surfaces, superior and inferior. On the superior aspect,
there is no line of distinction between vermis and
hemispheres. On the inferior aspect, the two hemispheres
are separated by a deep depression called the vallecula. The
vermis lies in the depth of this depression. Anteriorly and
posteriorly the hemispheres extend beyond the vermis and
are separated by anterior and posterior cerebellar notches.
The surface of the cerebellum is marked by a
series of fissures that run more or less parallel
to one another. The fissures subdivide the
surface of the cerebellum into narrow leaf
like bands or folia. The long axis of the
majority of folia is more or less transverse.
Sections of the cerebellum cut at right angles
to this axis have a characteristic tree-like
appearance to which the term arbor-vitae
(tree of life) is applied.
Some of the fissures on the surface of the
cerebellum are deeper than others. They
divide the cerebellum into lobes within which
smaller lobules may be recognised. To show
the various subdivisions of the cerebellum
in a single illustration it is usual to represent
it as if it has been opened out so that the
superior and inferior aspects can both be
seen. Such an illustration is shown in Figure
48.10.
The deepest fissures in the cerebellum are
(a) the primary fissure seen on the superior
surface, and (b) the posterolateral fissure
seen on the inferior aspect. These fissures
Fig. 48.10. Scheme to show the subdivisions of the cerebellum.
divide the cerebellum into three lobes. The
part anterior to the primary fissure is the
anterior lobe. The part between the two
fissures is the middle lobe (sometimes called the posterior The upper part of this lamina forms the superior medullary
lobe). The remaining part is the flocculonodular lobe. The velum, and its inferior part forms the inferior medullary velum.
anterior and middle lobes together form the corpus cerebelli. Both these take part in forming the roof of the fourth ventricle.
Further subdivisions of the cerebellum are shown in Figure
Grey matter of the cerebellum
48.10.
Most of the grey matter of the cerebellum is arranged as a
thin layer covering the central core of white matter. This
Cerebellar Peduncles layer is the cerebellar cortex. The subdivisions of the
cerebellar cortex correspond to the subdivisions of the
The fibres entering or leaving the cerebellum pass through three cerebellum described above. Embedded within the central
thick bundles called the cerebellar peduncles. The inferior core of white matter there are masses of grey matter that
cerebellar peduncle connects the posterolateral part of the constitute the cerebellar nuclei. These are as follows (Fig.
medulla with the cerebellum. The middle cerebellar peduncle 48.11).
looks like a lateral continuation of the ventral part of the pons.
It connects the pons to the cerebellum. The
superior cerebellar peduncle is the main
connection between the midbrain and the
cerebellum.
White matter of the cerebellum
The central core of each cerebellar

hemisphere is formed by white matter. The
peduncles are continued into this white
matter. The white matter of the two sides is
connected by a thin lamina of fibres that
are closely related to the fourth ventricle.
Fig. 48.11. Scheme to show the cerebellar nuclei
449
450
1. The dentate nucleus lies in the centre of each cerebellar four major subdivisions or lobes. To consider the boundaries
hemisphere. Cross sections through the nucleus have a striking of these lobes reference has to be made to some sulci and
resemblance to those through the inferior olivary nucleus. Like other features to be seen on each hemisphere (Fig. 48.12).
the latter it is made up of a thin lamina of grey matter that is a. On the superolateral surface of the hemisphere there are
folded upon itself so that it resembles a crumpled purse. Both two prominent sulci. One of these is the posterior ramus of
the nuclei have a hilum directed medially. the lateral sulcus that begins near the temporal pole and
2. The emboliform nucleus lies on the medial side of the dentate runs backwards and slightly upwards. Its posteriormost part
nucleus. curves sharply upwards. The second sulcus that is used to
3. The globose nucleus lies medial to the emboliform delimit the lobes is the central sulcus. It begins on the
nucleus. superomedial border a little behind the midpoint between
4. The fastigial nucleus lies close to the middle line in the the frontal and occipital poles, and runs downwards and
anterior part of the superior vermis. forwards to end a little above the posterior ramus of the
lateral sulcus.
b. On the medial surface of the hemisphere, near the occipital
pole, there is a sulcus called the parieto-occipital sulcus
(Fig. 48.16). The upper end of this sulcus reaches the
GROSS ANATOMY OF
superomedial border and a small part of it can be seen on the

THE CEREBRAL HEMISPHERES
superolateral surface (Fig. 48.12).
c. A little anterior to the occipital pole the inferolateral border
shows a slight indentation called the preoccipital notch
EXTERIOR OF THE CEREBRAL HEMISPHERES
(or preoccipital incisure).
To complete the subdivision of the hemisphere into lobes
Poles, Surfaces, and Borders we now have to draw two imaginary lines. The first imaginary
The cerebrum consists of two cerebral hemispheres that are line connects the upper end of the parieto-occipital sulcus
partially connected with each other. When viewed from the to the preoccipital notch. The second imaginary line is a
lateral aspect each cerebral hemisphere has the appearance backward continuation of the posterior ramus of the lateral
shown in figure 48.12. Three somewhat pointed ends or poles sulcus (excluding the posterior upturned part) to meet the
can be recognised. These are the frontal pole anteriorly, the first line. We are now in a position to define the limits of the
occipital pole posteriorly, and the temporal pole that lies various lobes as follows.
between the frontal and occipital poles, and points forwards 1. The frontal lobe lies anterior to the central sulcus, and
and somewhat downwards. A coronal section through the above the posterior ramus of the lateral sulcus.
cerebral hemispheres (Fig. 48.13) shows that each hemisphere 2. The parietal lobe lies behind the central sulcus. It is
has three borders, superomedial, inferolateral and bounded below by the posterior ramus of the lateral sulcus
inferomedial. These borders divide the surface of the and by the second imaginary line; and behind by the upper
hemisphere into three large surfaces, superolateral, medial part of the first imaginary line.
and inferior. The inferior surface is further subdivided into an 3. The occipital lobe is the area lying behind the first
anterior orbital part and a posterior tentorial part. (Fig. 48.13). imaginary line.
Corresponding to these subdivisions, the inferomedial border
is divided into an anterior part
called the medial orbital
border and a posterior part
called the medial occipital
border. The orbital part of the
inferolateral border is called
the superciliary border (as it
lies just above the level of the
eyebrows). The surfaces of
the cerebral hemisphere are
not smooth. They show a
series of grooves or sulci that
are separated by intervening
areas that are called gyri.
Lobes
For convenience of des-
cription each cerebral
Fig. 48.12. Lateral aspect of the cerebral hemisphere to show borders, poles and lobes.
hemisphere is divided into
4. The temporal lobe lies below the posterior ramus of the
lateral sulcus and the second imaginary line. It is separated
from the occipital lobe by the lower part of the first imaginary
line.
Before going on to consider further subdivisions of each of the
lobes named above, attention has to be directed to details of
some structures already mentioned.
a. The upper end of the central sulcus winds round the
superomedial border to reach the medial surface. Here its end
is surrounded by a gyrus called the paracentral lobule (Fig.
48.16). The lower end of the central sulcus is always separated
by a small interval from the posterior ramus of the lateral sulcus
(Fig. 48.12).
b. The lateral sulcus begins on the inferior aspect of the cerebral
hemisphere where it lies between the orbital surface and the
anterior part of the temporal lobe (Fig. 48.18). It runs laterally to
reach the superolateral surface. On reaching this surface it
divides into three rami (branches). These rami are anterior (or
anterior horizontal), ascending (or anterior ascending) and
posterior (Fig. 48.15). The anterior and ascending rami are short
and run into the frontal lobe in the directions indicated by their Fig. 48.13. Coronal section through a cerebral
names. The posterior ramus has already been considered. Unlike hemisphere to show its borders and surfaces.
most other sulci, the lateral sulcus is very deep. Its walls cover
a fairly large area of the surface of the hemisphere called the
insula (Fig. 48.14).
Further Subdivisions of the Superolateral Surface

Frontal Lobe
The frontal lobe is further subdivided as follows (Fig. 48.15).
The precentral sulcus runs downwards and forwards parallel
to and a little anterior to the central sulcus. The area between it
and the central sulcus is the precentral gyrus. In the region
anterior to the precentral gyrus there are two sulci that run in an
anteroposterior direction. These are the superior and inferior
frontal sulci. They divide this region into superior, middle and
inferior frontal gyri. The anterior and ascending rami of the
lateral sulcus extend into the inferior frontal gyrus dividing it
into three parts. The part below the anterior ramus is the pars
orbitalis; that between the anterior and ascending rami is the
pars triangularis; and the part posterior to the ascending ramus
is the pars opercularis.
Temporal Lobe
The temporal lobe has two sulci that run parallel to the posterior
Fig. 48.14. Inferior aspect of a cerebral hemisphere
ramus of the lateral sulcus. They are termed the superior and to show its borders, poles and surfaces.
inferior temporal sulci. They divide the superolateral surface
of this lobe into superior, middle and inferior temporal gyri.
Parietal Lobe inferior temporal sulci also turn upwards to enter this lobule.
The parietal lobe shows the following subdivisions. The The upturned ends of these three sulci divide the inferior
postcentral sulcus runs downwards and forwards parallel to parietal lobule into three parts. The part that arches over the
and a little behind the central sulcus. The area between these upturned posterior end of the posterior ramus of the lateral
two sulci is the postcentral gyrus. The rest of the parietal lobe sulcus is called the supramarginal gyrus. The part that
is divided into a superior parietal lobule and an inferior parietal arches over the superior temporal sulcus is called the angular
lobule by the intraparietal sulcus. The upturned posterior end gyrus. The part that arches over the posterior end of the
of the posterior ramus of the lateral sulcus extends into the inferior temporal sulcus is called the arcus temporo-
inferior parietal lobule. The posterior ends of the superior and occipitalis.
451
452
Occipital Lobe surface from the medial surface) is surrounded by the arcus
The occipital lobe shows three rather short sulci. One of these, parieto-occipitalis. As its name suggests, it belongs partly
the lateral occipital sulcus lies horizontally and divides the to the parietal lobe and partly to the occipital lobe.
lobe into superior and inferior occipital gyri. The lunate sulcus Insula
runs downwards and slightly forwards just in front of the In the depth of the stem and posterior ramus of the lateral
occipital pole. The vertical strip just in front of it is the gyrus sulcus there is a part of the cerebral hemisphere called the
descendens. The transverse occipital sulcus is located in the insula (insula = insulated or hidden). It is surrounded by a
uppermost part of the occipital lobe. The upper end of the circular sulcus. During development of the cerebral
parieto-occipital sulcus (that just reaches the superolateral hemisphere of this area grows less than surrounding areas
Fig. 48.15. Simplified presentation of sulci and gyri on the superolateral surface of the cerebral hemisphere.
a= pars orbitalis b= pars triangularis c=pars opercularis
Fig. 48.16. Simplified presentation of sulci and gyri on the cerebral hemisphere as seen from the medial aspect.
The medial surface and the tentorial surface (green) are seen. The corpus callosum and some other median
structures have been cut across.
that, therefore, come to overlap it and occlude it from surface right and left lateral ventricles from each other. Removal of
view. These surrounding areas are called opercula (= lids). The the septum pellucidum brings the interior of the lateral
frontal operculum lies between the anterior and ascending ventricle into view.
rami of the lateral sulcus. The frontoparietal operculum lies In the anterior wall of the third ventricle there are the anterior
above the posterior ramus of the lateral sulcus. The temporal commissure and the lamina terminalis. The anterior
operculum lies below this sulcus. The temporal operculum has commissure is attached to the genu of the corpus callosum
a superior surface hidden in the depth of the lateral sulcus (Fig. through a thin lamina of fibres that constitutes the rostrum
48.14). On this surface we see two gyri called the anterior and of the corpus callosum. Inferiorly, the anterior commissure
posterior transverse temporal gyri. is continuous with the lamina terminalis that is a thin lamina
of nervous tissue. The lower end of the lamina terminalis is
Medial Surface of Cerebral Hemisphere
attached to the optic chiasma. Posteriorly, the third ventricle
When the two cerebral hemispheres are separated from each
is related to the pineal gland and inferiorly to the hypophysis
other by a cut in the middle line the appearances seen are shown
cerebri.
in Figures 48.16 and 48.17. The structures seen are as follows.
Above the corpus callosum (and also in front of and behind
The corpus callosum is a prominent arched structure consisting
it) we see the sulci and gyri of the medial surface of the
of commissural fibres passing from one hemisphere to the other
hemisphere (Fig. 48.16). The most prominent of the sulci is
(Fig. 48.17). It consists of a central part called the trunk, a
the cingulate sulcus that follows a curved course parallel to
posterior end or splenium, and an anterior end or genu. A little
the upper convex margin of the corpus callosum. Anteriorly,
below the corpus callosum we see the third ventricle of the
it ends below the rostrum of the corpus callosum. Posteriorly,
brain. A number of structures can be identified in relation to
it turns upwards to reach the superomedial border a little
this ventricle. The interventricular foramen through which the
behind the upper end of the central sulcus. The area between
third ventricle communicates with the lateral ventricle can be
the cingulate sulcus and the corpus callosum is called the
seen in the upper and anterior part. Posteroinferiorly, the
gyrus cinguli. It is separated from the corpus callosum by
ventricle is continuous with the cerebral aqueduct. The lateral
the callosal sulcus. The part of the medial surface of the
wall of the ventricle is formed in greater part by a large mass of
hemisphere between the cingulate sulcus and the
grey matter called the thalamus. The right and left thalami are
superomedial border consists of two parts. The smaller
usually interconnected (across the middle line) by a strip of
posterior part that is wound around the end of the central
grey matter called the interthalamic connexus. The
sulcus is called the paracentral lobule. The large anterior
anteroinferior part of the lateral wall of the third ventricle is
part is called the medial frontal gyrus. These two parts are
formed by a collection of grey matter that constitutes the
separated by a short sulcus continuous with the cingulate
hypothalamus.
sulcus.
Above the thalamus there is a bundle of fibres called the fornix.
The part of the medial surface behind the paracentral lobule
Posteriorly, the fornix is attached to the undersurface of the
and the gyrus cinguli shows two major sulci that cut off a
corpus callosum, but anteriorly it disappears from view just in
triangular area called the cuneus. The triangle is bounded
front of the interventricular foramen. Extending between the
anteriorly and above by the parieto-occipital sulcus;
fornix and the corpus callosum there is a thin lamina called the
inferiorly by the calcarine sulcus; and posteriorly by the
septum pellucidum (or septum lucidum), that separates the
superomedial border of the hemisphere. The
calcarine sulcus extends forwards beyond its
junction with the parieto-occipital sulcus and
ends a little below the splenium of the corpus
callosum. The small area separating the
splenium from the calcarine sulcus is called
the isthmus. Between the parieto-occipital
sulcus and the paracentral lobule there is a
quadrilateral area called the precuneus.
Anteroinferiorly the precuneus is separated
from the posterior part of the gyrus cinguli by
the suprasplenial (or subparietal) sulcus.
The precuneus and the posterior part of the
paracentral lobule form the medial surface of
the parietal lobe.
Although the parieto-occipital and calcarine
sulci appear to be continuous with each other
on surface view, they are separated by the
Fig. 48.17. Enlarged view of part of Figure 48.16 to show some cuneate gyrus that lies in the depth of the area
structures to be seen on the medial aspect of the cerebral hemisphere. where the two sulci meet. The parts of the
453
454
calcarine sulcus anterior and posterior to the junction with the insula by a band of grey matter called the limen insulae that
parieto-occipital sulcus are separated by a deeply situated lies in the depth of the stem of the lateral sulcus.
anterior cuneolingual gyrus. In addition to these structures we see the sulci and gyri on
the orbital and tentorial parts of the inferior surface of the
Inferior Surface of Cerebrum
each cerebral hemisphere (described below). The orbital and
When the cerebrum is separated from the hindbrain by cutting
tentorial parts of the inferior surface are separated from each
across the midbrain, and is viewed from below, the appearances
other by the stem of the lateral sulcus.
seen are shown in Figure 48.18. Posterior to the midbrain we
see the undersurface of the splenium of the corpus callosum. Orbital Surface
Anterior to the midbrain there is a depressed area called the Close to the medial border of the orbital surface there is an
interpeduncular fossa. The fossa is bounded in front by the anteroposterior sulcus: it is called the olfactory sulcus
optic chiasma and on the sides by the right and left optic tracts. because the olfactory bulb and tract lie superficial to it. The
The optic tracts wind round the sides of the midbrain to area medial to this sulcus is called the gyrus rectus. The rest
terminate on its posterolateral aspect. In this region two of the orbital surface is divided by an H-shaped orbital sulcus
swellings, the medial and lateral geniculate bodies, can be into anterior, posterior, medial and lateral orbital gyri.
seen.
Certain structures are seen within the interpeduncular fossa. Tentorial Surface
These are closely related to the floor of the third ventricle (see The tentorial surface is marked by two major sulci that run in
also Figure 48.17). Anterior and medial to the crura of the an anteroposterior direction. These are the collateral sulcus
midbrain there are two rounded swellings called the mamillary medially, and the occipitotemporal sulcus laterally. The
bodies. Anterior to these bodies there is a median elevation posterior part of the collateral sulcus runs parallel to the
called the tuber cinereum, to which the infundibulum of the calcarine sulcus: the area between them is the lingual gyrus.
hypophysis cerebri is attached. The triangular interval between Anteriorly, the lingual gyrus becomes continuous with the
the mamillary bodies and the midbrain is pierced by numerous parahippocampal gyrus that is related medially to the
small blood vessels and is called the posterior perforated midbrain and to the interpeduncular fossa. The anterior end
substance. A similar area lying on each side of the optic of the parahippocampal gyrus is cut off from the curved
chiasma is called the anterior perforated substance. The temporal pole of the hemisphere by a curved rhinal sulcus.
anterior perforated substance is bounded anterolaterally by the This part of the parahippocampal gyrus forms a hook-like
lateral olfactory stria and posterolaterally by the uncus (see structure called the uncus. Posteriorly, the parahippocampal
below). The anterior perforated substance is connected to the gyrus becomes continuous with the gyrus cinguli through
Fig. 48.18. Structures to be seen on the inferior aspect of the cerebral hemisphere.
the isthmus (Fig. 48.16). The area
between the collateral sulcus and
the rhinal sulcus medially, and the
occipitotemporal sulcus laterally,
is the medial occipitotemporal
gyrus. The area lateral to the
occipitotemporal sulcus is called
the lateral occipitotemporal
gyrus. This gyrus is continuous
(around the inferolateral margin
of the cerebral hemisphere) with
the inferior temporal gyrus.
Fig. 48.19. Two stages in the development of the brain.
AN INTRODUCTION TO SOME represent the sites of the original telencephalic evaginations.

STRUCTURES WITHIN THE Keeping these facts in mind we may now examine the basic
CEREBRAL HEMISPHERES structure of the cerebral hemispheres as seen in a coronal
section (Fig. 48.20).
The surface of the cerebral hemisphere is covered by a thin
For a proper understanding of the structure of the cerebrum, layer of grey matter called the cerebral cortex. The cortex
brief reference to the development of the brain is necessary. At follows the irregular contour of the sulci and gyri of the
an early stage of development the brain is made up of three hemisphere and extends into the depths of the sulci. As a
hollow vesicles. These are the prosencephalon, the result of this folding of the cerebral surface, the cerebral
mesencephalon and the rhombencephalon (in craniocaudal cortex acquires a much larger surface area than the size of
sequence) (Fig. 48.19). The mesencephalon gives rise to the the hemispheres would otherwise allow.
midbrain, while the rhombencephalon forms the hindbrain (i.e. The greater part of the cerebral hemisphere deep to the
the pons, the medulla, and the cerebellum). The cerebrum cortex is occupied by white matter within which are
develops from the prosencephalon that soon shows a subdivision embedded certain important masses of grey matter.
into a median part, the diencephalon, and two lateral Immediately lateral to the third ventricle there are the
evaginations (the telencephalic vesicles) that together constitute thalamus and hypothalamus (and certain smaller masses)
the telencephalon. In subsequent development, the
telencephalic vesicles grow much
faster than the diencephalon. As
they enlarge they eventually overlap
the diencephalon and fuse with its
lateral aspect. One telencephalic
vesicle, along with the
corresponding half of the
diencephalon constitutes one
cerebral hemisphere. From what has
been said above it will be clear that
the diencephalic part of the
hemisphere lies medially and
inferiorly relative to the part derived
from the telencephalon.
The developing brain has a series of
cavities within it. The cavity of each
telencephalic vesicle becomes one
lateral ventricle. The third ventricle
may be regarded as the cavity of the
diencephalon. The interventricular Fig. 48.20. Coronal section through a cerebral hemisphere to show some
foramina connecting the lateral important masses of grey matter, and some other structures, within it.
ventricles to the third ventricle
455
456
derived from the diencephalon. More laterally there is the recorded from the sensory area when individual parts of the
corpus striatum that is derived from the telecephalon. It body are stimulated. A definite representation of various
consists of two masses of grey matter, the caudate nucleus parts of the body can be mapped out in the sensory area. It
and the lentiform nucleus. A little lateral to the lentiform corresponds to that in the motor area in that the body is
nucleus we see the cerebral cortex in the region of the insula. represented upside down. The area of cortex that receives
Between the lentiform nucleus and the insula there is a thin sensations from a particular part of the body is not
layer of grey matter called the claustrum. The caudate nucleus, proportional to the size of that part, but rather to the
the lentiform nucleus, the claustrum and some other masses of complexity of sensations received from it. Thus the digits,
grey matter (all of telencephalic origin) are referred to as basal the lips and the tongue have a disproportionately large
ganglia. representation.
The white matter that occupies the interval between the
Visual Areas
thalamus and caudate nucleus medially, and the lentiform
The areas concerned with vision are located in the occipital
nucleus laterally, is called the internal capsule. It is a region
lobe, mainly on the medial surface, both above and below
of considerable importance as major ascending and descending
the calcarine sulcus (area 17). Area 17 extends into the
tracts pass through it. The white matter that radiates from the
cuneus, and into the lingual gyrus. Posteriorly, it may extend
upper end of the internal capsule to the cortex is called the
onto the superolateral surface where it is limited (anteriorly)

corona radiata.
by the lunate sulcus. Area 17 is continuous, both above and
The two cerebral hemispheres are interconnected by fibres
below, with area 18 and beyond this with area 19. Areas 18
passing from one to the other. These fibres constitute the
and 19 are responsible mainly for interpretation of visual
commissures of the cerebrum. The largest of these is the corpus
impulses reaching area 17: they are often described as
callosum that is seen just above the lateral ventricles in Figure
psychovisual areas.
48.20.
Acoustic Area
The acoustic area, or the area for hearing, is situated in the
temporal lobe. It lies in that part of the superior temporal
gyrus that forms the inferior wall of the posterior ramus of
IMPORTANT FUNCTIONAL AREAS the lateral sulcus. In this situation there are two short oblique
OF THE CEREBRAL CORTEX gyri called the anterior and posterior transverse temporal
gyri (areas 41, 42 and 52). The acoustic area lies in the
Some areas of the cerebral cortex can be assigned specific anterior transverse temporal gyrus (area 41) and extends to
functions. These areas can be defined in terms of sulci and a small extent onto the surface of the hemisphere in the
gyri described in preceding pages. However, some areas are superior temporal gyrus (areas 41, 42).
commonly referred to by numbers.
Motor area
The motor area of classical description is located in the
precentral gyrus on the superolateral surface of the hemisphere
(Fig. 48.21), and in the anterior part of the paracentral lobule
on the medial surface.
Premotor area
The premotor area is located just anterior to the
motor area. It occupies the posterior parts of the
superior, middle and inferior frontal gyri (Fig.
48.21).
The part in the inferior frontal gyrus corresponds
to areas 44 and 45 and constitutes the motor
speech area (of Broca). Stimulation of the
premotor area results in movements, but these
are somewhat more intricate than those produced
by stimulation of the motor area.
Sensory Area
The sensory area of classical description is
located in the postcentral gyrus (Fig. 48.21). It
corresponds to areas 1, 2, and 3 of Brodmann. It
also extends on to the medial surface of the
hemisphere where it lies in the posterior part of Fig. 48.21. Functional areas on the superolateral aspect of the cerebral
the paracentral lobule. Responses can be hemisphere.
WHITE MATTER OF hypothalamus and the basal ganglia, are also projection
CEREBRAL HEMISPHERES fibres. Many of the major projection fibres pass through the
internal capsule, which is considered below.
Deep to the cerebral cortex the greater part of each cerebral
hemisphere is occupied by nerve fibres that constitute the white
matter. These fibres may be: The Internal Capsule
a. Association fibres that interconnect different regions of the
cerebral cortex. We have seen that a large number of nerve fibres interconnect
b. Projection fibres that connect the cerebral cortex with other the cerebral cortex with centres in the brainstem and spinal
masses of grey matter; and vice versa. cord, and with the thalamus. Most of these fibres pass
c. Commissural fibres that interconnect identical areas in the through the interval between the thalamus and caudate
two hemispheres. nucleus medially, and the lentiform nucleus laterally. This
region is called the internal capsule. Superiorly, the internal
Association Fibres
capsule is continuous with the corona radiata; and, below,
These may be short and may connect adjoining gyri.
with the crus cerebri (of the midbrain). The internal capsule
Alternatively, they may be long and may connect distant parts
may be divided into the following parts (Fig. 48.22).
of the cerebral cortex. Many of the association fibres form
1. The anterior limb lies between the caudate nucleus
bundles that can be seen by gross dissection. Some association
medially, and the anterior part of the lentiform nucleus
fibres pass through commissures to connect dissimilar areas in
laterally.
the two cerebral hemispheres.
2. The posterior limb lies between the thalamus medially,
Projection Fibres and the posterior part of the lentiform nucleus on the lateral
These fibres connect the cerebral cortex to centres in the side.
brainstem and spinal cord, in both directions. Fibres to the cortex 3. In transverse sections through the cerebral hemisphere
are often referred to as corticopetal fibres, while those going the anterior and posterior limbs of the internal capsule are
away from the cortex are referred to as corticofugal fibres. seen to meet at an angle open outwards. This angle is called
Fibres connecting the cortex with the thalamus, the the genu (genu = bend).
Fig. 48.22. Scheme to show the subdivisions of the internal capsule.
457
458
(4) Some fibres of the internal capsule lie behind the posterior The fibres of the corpus callosum interconnect the
end of the lentiform nucleus. They constitute its retrolentiform corresponding regions of almost all parts of the cerebral
part. cortex of the two hemispheres. The fibres of the genu run
(5) Some other fibres pass below the lentiform nucleus (and forwards into the frontal lobes, the fibres of the two sides
not medial to it). These fibres constitute the sublentiform part forming a fork-like structure called the forceps minor. Many
of the internal capsule. fibres of the splenium run backwards into the occipital lobe
to form a similar structure called the forceps major. (Each
half of the forceps major bulges into the posterior horn of
the corresponding lateral ventricle, forming the bulb of the
Corpus Callosum
posterior horn). The fibres of the trunk of the corpus
callosum (and some from the splenium) run laterally and as
The corpus callosum is made up of a large mass of nerve fibres
they do so they intersect the fibres of the corona radiata.
that connect the two cerebral hemispheres (Fig. 48.17). It is
Some fibres of the trunk and of the splenium, of the corpus
subdivided into a central part or trunk, an anterior end that is
callosum form a flattened band called the tapetum. The
bent on itself to form the genu, and an enlarged posterior end
tapetum is closely related to the posterior and inferior horns
called the splenium. A thin lamina of nerve fibres connects
of the lateral ventricle.
the genu to the upper end of the lamina terminalis. These fibres
As mentioned above all fibres passing through the corpus
form the rostrum of the corpus callosum. The corpus callosum
callosum are not strictly commissural. Some fibres that
is intimately related to the lateral ventricles. Its undersurface
interconnect dissimilar areas in the two hemispheres are
gives attachment to the septum pellucidum (Figs. 48.17).
really association fibres.
49 : Tracts of Spinal Cord and Brainstem

Cerebellar Connections
TRACTS OF SPINAL CORD AND BRAINSTEM
A collection of nerve fibres within the central nervous system, DESCENDING TRACTS ENDING
that connects two masses of grey matter, is called a tract. A IN THE SPINAL CORD
tract may be defined as a collection of nerve fibres having the
same origin, course, and termination. Tracts may be ascending
or descending. They are usually named after the masses of Corticospinal tract
grey matter connected by them. Thus, a tract beginning in the
cerebral cortex and descending to the spinal cord is called the The corticospinal tract is made up, predominantly, of axons
corticospinal tract, while a tract ascending from the spinal of cells lying in the motor area of the cerebral cortex (area
cord to the thalamus is called the spinothalamic tract. Tracts 4). Some fibres also arise from the premotor area (area 6)
are sometimes referred to as fasciculi or lemnisci. The major and some from the somatosensory area (areas 3, 2, 1) (Fig.
tracts passing through the spinal cord and brainstem are shown 49.3). From this origin fibres pass through the corona radiata
schematically in Figure 49.2. The position of the tracts in a to enter the internal capsule where they lie in the posterior
transverse section of the spinal cord is shown in Figure 49.1. limb. After passing through the internal capsule the fibres
enter the crus cerebri (of the midbrain): they occupy the
middle two-thirds of the crus. The fibres then descend
through the ventral part of the pons to enter the pyramids in
the upper part of the medulla. Near the lower end of the
medulla about 80 per cent of the fibres cross to the opposite
side. (The crossing fibres of the two sides constitute the
decussation of the pyramids.)
Fig. 49.1. Transverse section through spinal cord showing position of tracts in it.
The fibres that have crossed in the medulla enter the lateral leads to paralysis, but the nature of the paralysis is distinctive
funiculus of the spinal cord and descend as the lateral in each case.
corticospinal tract (Fig. 49.1). The fibres of this tract terminate
Rubrospinal tract
in grey matter at various levels of the spinal cord.
This tract is made up of axons of neurons lying in the red
The corticospinal fibres that do not cross in the pyramidal
nucleus (that lies in the upper part of the midbrain). The
decussation enter the anterior funiculus of the spinal cord to
fibres of the tract cross to the opposite side in the lower part
form the anterior corticospinal tract. On reaching the
of the tegmentum of the midbrain. The crossing fibres
appropriate level of the spinal cord the fibres of this tract cross
constitute the ventral tegmental decussation. The tract
the middle line to reach grey matter on the opposite side of the
descends through the pons and medulla to enter the lateral
cord. In this way the corticospinal fibres of both the lateral and
funiculus of the spinal cord (Fig. 49.1). The fibres of the
anterior tracts ultimately connect the cerebral cortex of one
tract end by synapsing with ventral column neurons through
side with neurons in the ventral grey column in the opposite
internuncial neurons located in spinal grey matter.
half of the spinal cord.
The cerebral cortex controls voluntary movement through this Tectospinal tract
tract. Interruption of the tract anywhere in its course leads to The fibres of this tract arise from neurons in the superior
paralysis of the muscles concerned. As the fibres are closely colliculus (midbrain). The fibres cross to the opposite side
packed in their course through the internal capsule and in the upper part of the tegmentum of the midbrain. The
brainstem small lesions here can cause widespread paralysis. crossing fibres form the dorsal tegmental decussation. The
The neurons that give origin to the fibres of the corticospinal tract descends through the pons and medulla into the anterior
tracts are often referred to as upper motor neurons in distinction funiculus of the spinal cord. The fibres terminate by
to the ventral column neurons and their processes that constitute synapsing with ventral column neurons in cervical segments
the lower motor neurons. Interruption of either of these neurons of the cord.
459
460
Olivospinal tract
This tract arises the inferior olivary
nucleus (medulla) and terminates
in the spinal cord.
Reticulospinal tracts
Fibres arising in the reticular
formation of the brainstem
descend to end in the grey matter
of the spinal cord. The medial
reticulospinal tract begins in the
reticular formation of the pons.
Most of its fibres are uncrossed.
The lateral reticulospinal tract
begins in the reticular formation
of the medulla. It contains both
crossed and uncrossed fibres.
Significance of
Descending tracts
The various descending tracts

described above, that end in
relation to ventral column
neurons, influence their activity,
and thereby have an effect on
contraction and tone of skeletal
muscle. Although a small number
of the fibres of these tracts may
synapse directly with ventral
column neurons, most of them
influence these cells through
intervening internuncial neurons.
The corticospinal tracts are often
referred to as pyramidal tracts.
Traditionally all other descending
tracts have been collectively
referred to as extrapyramidal
tracts.
DESCENDING
Fig. 49.2. Scheme to show the various tracts passing through the brainstem. SC =
TRACTS ENDING IN
superior colliculus; RN = red nucleus; VN = vestibular nuclei; OL = inferior olivary THE BRAINSTEM
nucleus. RFP = reticular formation of pons. RFM = reticular formation of medulla;
IC = inferior collicus; SO = superior olivary nucleus.
Corticonuclear tracts
The nuclei of cranial nerves that
Vestibulospinal tract supply skeletal muscle (i.e.
The neurons of origin of the vestibulospinal tract lie in the somatic efferent and special visceral efferent nuclei) are
lateral vestibular nucleus. This tract is uncrossed and lies in functionally equivalent to ventral column neurons of the
the anterior funiculus of the spinal cord. Its fibres end in relation spinal cord. They are under cortical control through fibres
to neurons in the ventral grey column. This tract is an important that are closely related in their origin and course to
efferent path for equilibrium. corticospinal fibres. At various levels of the brainstem these
fibres cross to the opposite side to end by synapsing with
cells in cranial nerve nuclei, either directly or through
interneurons (Fig. 49.3).
Fig. 49. 3. Scheme of the corticospinal tracts.
Cortico-ponto-cerebellar pathway fibres occupy the medial one sixth of the crus; and the
temporopontine fibres (along with occipitopontine and
Fibres arising in the cerebral cortex of the frontal, temporal, parieto-pontine fibres) occupy the lateral one sixth of the
parietal and occipital lobes descend through the corona radiata crus. These fibres enter the ventral part of the pons to end in
and internal capsule to reach the crus cerebri. The frontopontine pontine nuclei of the same side.
461
462
Fig. 49. 4. Scheme of the posterior column medial lemniscus pathway.
ASCENDING TRACTS
Introductory Remarks
Axons of neurons in the pontine nuclei form the transverse The ascending tracts of the spinal cord and brainstem
fibres of the pons. These fibres cross the middle line and pass represent one stage of multineuron pathways by which
into the middle cerebellar peduncle of the opposite side. The afferent impulses arising in various parts of the body are
fibres of this peduncle reach the cerebellar cortex. conveyed to different parts of the brain. The first order
The cortico-ponto-cerebellar pathway forms the anatomical neurons of these pathways are usually located in spinal
basis for control of cerebellar activity by the cerebral cortex. (dorsal nerve root) ganglia. The neurons in these ganglia
are unipolar (really pseudounipolar). Each neuron gives off a (as internal arcuate fibres) to cross the middle line. The
peripheral process and a central process. The peripheral crossing fibres of the two sides constitute the sensory
processes of the neurons form the afferent fibres of peripheral decussation. Having crossed the middle line, the fibres
nerves. They end in relation to sensory end organs (receptors) turn upwards to form a prominent bundle called the medial
situated in various tissues. The central processes of these lemniscus (Fig. 49.4). The medial lemniscus runs upwards
neurons enter the spinal cord through the dorsal nerve roots. through the medulla, pons and midbrain to end in the
Having entered the cord the central processes, as a rule, thalamus (ventral posterolateral nucleus). Note the position
terminate by synapsing with cells in spinal grey matter. Some of the medial lemniscus at different levels of the brainstem
of them may run upwards in the white matter of the cord to in Figure 49.4.
form ascending tracts (Fig. 49.4). The majority of ascending c. Third order sensory neurons located in the thalamus
tracts are, however, formed by axons of cells in spinal grey give off axons that pass through the internal capsule and
matter. These are second order sensory neurons (Fig. 49.6). In the corona radiata to reach the somatosensory areas of the
the case of pathways that convey sensory information to the cerebral cortex.
cerebral cortex the second order neurons end by synapsing with The pathway described above carries:
neurons in the thalamus. Third order sensory neurons located 1. Some components of the sense of touch. These include
in the thalamus carry the sensations to the cerebral cortex. deep touch and pressure, the ability to localise exactly the
The following additional points may now be noted. part touched (tactile localisation), the ability to recognise
1. The axons of the second orders neurons may enter white as separate two points on the skin that are touched
matter on the same side, forming an uncrossed tract; or on the simultaneously (tactile discrimination), and the ability to
opposite side, forming a crossed tract. recognise the shape of an object held in the hand
2. In the case of the head (and other parts supplied by cranial (stereognosis).
nerves) the first order neurons are located in sensory ganglia 2. Proprioceptive impulses that convey the sense of
situated on the cranial nerves. (In some of these ganglia viz. position and of movement of different parts of the body.
cochlear and vestibular, the neurons are bipolar, not unipolar 3. The sense of vibration.
as in most ganglia). The central processes of these neurons end
in relation to afferent nuclei of cranial nerves. The neurons in
these nuclei constitute second order sensory neurons.
Spinothalamic Pathway
3. Only those afferent impulses, which reach the cerebral cortex,
are consciously perceived. One exception to this may be
a. The first order neurons of this pathway are located in
perception of some degree of pain in the thalamus. Afferent
spinal ganglia. The central processes of these neurons enter
impulses ending in the cerebellum or in the brainstem influence
the spinal cord and terminate in relation to spinal grey
the activities of these centres.
matter. They may ascend in the dorsolateral tract (situated
near the tip of the dorsal grey column, figure 49.1) for one
or more segments before ending in spinal grey matter.
ASCENDING PATHWAYS CONNECTING THE b. The second order neurons of this pathway are located
SPINAL CORD TO THE CEREBRAL CORTEX in the spinal grey matter,
The axons of these neurons constitute the anterior and
lateral spinothalamic tracts. They cross to the opposite side
The Posterior Column Medial Lemniscus
of the spinal cord in the white commissure. This crossing
Pathway
is oblique. The fibres for the lateral spinothalamic tract
cross within the same segment of the cord, while those of
Fasciculus gracilis and fasciculus cuneatus: the anterior spinothalamic tract may ascend for one or more
These tracts occupy the posterior funiculus of the spinal cord segments before they cross to the opposite side.
and are, therefore, often referred to as the posterior column The fibres for the anterior spinothalamic tract enter the
tracts (Fig. 49.1). They are unique in being formed anterior funiculus (Fig. 49.5) and ascend to the medulla.
predominantly by central processes of neurons located in dorsal This tract merges with the medial lemniscus and travels in
nerve root ganglia, i.e. by first order sensory neurons (Fig. the lemniscus to the thalamus (ventral posterolateral
49.4). The fibres of these fasciculi extend upwards as far as the nucleus).
lower part of the medulla. Here the fibres of the gracile and The fibres for the lateral spinothalamic tract enter the lateral
cuneate fasciculi terminate by synapsing with neurons in the funiculus. They ascend through the medulla, pons and
nucleus gracilis and nucleus cuneatus respectively. midbrain (where this tract is often referred to as the spinal
lemniscus) to end in the thalamus (ventral posterolateral
Medial Lemniscus
nucleus).
The neurons of the gracile and cuneate nuclei are second order
sensory neurons. Their axons run forwards and medially
463
464
Fig. 49.5. Scheme to illustrate the main features of the spinothalamic tracts.
ASCENDING PATHWAYS ENDING

IN THE BRAINSTEM
The spinotectal tract connects the spinal

grey matter to the superior colliculus. It is a
crossed tract. It carries impulses that regulate
reflex movements of the head and eyes in
response to stimulation of some parts of the
body. According to some authorities the tract
may also carry sensations of pain and
temperature.
The spino-olivary tract is also a crossed
tract. It is believed to carry proprioceptive
impulses to accessory olivary nuclei.
SPINOCEREBELLAR PATHWAYS
These pathways carry proprioceptive

impulses arising in muscle, to the
cerebellum.
a. The first order neurons of these pathways
are located in dorsal nerve root ganglia. Their
Fig. 49.6. Scheme to illustrate the main features of peripheral processes end in relation to
spinocerebellar pathways. muscle spindles, Golgi tendon organs and
other proprioceptive receptors. The central
processes of the neurons concerned ascend
in the posterior funiculi for varying distances
before ending in spinal grey matter. Some
of them ascend all the way to the medulla and end in the become incorporated in the inferior cerebellar peduncle and
accessory cuneate nucleus. pass through it to reach the cerebellum (Fig. 49.6).
b. The second order neurons of the pathway are arranged in a 2. The fibres of the ventral (anterior) spinocerebellar tract
number of groups. are predominantly crossed. They ascend in the lateral
1. Neurons located in the dorsal nucleus (situated on the medial funiculus, anterior to the fibres of the dorsal spinocerebellar
side of the base of the dorsal grey column in segments C8 to L3 tract (Fig. 49.1), and pass through the medulla and pons. At
of the spinal cord) give origin to fibres of the dorsal (posterior) the upper end of the pons the fibres turn downwards to enter
spinocerebellar tract. This is an uncrossed tract lying in the the superior cerebellar peduncle through which they reach
lateral funiculus. It ascends to the medulla where its fibres the cerebellum (Fig. 49.6).
CONNECTIONS OF THE CEREBELLUM
The fundamental points to be appreciated in considering the CEREBELLAR PEDUNCLES

connections of the cerebellum are that, as a rule (Fig. 49.7):
a. afferent fibres terminate in the cortex;
b. efferent fibres arising in the cortex end in cerebellar nuclei; The various fibres entering or leaving the cerebellum pass
and through the superior, middle and inferior cerebellar
c. fibres arising in the nuclei project to centres outside the peduncles. These connect the cerebellum to the midbrain,
cerebellum. the pons and the medulla respectively. The main fibres
There are, however, important exceptions to these rules. composing each peduncle are enumerated below.
Superior Cerebellar Peduncle
A. Fibres entering the cerebellum
Afferent fibres entering the cerebellum 1. Ventral spinocerebellar tract.
The cerebellum receives direct afferents from the spinal cord B. Fibres leaving the cerebellum
and from various centres in the brainstem. The main afferents 1. Cerebello-rubral fibres.
are (Fig. 49.8): 2. Cerebello-thalamic fibres.
1. Spinocerebellar (through the various tracts described 3. Cerebello-reticular fibres.
above). These terminate predominantly in the paleocerebellum. Middle Cerebellar Peduncle
2. Pontocerebellar. These are part of the cortico-ponto- This is made up of ponto-cerebellar fibres.
cerebellar pathway. They end predominantly in the
neocerebellum. Inferior Cerebellar Peduncle
3. Olivocerebellar. These end mainly in the neocerebellum and A. Fibres entering the cerebellum
partly in the paleo-cerebellum. 1. Posterior spino-cerebellar tract.
4. Vestibulocerebellar, from the vestibular nuclei, and also
direct fibres of the vestibular nerve.
5. Reticulocerebellar fibres from the reticular formation of the
pons and of the medulla.
Efferent fibres leaving the cerebellum
The main efferents of the cerebellum are (Fig. 49.8):

1. Cerebello-rubral, to the red nucleus of the opposite side.
2. Cerebello-thalamic, to the thalamus of the opposite side.
3. Cerebello-vestibular, to the vestibular nuclei.
4. Cerebello-reticular, to the reticular formation.
Some fibres from the cerebellum are also believed to reach the
inferior olivary nucleus, the nucleus of the oculomotor nerve, Fig. 49.7. Scheme to show the fundamental
and the tectum. arrangement of cerebellar afferents and efferents.
465
466

the connections of the
cerebellum as a whole.
2. Cuneo-cerebellar tract (posterior external arcuate fibres). FUNCTIONS OF THE CEREBELLUM

3. Olivo-cerebellar fibres from inferior olivary nucleus.
4. Reticulo-cerebellar fibres. The cerebellum plays an essential role in the control of
5. Vestibulo-cerebellar fibres. movement. It is responsible for ensuring that movement takes
6. Parolivo-cerebellar fibres from accessory olivary nuclei. place smoothly, in the right direction, and to the right extent.
7. Anterior external arcuate fibres from arcuate nuclei. It is responsible for maintaining the equilibrium of the body.
B. Fibres leaving the cerebellum These functions are possible because the cerebellum receives
1. Cerebello-olivary fibres constant information regarding the state of contraction of
2. Cerebello-vestibular fibres. muscles, and of the position of various joints. It also receives
3. Cerebello-reticular fibres (from fastigial nucleus). information from the eyes, the ears, the vestibular apparatus,
4. Some cerebello-spinal and cerebello-nuclear fibres are also the reticular formation and the cerebral cortex. All this
present. information is integrated, and is used to influence movement
through motor centres in the brainstem and spinal cord, and
also through the cerebral cortex.
INTERNAL STRUCTURE OF BRAINSTEM
50 : Internal Structure of Brainstem
A brief outline of the internal structure of the brainstem has structure of the brainstem as seen in transverse sections at
been given in Chapter 48. (This chapter should be revised various level.
before proceeding further). We will now consider the internal
THE MEDULLA
1. A section through the medulla at the level of the pyramidal be seen at this level (in the anterolateral part of the medulla,
decussation is shown in Figure 50.1. Some features to be seen Figure 50.1, right half) are the rubrospinal tract, the
at this level have been reviewed in Chapter 48. The pyramids vestibulospinal tract, the olivospinal tract and the tectospinal
and their decussation, the nucleus gracilis, the nucleus cuneatus, tract. The tectospinal tract is incorporated within the medial
the spinal nucleus of the trigeminal nerve, the central grey longitudinal fasciculus. Among descending tracts we may
matter, the central canal, and the uppermost part of the ventral also include the spinal tract of the trigeminal nerve, which
grey column have been identified. forms a layer of fibres superficial to the spinal nucleus of
The main descending fibres to be seen at this level are the this nerve.
corticospinal fibres that form the pyramids. After crossing the The ascending tracts to be seen at this level include the
midline these fibres turn downwards in the region lateral to the fasciculus gracilis and fasciculus cuneatus that occupy the
central grey matter to form the lateral corticospinal tract. We areas behind the corresponding nuclei; and the
have already seen that those fibres of the pyramids that do not spinothalamic, spinocerebellar, spinotectal and spino-olivary
cross descend into the ventral funiculus of the spinal cord to tracts that occupy the anterolateral region.
form the ventral corticospinal tract. Other descending tracts to
Fig. 50.1. Transverse section through medulla at the level of the pyramidal decussation.
467
468
2. A section through the medulla at the level of the sensory just lateral to the middle line. The dorsal vagal nucleus lies
decussation is shown in Figure 50.2. Some features of a section dorsolateral to the hypoglossal nucleus. The nucleus of the
at this level have already been seen (Chapter 48). The central solitary tract is seen dorsal to the central canal near the middle
canal surrounded by central grey matter, the medial lemniscus, line. The lower ends of these nuclei of the two sides become
the pyramids, the nucleus gracilis, the nucleus cuneatus, the continuous with each other to form the commissural nucleus
spinal nucleus of the trigeminal nerve, and the reticular of the vagus. The nucleus ambiguus lies in the reticular
formation have been identified. formation medial to the spinal nucleus of the trigeminal
The nucleus gracilis and the nucleus cuneatus are much larger nerve.
than at lower levels. Internal arcuate fibres arising in these Other masses of grey matter that may be recognised at this
nuclei arch forwards and medially around the central grey level are:
matter to cross the middle line. Having crossed the middle a. the lowest part of the inferior olivary nucleus ;
line these fibres turn cranially to constitute the medial b. the medial accessory olivary nucleus that lies dorsal to
lemniscus. As the fibres from the nucleus gracilis and the the medial part of the inferior olivary nucleus (see below);
nucleus cuneatus pass forwards they intercross so that the fibres c. the lateral reticular nucleus lying in the lateral part of the
from the nucleus gracilis come to lie ventral to those from the reticular formation ; and
nucleus cuneatus. The most medial fibres (from the legs) come d. arcuate nuclei lying over the anterior aspect of the
to lie most anteriorly in the medial lemniscus. These are pyramids.
followed by fibres from the trunk and from the upper limb, in The gracile and cuneate fasciculi are much smaller than at
that order. Higher up in the brainstem the medial lemniscus lower levels as the fibres of these tracts progressively
changes its orientation, its long axis (as seen in cross section) terminate in the gracile and cuneate nuclei. Other ascending
becoming transverse (Fig. 50.5). The most anterior fibres tracts to be seen at this level are the spinothalamic,
become lateral, and the posterior fibres become medial. In its spinocerebellar, spinotectal and spino-olivary tracts all of
course through the medulla the medial lemniscus is probably which lie in the anterolateral region (Fig 50.2, left half).
joined by the anterior spinothalamic tract. The descending tracts present are (Fig. 50.2, right half) the
A number of cranial nerve nuclei can be identified at this level. pyramids, the rubro-spinal, vestibulospinal and olivospinal
Several of these are present in relation to the central grey matter. tracts, and the medial longitudinal fasciculus that includes
The hypoglossal nucleus is located ventral to the central canal the tectospinal tract.
Fig. 50.2. Transverse section through medulla at the level of the sensory decussation.
3. A section through the medulla at the level of the olive is and arcuate nuclei that occupy the same relative positions
shown in Figure 50.3. Some features of a transverse section at as at lower levels. The pontobulbar body lies on the
this level have been introduced in Chapter 48. The floor of the dorsolateral aspect of the inferior cerebellar peduncle (Fig.
fourth ventricle lined by grey matter, the reticular formation, 50.3, right).
the spinal nucleus and tract of the trigeminal nerve, the inferior The descending tracts to be seen at this level (Fig. 50.3,
cerebellar peduncle, the inferior olivary nucleus, the medial right half) are the pyramids, the tectospinal, vestibulospinal,
lemniscus and the pyramids have been briefly considered. and rubro-spinal tracts; and the spinal tract of the trigeminal
Several cranial nerve nuclei can be recognized in relation to nerve.
the floor of the fourth ventricle. From medial to lateral side The ascending tracts are the medial lemniscus forming an
these are the hypoglossal nucleus, the dorsal vagal nucleus, anteroposterior L-shaped band lying next to the middle line,
and the vestibular nuclei. The solitary tract and its nucleus lie the spinothalamic, spinocerebellar and spinotectal tracts. At
ventrolateral to the dorsal vagal nucleus. The nucleus ambiguus this level the dorsal spinocerebellar tract lies within the
lies much more ventrally within the reticular formation. inferior cerebellar peduncle. The ventral spinocerebellar tract
The dorsal and ventral cochlear nuclei can be seen in relation lies more anteriorly near the surface of the medulla. The
to the inferior cerebellar peduncle. spinothalamic tracts lie dorsolateral to the inferior olivary
Other masses of grey matter present are the medial and dorsal nucleus. The medial longitudinal fasciculus lies dorsal to
accessory olivary nuclei (lying medial and dorsal, respectively, the medial lemniscus.
to the inferior olivary nucleus), and the lateral reticular nucleus
Fig. 50.3. Transverse section through medulla at the level of the olive
469
470
THE PONS
Transverse sections through the upper and lower parts of the lower part of the pons, and by the superior cerebellar
pons are illustrated in Figures 50.4 and 50.5. Some features peduncle in the upper part. The region adjoining the ventral
common to both these levels have been already considered in part is occupied by important ascending tracts. The medial
Chapter 48. The subdivision of the pons into dorsal and ventral lemniscus occupies a transversely elongated oval area next
parts and its relationship to the superior, middle and inferior to the middle line. Lateral to this are the trigeminal lemniscus
cerebellar peduncles have been noted. We have seen that the and the spinal lemniscus (lateral spinothalamic tract). The
ventral part of the pons contains: (a) the pontine nuclei, (b) fibres of the spinotectal tract run along with the spinal
vertically running corticospinal and corticopontine fibres, and lemniscus, while those of the ventral spinothalamic tract lie
(c) transversely running fibres arising in the pontine nuclei within the medial lemniscus. Still more laterally, there is the
and projecting to the opposite half of the cerebellum through lateral lemniscus. Ventral to these lemnisci there are
the middle cerebellar peduncle. conspicuous transversely running fibres that form the
The pontine nuclei (or nuclei pontis) receive corticopontine trapezoid body. The ventral spinocerebellar tract lies
fibres from the frontal, temporal, parietal and occipital lobes ventromedial to the inferior cerebellar peduncle in the lower
of the cerebrum. Their efferents form the transverse fibres of part of the pons (Fig. 50.4). In the upper part of the pons it is
the pons. We have seen that most of these fibres cross to the seen within the superior cerebellar peduncle (Fig. 50.5).
opposite side, but some may end ipsilaterally. Descending tracts passing through the dorsal part of the
The dorsal part of the pons is occupied, predominantly, by the pons are the tectospinal tract and the rubrospinal tract. The
reticular formation. Its posterior surface helps to form the floor medial longitudinal fasciculus lies dorsally near the middle
of the fourth ventricle. This surface is lined by grey matter and line.
is related to some cranial nerve nuclei. The dorsal part is We will now consider those features of the pons that are
bounded laterally by the inferior cerebellar peduncle in the different in the upper and lower parts.
Fig. 50.4. Transverse section through lower part of pons.

Fig. 50.5. Transverse section through lower part of pons.
A section through the lower part of the pons (Fig. 50.4) shows medulla (Figs 50.3 and 50.4). Other masses of grey matter to
two cranial nerve nuclei that are closely related to the floor of be seen in the lower part of the pons are the superior olivary
the fourth ventricle. These are the abducent nucleus lying complex (made up of several nuclei) that lies dorsomedial
medially and the vestibular nuclei that lie laterally. At a deeper to the lateral lemniscus, and the nuclei of the trapezoid body
level in the lateral part of the reticular formation two additional that consist of scattered cells lying within this body.
nuclei are seen. These are the spinal nucleus of the trigeminal A section through the upper part of the pons (Fig. 50.5) shows
nerve (along with its tract) lying laterally, and the facial nucleus that the dorsal part is bounded laterally by the superior
lying medially. The dorsal and ventral cochlear nuclei lie dorsal cerebellar peduncles. Medial to the peduncle there is the
and ventral, respectively, to the inferior cerebellar peduncle. main sensory nucleus of the trigeminal nerve, and further
The fibres arising from the facial nucleus loop round the medially there is the motor nucleus of the same nerve. The
abducent nucleus and together form a surface elevation, the superior olivary nucleus extends to this level, but is less
facial colliculus, in the floor of the fourth ventricle. prominent; while the lateral lemniscus forms a more
The vestibular nuclei occupy the vestibular area in the lateral conspicuous bundle. Some fibres of the trapezoid body can
part of the floor of the fourth ventricle. These nuclei are to be be seen ventral to the medial lemniscus.
seen in the lower part of the pons and in the upper part of the
THE MIDBRAIN
Some features of the internal structure of the midbrain have level of the superior colliculus in Figure 50.7. We will first
been considered in Chapter 48. The subdivision of the midbrain consider those features that are common to both these levels.
into the tectum, the tegmentum, the substantia nigra, and the The crus cerebri (or basis pedunculi) consists of fibres
crus cerebri (or basis pedunculi) has been noted. The superior descending from the cerebral cortex. Its medial one-sixth is
and inferior colliculi, the red nucleus and the reticular formation occupied by corticopontine fibres descending from the
have been identified. frontal lobe; and the lateral one-sixth is occupied by similar
A transverse section through the midbrain at the level of the fibres from the temporal, occipital and parietal lobes. The
inferior colliculus is shown in Figure 50.6 and a section at the intermediate two-thirds of the crus cerebri are occupied by
471
472
Fig. 50.6. Transverse section through lower part of midbrain.

Fig. 50.7. Transverse section through upper part of midbain.

corticospinal and corticonuclear fibres. The fibres for the leg together forming a single complex. The Edinger-Westphal
are most lateral and those for the head are most medial. nucleus (that supplies the sphincter pupillae and ciliaris
The substantia nigra lies immediately behind and medial to muscle) forms part of the oculomotor complex. The
the basis pedunculi. It appears dark in unstained sections as oculomotor complex is related ventrally to the medial
neurons within it contain pigment (neuromelanin). longitudinal fasciculus. Closely related to the cranial part
The midbrain is traversed by the cerebral aqueduct that is of the superior colliculus there is a small collection of
surrounded by central grey matter. Ventrally, the central grey neurons that constitute the pretectal nucleus. This nucleus
matter is related to cranial nerve nuclei (oculomotor and is concerned with the pathway for the pupillary light reflex.
trochlear). The region between the substantia nigra and the The bundle of ascending fibres consisting of the medial
central grey matter is occupied by the reticular formation. lemniscus, the trigeminal lemniscus and the spinal lemniscus
A section through the midbrain at the level of the inferior lies more dorsally than at lower levels (because of the
colliculus shows the following additional features (Fig. 50.6). presence of the red nucleus). The lateral lemniscus is not
The inferior colliculus is a large mass of grey matter lying in seen at this level as its fibres end in the inferior colliculus.
the tectum. It forms a cell station in the auditory pathway and However, the inferior brachium that conveys auditory fibres
is probably concerned with reflexes involving auditory stimuli. to the medial geniculate body can be seen near the surface
The trochlear nucleus lies in the ventral part of the central of the tegmentum.
grey matter. Fibres arising in this nucleus follow an unusual The middle line region of the tegmentum shows two groups
course. They run dorsally and decussate (in the superior of decussating fibres. The dorsal tegmental decussation
medullary velum) before emerging on the dorsal aspect of the consists of fibres that have their origin in the superior
brainstem. The mesencephalic nucleus of the trigeminal nerve colliculus and cross to the opposite side to descend as the
lies in the lateral part of the central grey matter. tectospinal tract. The ventral tegmental decussation consists
A compact bundle of fibres is seen in the tegmentum of fibres that originate in the red nucleus and decussate to
dorsomedial to the substantia nigra. It consists of the medial form the rubrospinal tracts.
lemniscus, the trigeminal lemniscus and the spinal lemniscus
in that order from medial to lateral side. The medial lemniscus
includes fibres of the ventral spinothalamic tract while the spinal
lemniscus (made up mainly of the lateral spinothalamic tract)
RETICULAR FORMATION OF THE BRAINSTEM
includes fibres of the spinotectal tract. More dorsally, the lateral
lemniscus forms a bundle ventrolateral to the inferior colliculus
The term reticular formation was originally used to designate
(in which most of its fibres end). Important fibre bundles are
areas of the central nervous system that were not occupied
also located near the middle line of the tegmentum. The medial
by well defined nuclei or fibre bundles, but consisted of a
longitudinal fasciculus lies ventral to the trochlear nucleus; and
network of fibres within which scattered neurons were
ventral to the fasciculus there is the tectospinal tract. The region
situated. Such areas are to be found at all levels in the nervous
ventral to the tectospinal tracts is occupied by decussating fibres
system. In the spinal cord there is an intermingling of grey
of the superior cerebellar peduncle. These fibres have their
and white matter on the lateral side of the neck of the dorsal
origin in the dentate nucleus of the cerebellum. They cross the
grey column. This area is sometimes referred to as the
middle line in the lower part of the tegmentum. Some of these
reticular formation of the spinal cord. The reticular formation
fibres end in the red nucleus while others ascend to the thalamus.
is, however, best defined in the brainstem where it is now
The region of the tegmentum ventral to the decussation of the
recognized as an area of considerable importance.
superior cerebellar peduncle is occupied by the rubrospinal
The reticular formation extends throughout the length of
tracts.
the brainstem. In the medulla it occupies the region dorsal
A section through the upper part of the midbrain (Fig. 50.7)
to the inferior olivary nucleus. In the pons it lies in the dorsal
shows two large masses of grey matter not seen at lower levels.
part, while in the midbrain it lies in the tegmentum.
These are the superior colliculus in the tectum, and the red
nucleus in the tegmentum. The superior colliculus is a centre Functions of the Reticular Formation
concerned with visual reflexes. The red nucleus (so called Because of its diverse connections the reticular formation
because of a reddish colour in fresh material) lies in the anterior is believed to have a controlling or modifying influence on
part of the tegmentum dorsomedial to the substantia nigra. many functions. These include somatomotor control,
The oculomotor nucleus lies in relation to the ventral part of somatosensory control, visceral control, and neuroendocrine
the central grey matter. The nuclei of the two sides lie close control.
473
474
51 : Diencephalon, Basal Ganglia,

Olfactory Region and Limbic System
THE DIENCEPHALON
The diencephalon consists of the thalamus, the hypothalamus, surface is separated from the hypothalamus by the
the epithalamus, the subthalamus, and the metathalamus. The hypothalamic sulcus. This sulcus runs from the
third ventricle may be regarded as the cavity of the interventricular foramen to the aqueduct. The lateral surface
diencephalon. of the thalamus is related to the internal capsule that separates

it from the lentiform nucleus (Fig. 51.1). The superior (or
dorsal) surface of the thalamus is related laterally to the
caudate nucleus from which it is separated by a bundle of
fibres called the stria terminalis, and by the thalamostriate
THE THALAMUS
vein. The thalamus and the caudate nucleus together form
the floor of the central part of the lateral ventricle. The medial
The thalamus is a large mass of grey matter that lies part of the superior surface of the thalamus is, however,
immediately lateral to the third ventricle. It has two ends (or separated from the ventricle by the fornix, and by a fold of
poles), anterior and posterior; and four surfaces, superior, pia mater called the tela choroidea. At the junction of the
inferior, medial and lateral. medial and superior surfaces of the thalamus the ependyma
The anterior end (or pole) lies just behind the interventricular of the third ventricle is reflected from the lateral wall to the
foramen. The posterior end (or pole) is called the pulvinar. It roof. The line of reflection is marked by a line called the
lies just above and lateral to the superior colliculus. The medial taenia thalami. Underlying it there is a narrow bundle of
surface forms the greater part of the lateral wall of the third fibres called the stria medullaris thalami (not to be confused
ventricle, and is lined by ependyma. The medial surfaces of with the stria medullares present in the floor of the fourth
the two thalami are usually interconnected by a mass of grey ventricle). The inferior surface of the thalamus is related to
matter called the interthalamic connexus. Inferiorly, the medial the hypothalamus anteriorly, and to the subthalamus
Fig. 51.1. Coronal section through the cerebrum to show structures related to the thalamus.
DIENCEPHALON, BASAL GANGLIA, OLFACTORY REGION, LIMBIC SYSTEM
Afferent impulses from a large
number of subcortical
centres converge on the
thalamus. As mentioned
above, exteroceptive and
proprioceptive impulses
ascend to it through the
medial lemniscus, the
spinothalamic tracts, and the
trigeminothalamic tract. Visual
and auditory impulses reach
the lateral and medial
geniculate bodies respec-
tively. Sensations of taste are
conveyed to the thalamus
through solitariothalamic
fibres. Visceral information is
conveyed from the
hypothalamus, and probably
through the reticular
formation. In addition to
Fig. 51.2. Scheme to show the nuclei of the thalamus. A. Superior aspect. these afferents, the thalamus
B. Coronal section. receives profuse
connections from all parts of
the cerebral cortex, the
posteriorly. The subthalamus separates the thalamus from the cerebellum, and the corpus striatum. The thalamus is,
tegmentum of the midbrain. therefore, regarded as a great integrating centre where
information from all these sources is brought together. This
information is projected to almost the whole of the cerebral
cortex through profuse thalamocortical projections. These
Internal Structure of the Thalamus
thalamocortical fibres form large bundles that are described
as thalamic radiations or as thalamic peduncles. These
The thalamus consists mainly of grey matter. Its superior surface
radiations are anterior (or frontal), superior (or dorsal),
is covered by a thin layer of white matter called the stratum
posterior (or caudal), and ventral.
zonale; and its lateral surface by a similar layer called the
external medullary lamina.
The grey matter of the thalamus is subdivided into three main
parts by a Y-shaped sheet of white matter that is called the
internal medullary lamina (Fig. 51.2). This lamina is placed THE HYPOTHALAMUS
vertically. It divides the thalamus into a lateral part, a medial
part, and an anterior part situated between the two limbs of the
The hypothalamus is a part of the diencephalon. As its name
Y.
implies it lies below the thalamus. On the medial side, it
A number of nuclei can be distinguished within each of these
forms the wall of the third ventricle below the level of the
parts. These are shown in Figure 51.2.
hypothalamic sulcus. Laterally, it is in contact with the
internal capsule. Posteriorly, the hypothalamus merges with
Connections of the Thalamus the subthalamus, and through it with the tegmentum of the
midbrain. Inferiorly, the hypothalamus is related to structures
The most important nucleus of the thalamus is the ventral in the floor of the third ventricle. These are the tuber
posterior nucleus that receives the terminations of the major cinereum, the infundibulum, and the mamillary bodies, that
sensory pathways ascending from the spinal cord and brainstem. are considered as parts of the hypothalamus.
These include the medial lemniscus, the spinothalamic tracts,
the trigeminal lemniscus and the solitariothalamic fibres
carrying sensations of taste. All these sensations are carried to
Subdivisions of the Hypothalamus
the sensory areas of the cerebral cortex (areas 3,2,1) by fibres
passing through the posterior limb of the internal capsule
For convenience of description the hypothalamus may be
(superior thalamic radiation).
subdivided, roughly, into a number of regions (Fig. 51.3).
475
476
Some authorities divide it (from medial to lateral side) into three of the neurohypophysis. This phenomenon is called
zones that are as follows. neurosecretion.
a. Periventricular zone. The cells of the infundibular nucleus are believed to produce
b. Intermediate zone. releasing factors that travel along their axons and are
c. Lateral zone. released into the capillaries. These capillaries carry these
The periventricular and intermediate zones are often described factors into the pars anterior of the hypophysis cerebri
collectively as the medial zone. through the hypothalamo-hypophyseal portal system. In the
The hypothalamus is also subdivided anteroposteriorly into pars anterior these factors are responsible for release of
four regions. These are as follows. appropriate hormones.
a. The preoptic region adjoins the lamina terminalis.
Functions of the Hypothalamus
b. The supraoptic region lies above the optic chiasma.
The hypothalamus plays an important role in the control of
c. The tuberal (or infundibulotuberal) region includes the
many functions that are vital for the survival of an animal.
infundibulum, the tuber cinereum and the region above it.
d. The mamillary region consists of the mamillary body and (1) Regulation of eating and drinking behaviour
the region above it. The hypothalamus is responsible for feelings of hunger and
The zones and regions named above contain several nuclei of satiety, and this determines whether the animal will accept
that are shown in figure 51.3. or refuse food.
Some Connections of the Hypothalamus (2) Regulation of sexual activity and reproduction
The hypothalamus is concerned with visceral function and is, The hypothalamus controls sexual activity, both in the male
therefore, connected to other areas having a similar function. and female. It also exerts an effect on gametogenesis, on
These include the various parts of the limbic system, the ovarian and uterine cycles, and on the development of
reticular formation, and autonomic centres in the brainstem secondary sexual characters.
and spinal cord.
(3) Control of autonomic activity
The supraoptic, paraventricular and infundibular nuclei exert
The hypothalamus exerts an important influence on the
an important influence on the hypophysis cerebri. Fibres arising
activity of the autonomic nervous system, and thus has
from the supraoptic and paraventricular nuclei reach the pars
considerable effect on cardiovascular, respiratory and
posterior (neurohypophysis) through the supraoptico-
alimentary functions.
hypophyseal and paraventriculo hypophyseal tracts. The cells
in these nuclei are peculiar in that they produce a secretion
that travels along their axons and is released into the sinusoids
(4) Emotional behaviour
The hypothalamus has an important influence on
emotions like fear, anger and pleasure.
(5) Control of endocrine activity
Through control of the adenohypophysis the
hypothalamus indirectly influences the thyroid gland,
the adrenal cortex, and the gonads.
(6) Temperature regulation
The hypothalamus acts as a thermostat to control body
temperature.
(7) Biological clock
Several functions of the body show a cyclic variation
in activity, over the twenty-four hours of a day. The
most conspicuous of these is the cycle of sleep and
waking. Such cycles (called circadian rhythms) are
believed to be controlled by the hypothalamus, which
Fig. 51.4. Diagram to show the location of the medial and lateral
is said to function as a biological clock.
geniculate bodies.
THE METATHALAMUS related structures. The pineal gland has been described in
Chapter 45.
The metathalamus is constituted by the medial and lateral

geniculate bodies. These are small oval collections of grey
matter situated below the posterior part of the thalamus, lateral
to the colliculi of the midbrain (Fig. 51.4). Each mass of grey THE SUBTHALAMIC REGION
matter is bent on itself, hence the term geniculate.
The part of the diencephalon that is called the subthalamus
lies below the posterior part of the thalamus, behind and
The Medial Geniculate Body lateral to the hypothalamus. It is also referred to as the ventral
thalamus. Inferiorly, it is continuous with the tegmentum
The medial geniculate body is a relay station on the auditory
pathway. The medial geniculate body receives fibres of the
lateral lemniscus, either directly, or after relay in the inferior
colliculus (Fig. 51.5). These fibres pass through the brachium
of the inferior colliculus. Fibres arising in the medial geniculate
body constitute the acoustic radiation. The acoustic radiation
passes through the sublentiform part of the internal capsule to
reach the acoustic areas of the cerebral cortex.
The Lateral Geniculate Body
The lateral geniculate body is a relay station on the visual

pathway. It receives fibres from the retinae of both eyes (Fig.
51.6). Efferents arising in this body constitute the optic radiation
that passes through the retrolentiform part of the internal capsule
to reach the visual areas of the cerebral cortex.
THE EPITHALAMUS
The epithalamus lies in relation to the posterior part of the roof

of the third ventricle, and in the adjoining part of its lateral Fig. 51.5. Connections of the medial geniculate body
wall. It consists of the pineal gland, the habenular nuclei, and (MGB)
477
478
of the midbrain. Laterally, it is related
to the lowest part of the internal
capsule.
Apart from some small aggregations
of neurons the grey matter of the
region consists of the subthalamic
nucleus and the zona incerta.
Fig. 51.6. Connections of the lateral geniculate body. Some additional

connections not described in the text are also shown .
THE BASAL GANGLIA
The basal ganglia (or basal nuclei) are large masses of grey nucleus together constitute the corpus striatum. This
matter situated in the cerebral hemispheres. They are derived consists of two functionally distinct parts. The caudate
from the telencephalon. The basal ganglia are as follows (Fig. nucleus and the putamen form one unit called the striatum,
51.7). while the globus pallidus forms the other unit, the pallidum.
a. Caudate nucleus.
b. Lentiform nucleus, that consists of two functionally distinct
parts, the putamen and the globus pallidus.
The Caudate Nucleus
c. Amygdaloid nuclear complex.
d. The claustrum is often included among the basal ganglia.
The caudate nucleus is a C-shaped mass of grey matter (Fig.
Various other terms commonly used for some of the above
51.7). It consists of a large head, a body and a thin tail. The
nuclei are as follows. The caudate nucleus and the lentiform
nucleus is intimately related to the lateral ventricle. The head
of the nucleus bulges into the anterior horn of the ventricle
and forms the greater part of its floor.
The body of the nucleus lies in the floor of the central part
of the ventricle; and the tail in the roof of the inferior horn.
The anterior part of the head of the caudate nucleus is fused,
inferiorly, with the lentiform nucleus. In this situation the
grey matter of these two nuclei is continuous with that of the
anterior perforated substance. The anterior end of the tail of
the caudate nucleus ends in relation to the amygdaloid
complex. The body of the caudate nucleus is related medially
to the thalamus, and laterally to the internal capsule that
separates it from the lentiform nucleus (Fig. 51.8).
The Lentiform Nucleus

Fig. 51.7. The corpus striatum viewed from
the lateral aspect. The lentiform nucleus lies lateral to the internal capsule.
Laterally, it is separated from the claustrum by fibres of the
external capsule. Superiorly, the lentiform nucleus is related to
the corona radiata, and inferiorly to the sublentiform part of the
internal capsule. Some other relationships are evident in Figure
51.1. The lentiform nucleus appears triangular (or wedge shaped)
in coronal section. It is divided, by a thin lamina of white matter,
into a lateral part, the putamen; and a medial part, the globus
pallidus. The globus pallidus is further subdivided into medial
and lateral segments.
The Amygdaloid Complex
This complex (also called the amygdaloid body, amygdala) lies
in the temporal lobe of the cerebral hemisphere, close to the
temporal pole. It lies deep to the uncus, and is related to the
anterior end of the inferior horn of the lateral ventricle.
Fig. 51.8. Relationship of the corpus striatum to the

internal capsule (viewed from the lateral side).
THE OLFACTORY REGION

AND LIMBIC SYSTEM
THE OLFACTORY REGION and medial to the temporal pole. It represents the anterior
end of the parahippocampal gyrus and is separated from
the temporal pole by the rhinal sulcus.
The peripheral end organ for smell is the olfactory mucosa
The anterior part of the parahippocampal gyrus, including
that lines the upper and posterior parts of the nasal cavity. Nerve
the uncus, is referred to as the entorhinal area (area 28).
fibres arising in this mucosa collect to form about twenty
bundles that together constitute an olfactory
nerve. The bundles pass through foramina in the
cribriform plate of the ethmoid bone to enter the
cranial cavity where they terminate in the
olfactory bulb (Fig. 51.9).
The olfactory bulb is an elongated oval structure
that lies just above the cribriform plate. It is
continuous posteriorly with the olfactory tract
through which it is connected to the base of the
cerebral hemisphere. When traced posteriorly the
olfactory tract divides into medial and lateral
olfactory striae (Fig. 51.9). The point of
bifurcation is expanded and forms the olfactory
trigone. An intermediate stria is sometimes
present.
The olfactory striae are intimately related to a
mass of grey matter called the anterior
perforated substance. The medial and lateral
striae form the anteromedial and anterolateral
boundaries of this substance.
Fig. 51.9. Some structures related to the anterior part of the
The uncus is a part of the cerebral hemisphere base of the brain.
that lies on the tentorial surface a little behind
479
480
prominent parts, including the hippocampal formation are
THE OLFACTORY PATHWAY briefly described below.
Amygdaloid Nuclear Complex
The fibres of the olfactory nerves are processes of olfactory This region is also called the amygdaloid body or amygdala.
receptor cells lying in the epithelium lining the olfactory It is situated near the temporal pole of the cerebral
mucosa. hemisphere in close relation to the anterior end of the inferior
Each receptor cell consists of a cell body and of two processes horn of the lateral ventricle. Superiorly, the complex is related
i.e. it is a bipolar cell. The peripheral process (dendrite) reaches to the anterior part of the lentiform nucleus. Posteriorly, it
the surface of the olfactory epithelium. The central process becomes continuous with the tail of the caudate nucleus and
(axon) enters the submucosa, and forms one fibre of the with the stria terminalis.
olfactory nerve. The olfactory nerve fibres terminate in the
olfactory bulb. Fibres arising in the olfactory bulb form the Stria Terminalis
olfactory tract. This bundle of fibres is closely related to the inferior horn
The fibres of the olfactory tract pass through the lateral and central part of the lateral ventricle. It begins in the
olfactory stria to terminate in the anterior perforated substance amygdaloid complex and runs backwards in the roof of the
and in some neighbouring areas that collectively constitute the inferior horn. It then winds upwards and forwards to lie in
primary olfactory cortex. Fibres arising in the primary cortex the floor of the central part of the ventricle. Finally, it
project to the entorhinal area. The entorhinal area is, therefore, terminates near the interventricular foramen and anterior
called the secondary olfactory cortex. The sense of smell is commissure by dividing into various smaller bundles.
believed to be perceived in both the primary and secondary Throughout its course, it is closely related to the medial side
olfactory cortex. of the caudate nucleus (Fig. 51.1). In the inferior horn it is
related to the tail of this nucleus. In the central part of the
ventricle it lies medial to the body of the caudate nucleus.
Here the thalamus is medial to it.
THE LIMBIC SYSTEM Anterior Commissure
The anterior commissure is situated in the anterior wall of
the third ventricle at the upper end of the lamina terminalis.
The term limbic system is applied to certain regions of the When traced laterally, it divides into anterior and posterior
brain that are believed to play an important role in the control bundles. Fibres passing through the commissure interconnect
of visceral activity. Many of these areas have, in the past, been the regions of the two cerebral hemispheres concerned with
considered to have a predominantly olfactory function; but it the olfactory pathway.
is now realised that this is not so. Many parts included in the
limbic system are difficult to identify. Some relatively
Hippocampal Formation
In the human embryo, the hippocampal

formation develops in relation to the
medial surface of each cerebral
hemisphere close to the choroid fissure
of the lateral ventricle. It is at first
approximately C-shaped in accordance
with the outline of the body and inferior
horn of the ventricle. The upper part of
the formation is, however, separated from
the ventricle because of the development
of the corpus callosum between the two.
For the same reason, this part of the
formation remains underdeveloped and is
represented by a thin layer of grey matter
lining the upper surface of the corpus
callosum. This layer is the indusium
griseum. Within the indusium griseum are
embedded two bundles of longitudinally
running fibres called the medial and
Fig. 51.10. The hippocampal formation and related structures. lateral longitudinal striae (on each side
of the middle line). Posteriorly, the
indusium griseum is continuous with a thin layer of grey matter The Fornix
related to the inferior aspect of the splenium of the corpus The fornix is a prominent bundle of fibres seen on the medial
callosum. This grey matter is the splenial gyrus or gyrus aspect of the cerebral hemisphere. It is made up,
faciolaris. The splenial gyrus runs forwards to become predominantly, of fibres arising in the hippocampus. The
continuous with the dentate gyrus present in relation to the body of the fornix is suspended from the corpus callosum
inferior horn of the lateral ventricle. by the septum pellucidum (Fig. 51.1) and comes into close
In the region of the inferior horn of the lateral ventricle, the relationship with the tela choroidea in the roof of the third
developing hippocampus is pushed into the cavity of the ventricle. When traced posteriorly, the body of the fornix
ventricle because of the great development of the neighbouring
divides into two parts called crura. Each crus of the fornix
neocortex. The hippocampal formation is best developed in
becomes continuous with the fimbria of the corresponding
this region and forms the hippocampus: this term includes the
side. The two crura are interconnected by fibres passing
dentate gyrus.
from one crus to the other. These crossing fibres constitute
The hippocampus forms a longitudinal projection that occupies
the greater part of the floor of the inferior horn of the lateral the hippocampal commissure or commissure of the fornix.
ventricle. Its anterior end is expanded and notched and The anterior end of the body of the fornix also divides into
resembles a foot. It is, therefore, called the pes hippocampi. right and left halves called the columns of the fornix. Each
The ventricular surface of the hippocampus is covered by a column turns downwards just in front of the interventricular
layer of nerve fibres that constitute the alveus. The fibres of foramen and passes through the hypothalamus to reach the
the alveus pass medially and collect to form a bundle of fibres, mamillary body.
the fimbria, that projects above the medial part of the
hippocampus. The fimbria runs backwards along the medial
Main Connections of the Limbic System
side of the hippocampus to become continuous with the fornix
The main inputs into the limbic system are olfactory (from
(see below).
primary olfactory areas); visceral through fibres ascending
The dentate gyrus is a longitudinal strip of grey matter. Laterally,
it is fused with the hippocampus. Its medial margin is free, and from the brainstem and terminating in the hypothalamus,
bears a series of notches that give it a dentate appearance (Fig. the septal region and the amygdaloid complex; and probably
51.10): hence the name dentate gyrus. When traced anteriorly somatic through interconnections between the thalamus and
the dentate gyrus runs medially across the inferior surface of the hypothalamus. The limbic system may possibly be
the uncus. This part is called the tail of the dentate gyrus. As influenced by afferents from some areas of the neocortex.
stated above the posterior end of the dentate gyrus is continuous The output from the limbic system is concentrated upon the
with the splenial gyrus (gyrus faciolaris) (Fig. 51.10). Because midbrain reticular formation. These inputs reaching the
of its close relationship to the dentate gyrus the uncus is midbrain reticular formation are relayed to autonomic centres
sometimes regarded as part of the hippocampal formation. in the brainstem and spinal cord.
481
482
52 : Internal Capsule, Commissures,

Pathways for Special Senses
INTERNAL CAPSULE AND COMMISSURES
THE INTERNAL CAPSULE lie in the retrolentiform part of the internal capsule. The
retrolentiform part also contains some fibres passing from
the thalamus to the posterior part of the parietal lobe.

The fibres passing through the internal capsule may be Fibres from the thalamus to the temporal lobe constitute the
ascending (to the cerebral cortex) or descending (from the inferior thalamic radiation (or ventral thalamic peduncle).
cortex). The arrangement of fibres is easily remembered if it
It includes the acoustic radiation from the medial geniculate
is realised that any group of fibres within the capsule takes the
body to the acoustic area of the cerebral cortex. These fibres
most direct path to its destination. Thus fibres to and from the
pass through the sublentiform part of the internal capsule.
anterior part of the frontal lobe pass through the anterior limb
of the internal capsule. Those to and from the posterior part of
the frontal lobe, and from the greater part of the parietal lobe,
occupy the genu and posterior limb of the capsule. Fibres to Descending Fibres
and from the temporal lobe occupy the sublentiform part, while
those to and from the occipital lobe pass through the
(1) Corticospinal and corticonuclear fibres
retrolentiform part. Some fibres from the lowest parts of the
parietal lobe accompany the temporal fibres through the Corticonuclear fibres (for motor cranial nerve nuclei) pass
sublentiform part. through the genu of the internal capsule (Fig. 52.1).
Corticospinal fibres form several discrete bundles in the
posterior limb. The fibres for the upper limb are most anterior,
followed (in that order) by fibres for the trunk and lower
Ascending Fibres limb.
These are predominantly thalamocortical fibres that go from (2) Corticopontine fibres
the thalamus to all parts of the cerebral cortex (Fig. 52.1). Frontopontine fibres are the most numerous. They pass
Fibres to the frontal lobe constitute the anterior thalamic through the anterior limb, genu, and posterior limb of the
radiation (or frontal thalamic peduncle). They pass through internal capsule.
the anterior limb of the internal capsule. The anterior thalamic Parietopontine fibres pass mainly through the retrolentiform
radiation also carries fibres from the hypothalamus and limbic part. Some fibres pass through the sublentiform part.
structures to the frontal lobe. Temporopontine fibres pass through the sublentiform part.
Fibres travelling from the ventral posterior nuclei of the Occipitopontine fibres pass through the retrolentiform part.
thalamus to the somatosensory area (in the postcentral gyrus)
(3) Corticothalamic fibres
constitute the superior thalamic radiation (or the superior, or
These pass from various parts of the cerebral cortex to the
dorsal, thalamic peduncle). These fibres occupy the genu and
thalamus. They form part of the thalamic radiations described
posterior limb of the capsule. It should be noted that these
above.
fibres are third order sensory neurons responsible for conveying
somesthetic sensations to the cerebral cortex. The superior (4) Fibres from Cerebral Cortex to Brainstem nuclei
thalamic radiation also contains some fibres that go from the a. Corticonuclear fibres to cranial nerve nuclei have been
thalamus to parts of the frontal and parietal lobes adjoining mentioned above.
the postcentral gyrus. b. Corticorubral fibres pass through the posterior limb.
Fibres from the thalamus to the occipital lobe constitute the c. Corticoreticular fibres pass through the genu and
posterior thalamic radiation (or the posterior, or caudal, posterior limb.
thalamic peduncle). This includes the optic radiation from d. Occipitotectal fibres pass through the retrolentiform part.
the lateral geniculate body to the visual cortex. These radiations
INTERNAL CAPSULE, COMMISSURES, PATHWAYS FOR SPECIAL SENSES
Fig. 52.1. Scheme to show the fibres passing through the internal capsule.
COMMISSURES OF THE BRAIN

such fibres form recognisable bundles that are called
The two halves of the brain and spinal cord are interconnected commissures. Strictly speaking commissural fibres are those
by numerous fibres that cross the middle line. In some situations that connect corresponding regions of the two sides. Many
of the fibres passing through the so-called commissures do
483
484
not fulfil this criterion as they connect different regions of the The Corpus Callosum
two sides. Such fibres are really association fibres. We have The corpus callosum is the largest commissure connecting
seen that several tracts passing through the spinal cord and the right and left cerebral hemispheres. The fibres passing
brainstem cross from one side to the other. These crossings through the corpus callosum are generally believed to
are decussations, but collections of such fibres are sometimes interconnect corresponding regions of the entire neocortex
loosely referred to as commissures, e.g. the ventral white of the right and left sides.
commissure of the spinal cord.
PATHWAYS FOR SPECIAL SENSES

Other Commissures
Other commissures connecting the two cerebral hemispheres The Visual Field and Retinal Quadrants
are the anterior commissure, the posterior commissure, the When the head and eyes are maintained in a fixed position,
hippocampal commissure or commissure of the fornix and the and one eye is closed, the area seen by that eye constitutes
habenular commissure. the visual field for that eye. Now if the other eye is also
In this section we will consider the pathways responsible for opened the area seen is more or less the same as was seen
perception of the special senses of vision, smell, taste, and with one eye. In other words the visual fields of the two
hearing. eyes overlap to a very great extent. On either side, however,
there is a small area seen only by the eye of that side.
Although the two eyes view the same area, the relative
position of objects within the area appears somewhat
VISUAL PATHWAY dissimilar to the two eyes as they view the object from slightly
different angles. The difference though slight, is of
The peripheral organ for sight is the eyeball. We have
seen that receptors for vision are the rods and cones
located in the retina. Rods and cones are modified
neurons. They give off central processes that synapse
with peripheral processes of bipolar cells. The central
processes of bipolar cells synapse with the dendrites
of ganglion cells. Axons arising from ganglion cells
form the fibres of the optic nerve.
Opposite the posterior pole of the eyeball the retina
shows a central region about 6 mm in diameter. This
region is responsible for sharp vision. In the centre of
this region an area about 2 mm in diameter has a
yellow colour and is called the macula lutea. The
fovea centralis is a depression in the centre of the
macula and is 0.4 mm in diameter.
Visual impulses arising in the retina are carried to the
brain through the optic nerve. The optic nerves enter
the cranial cavity through the optic canal and join each
other to form the optic chiasma (Fig. 52.2). Many
fibres of each optic nerve cross to the opposite side
through the chiasma. The uncrossed fibres, along with
those that have crossed over from the opposite side,
form the optic tract. The optic tract terminates
predominantly in the lateral geniculate body. Fresh Fig. 52.2. The optic pathway. Note that the fibres from the
fibres arising in the lateral geniculate body form the medial (or nasal) half of each retina cross to the optic tract of the
opposite side.
geniculocalcarine tract (or optic radiation) that ends
in the visual areas of the cerebral cortex.
Fig. 52.3. Scheme to show the representation of the visual field in the retinae, the
lateral geniculate bodies, and the visual cortex of the two sides. The retinal quadrants
for the peripheral parts of the field of vision are represented in light colour, while the
corresponding macular areas are represented in dark colour.
considerable importance as it forms the basis for the perception vision are formed on the retina by the lens of the eyeball. As
of depth (stereoscopic vision). with any convex lens the image is inverted. If an object is
For convenience of description, the visual field is divided into placed in the right half of the field of vision its image is
right and left halves. It may also be divided into upper and formed on the left half of the retina and vice versa. The two
lower halves so that the visual field can be said to consist of halves of the retina are usually referred to as nasal (= medial)
four quadrants (Fig. 52.3). In a similar manner each retina can and temporal (= lateral) halves. The image of an object
also be divided into quadrants. Images of objects in the field of placed in the right half of the field of vision falls on the
485
486

the pathway for hearing.
temporal half of the left retina, and on the nasal half of the right retina is represented medially. Specific points on the retina
retina. project to specific points in the lateral geniculate body. In
Optic Nerve, Optic Chiasma and Optic Tract turn, specific points of this body project to specific points
The optic nerve is made up of axons of the ganglion cells of in the visual cortex. In this way a point to point relationship
the retina. The fibres of the optic nerve arising in the nasal is maintained between the retinae and the visual cortex.
half of each retina enter the optic tract of the opposite side Geniculocalcarine Tract and Visual Cortex
after crossing in the chiasma. Fibres from the temporal half of Fibres arising from cells of the lateral geniculate body
each retina enter the optic tract of the same side (Fig. 52.2). constitute the geniculocalcarine tract or optic radiation.
Thus the right optic tract comes to contain fibres from the right These fibres pass through the retrolentiform part of the
halves of both retinae, and the left tract from the left halves. In internal capsule. The optic radiation ends in the visual areas
other words, all optic nerve fibres carrying impulses relating of the cerebral cortex (areas 17, 18, 19).
to the left half of the field of vision are brought together in the The cortex of each hemisphere receives impulses from the
right optic tract and vice versa. Each optic tract carries these retinal halves of the same side (i.e. from the opposite half of
fibres to the lateral geniculate body of the corresponding side. the field of vision). The upper quadrants of the retina are
The Lateral Geniculate Body represented above the calcarine sulcus, and the lower
The macular fibres end in the central and posterior part of the quadrants below it (Fig. 52.3). The cortical area for the macula
lateral geniculate body, and this area is relatively large (Fig. is larger than that for peripheral areas. It occupies the
52.3). Fibres from the peripheral parts of the retina end in the posterior part of the visual area. The cortical area for the
anterior part of the lateral geniculate body. The upper half of peripheral part of the retina is situated anterior to the area
the retina is represented laterally, and the lower half of the for the macula.
PATHWAY FOR SMELL The fibres of the lateral lemniscus ascend to the midbrain
and terminate in the inferior colliculus (Fig. 52.4). Fibres
arising in the colliculus enter the inferior brachium to reach
The peripheral organ for smell is the olfactory mucosa, and the
the medial geniculate body. Fibres arising in the medial
cranial nerve concerned is the olfactory nerve. A description of
geniculate body form the acoustic radiation that ends in
olfactory pathways is given in Chapter 51.
the acoustic area of the cerebral cortex. It may be stressed
that each lateral lemniscus carries impulses arising in both
the right and left cochleae.
PATHWAY FOR HEARING
Sound waves travelling through air enter the external acoustic

meatus and produce vibrations in the tympanic membrane. PATHWAYS FOR TASTE
These vibrations are transmitted through the chain of ossicles
present in the middle ear to reach the internal ear. Pressure
The end organs for taste are taste buds located mainly on
waves set up in the perilymph reach the spiral organ (of Corti)
the tongue. They are most numerous in relation to vallate
present in intimate relationship to the cochlea. Hair cells present
papillae. Some taste buds are present in the mucosa of the
in the spiral organ convert these vibrations into nervous
soft palate, and of the epiglottis. Sensations of taste arising
impulses.
in the taste buds travel through a number of different
The first neurons of the pathway of hearing are located in the
pathways as follows.
spiral ganglion located in a bony tunnel running along the
1. Sensations of taste from the anterior two-thirds of the
cochlea. These neurons are bipolar. Peripheral processes of
tongue (the part of the tongue lying anterior to the sulcus
neurons lying in this ganglion innervate the hair cells of the
terminalis, but excluding the vallate papillae) travel through
spiral organ. The central processes of the neurons form the
the lingual nerve, the chorda tympani and the facial nerve.
cochlear nerve. The fibres of the cochlear nerve terminate in
2. Sensations of taste from the posterior one-third of the
the dorsal and ventral cochlear nuclei. The neurons in these
tongue (part of the tongue posterior to the sulcus terminalis,
nuclei are, therefore, second order neurons. Their axons pass
and including the vallate papillae) are carried by the
medially in the dorsal part of the pons. Most of them cross to
glossopharyngeal nerve.
the opposite side, but some remain uncrossed. The crossing
3. Taste fibres from the posteriormost part of the tongue
fibres of the two sides form a conspicuous mass of fibres called
(just in front of the epiglottis), and from taste buds on the
the trapezoid body.
epiglottis, are carried by the superior laryngeal branch of
The large majority of fibres from the cochlear nuclei terminate
the vagus nerve.
in the superior olivary complex (made up of a number of nuclei).
On entering the brainstem all fibres of taste (travelling
Third order neurons arising in this complex form an important
through the facial, glosso-pharyngeal and vagus nerves) end
ascending bundle called the lateral lemniscus (Fig. 52.4). Some
in the upper part of the nucleus of the tractus solitarius. New
cochlear fibres that do not relay in the superior olivary nucleus
fibres arising in this nucleus travel to the thalamus through
join the lemniscus after relaying in scattered cells lying within
the solitario-thalamic tract. The fibres reach the ventral
the trapezoid body: these cells constitute the trapezoid nucleus
posteromedial nucleus of the thalamus. From here they are
(nucleus of the trapezoid body). Still other cochlear fibres relay
relayed to the cerebral cortex (areas 3, 2, 1).
in cells that lie within the lemniscus itself: these neurons form
the nucleus of the lateral lemniscus.
487
488
53: The Ventricles of the Brain

and Cerebrospinal Fluid
The interior of the brain contains a series of cavities (Fig. 53.1).

The cerebrum contains a median cavity, the third ventricle;
and two lateral ventricles, one in each hemisphere. Each lateral
ventricle opens into the third ventricle through an
interventricular foramen. The third ventricle is continuous,
caudally, with the cerebral aqueduct that traverses the midbrain
and opens into the fourth ventricle. The fourth ventricle is
situated dorsal to the pons and medulla, and ventral to the

cerebellum. It communicates, inferiorly, with the central canal
that traverses the lower part of the medulla and the spinal cord.
The entire ventricular system is lined by an epithelial layer
called the ependyma.
THE LATERAL VENTRICLES Fig. 53.1. The ventricular system of the brain.
Lateral view.
The lateral ventricles are two cavities, one situated within each
cerebral hemisphere. Each ventricle consists of a central part thalamus. The tela choroidea is common to the two lateral
that gives off three extensions called the anterior, posterior ventricles, and to the third ventricle. Within each lateral edge
and inferior horns (Fig. 53.1). of the tela choroidea there are plexuses of blood vessels that
The Central Part constitute the choroid plexus (Fig. 53.2). The tela choroidea
The central part of the lateral ventricle is elongated and other structures forming the walls of the ventricle are
anteroposteriorly. Anteriorly, it becomes continuous with the lined by ependyma.
anterior horn, at the level of the interventricular foramen.
Posteriorly, the central part reaches the
splenium of the corpus callosum. The central
part is triangular in cross section (Fig. 53.2).
It has a roof, a floor, and a medial wall. The
roof and floor meet on the lateral side.
The roof is formed by the trunk of the corpus
callosum. The medial wall is formed by the
septum pellucidum and by the body of the
fornix. It is common to the two lateral
ventricles. The floor is formed mainly by the
superior surface of the thalamus (medially),
and by the caudate nucleus (laterally).
Between these two structures there are the
stria terminalis (laterally) and the
thalamostriate vein (medially).
From Figure 53.2 it will be seen that there is a
space between the fornix and the upper
surface of the thalamus. This is the choroid
fissure. A fold of pia mater, the tela Fig. 53.2. Boundaries of the central part of the lateral ventricle and of the
choroidea, invaginates into the ventricle third ventricle. Note the relationship of the tela choroidea and choroid
through the fissure and covers part of the plexuses to these ventricles.
VENTRICLES OF BRAIN AND CEREBROSPINAL FLUID
wall, and a medial wall (Fig. 53.4). The roof and lateral wall
are formed by the tapetum. The medial wall shows two
elevations. The upper of these is the bulb of the posterior
horn, which is produced by fibres of the forceps major as
they run backwards from the splenium of the corpus
callosum. The lower elevation is called the calcar avis. It
represents white matter pushed in by formation of the
calcarine sulcus.
The Inferior Horn
The inferior horn of the lateral ventricle begins at the
posterior end of the central part. It runs downwards and
forwards into the temporal lobe, its anterior end reaching
Fig. 53.3. Boundaries of the anterior horn of the
close to the uncus. In considering the structures to be seen
lateral ventricle. in the walls of the inferior horn it is useful to note that the
anterior horn, the central part, and the inferior horn form
one continuous C-shaped cavity. From Figure 53.1 it will be
obvious that the floor of the central part of the ventricle is
continuous with the roof of the inferior horn. It is also useful
to recall that the body of the fornix divides, posteriorly, into
two crura that become continuous with the fimbria and
hippocampus.
In the central part of the ventricle, the choroid fissure lies
below the fornix. When traced into the inferior horn, the
fissure lies above the fimbria and hippocampus. The choroid
plexus extends into the inferior horn through the choroid
fissure.
In cross section, the inferior horn is seen to have a narrow
cavity (Fig. 53.5). The cavity is bounded above, and laterally,
by the roof; and below, and medially, by the floor. (Because
Fig. 53. 4. Boundaries of the posterior horn of the of this orientation the lateral part of the roof is sometimes
lateral ventricle. called the lateral wall, and the medial part of the floor is
called the medial wall).
The lateral part of the roof (or lateral wall) is formed by fibres
The Anterior Horn of the tapetum. The medial part of the roof is formed by the
The anterior horn of the lateral ventricle lies anterior to its tail of the caudate nucleus (laterally) and the stria terminalis
central part, the two being separated by an imaginary vertical (medially). These structures are continued into the roof of
line drawn at the level of the interventricular foramen (Fig. the inferior horn from the floor of the central part. Anteriorly,
53.1). This horn is triangular in section. It has a roof, a floor the tail of the caudate nucleus and the stria terminalis end in
and a medial wall (Fig. 53.3). It is closed, anteriorly, by the relation to the amygdaloid complex, that lies in the most
genu and rostrum of the corpus callosum. anterior part of the roof. The floor of the inferior horn is
The roof is formed by the most anterior
part of the trunk of the corpus callosum.
The floor is formed mainly by the head
of the caudate nucleus. A small part of
the floor, near the middle line, is formed
by the upper surface of the rostrum of
the corpus callosum. The medial wall
(common to the two sides) is formed by
the septum pellucidum. It may be noted
that the tela choroidea and the choroid
plexus do not extend into the anterior
horn.
The Posterior Horn
The posterior horn of the lateral
ventricle extends backwards into the Fig. 53. 5. Boundaries of the inferior horn of the lateral ventricle.
occipital lobe. It has a roof, a lateral
489
490
formed mainly by the hippocampus, along with the alveus and commissure, and by the columns of the fornix as they diverge
fimbria. In the lateral part of the floor there is an elevation, the from each other.
collateral eminence, produced by inward bulging of the white The posterior wall is formed by the pineal body and the
matter that lies deep to the collateral sulcus. posterior commissure.
The floor is formed by the optic chiasma, the tuber cinereum
and the infundibulum, the mamillary bodies, the posterior
perforated substance and the tegmentum of the midbrain.
The roof of the ventricle is formed by the ependyma that
THE THIRD VENTRICLE stretches across the two thalami (Fig. 53.2). Above the
ependyma there is the tela choroidea. Within the tela
The third ventricle is the cavity of the diencephalon. It is a choroidea there are two plexuses of blood vessels (one on
median cavity situated between the right and left thalami (Fig. either side of the middle line) that bulge downwards into the
53.2). It communicates, on either side, with the lateral ventricle cavity of the third ventricle. These are the choroid plexuses
through the interventricular foramen (Figs 53.1 and 53.6). of the third ventricle (See below).
Posteriorly, it continues into the cerebral aqueduct that connects The cavity of the third ventricle shows a number of
it to the fourth ventricle. The ventricle has two lateral walls, prolongations or recesses (Fig. 53.6). The infundibular
an anterior wall, a posterior wall, a floor and a roof. recess extends into the infundibulum. The optic recess lies
Each lateral wall is marked by the hypothalamic sulcus (Fig. just above the optic chiasma. The pineal recess lies between
53.6) that follows a curved course from the interventricular the superior and inferior laminae of the stalk of the pineal
foramen to the aqueduct. Above the sulcus, the wall is formed body. The suprapineal recess lies above the pineal body in
by the medial surface of the thalamus. The two thalami are relation to the epithalamus.
usually connected by a band of grey matter called the
interthalamic connexus, which passes through the ventricle.
The lateral wall, below the hypothalamic sulcus, is formed by
Tela Choroidea of the third and lateral ventricles
the medial surface of the hypothalamus. A small part of the
lateral wall, above and behind the thalamus, is formed by the
The tela choroidea is a double-layered fold of pia mater that
epithalamus. The interventricular foramen is seen on the lateral
occupies the interval between the splenium of the corpus
wall, just behind the column of the fornix.
callosum and fornix, above, and the two thalami below.
The anterior wall of the third ventricle is formed mainly by
the lamina terminalis. Its upper part is formed by the anterior
Fig. 53.6. Boundaries and recesses of the third ventricle. Note the mode of formation of the tela
choroidea that lies in the roof of the ventricle.
VENTRICLES OF BRAIN AND CEREBROSPINAL FLUID
It is triangular in shape. Its posterior end is
broad and lies in the gap between the
splenium (above) and the posterior part of
the roof of the third ventricle (below) (Fig.
53.6). This gap is called the transverse
fissure. The anterior end (representing the
apex of the triangle) lies near the right and
left interventricular foramina.
Choroid Plexuses
The choroid plexuses are highly vascular

structures that are responsible for the
formation of cerebrospinal fluid.
Four choroid plexuses are to be seen in
relation to the tela choroidea of the third and
lateral ventricles. Two of these (one right and
one left) lie along the corresponding lateral
margins, and project into the central part of
the corresponding lateral ventricle. Two other
plexuses run parallel to each other, one on Fig. 53.7. Mid-sagittal section through the fourth ventricle and related
either side of the middle line. These are the structures. Note how the tela choroidea is formed. The ependyma is
choroid plexuses of the third ventricle. shown in blue and the pia mater in pink.
by the upper part of the posterior surface of the medulla;

and an intermediate part at the junction of the medulla and
pons. The intermediate part is prolonged laterally over the
THE FOURTH VENTRICLE inferior cerebellar peduncle as the floor of the lateral recess.
Its surface is marked by the presence of delicate bundles of
The fourth ventricle is a space situated dorsal to the pons and transversely running fibres. These bundles are the striae
to the upper part of the medulla; and ventral to the cerebellum. medullares.
For descriptive purposes the ventricle may be considered as The entire floor is divided into right and left halves by a
having a cavity, a floor, a roof and lateral walls. median sulcus. Next to the middle line there is a longitudinal
elevation called the median eminence. The eminence is
The Cavity
The cavity of the ventricle is
continuous, inferiorly, with the central
canal; and, superiorly, with the
cerebral aqueduct. It communicates
with the subarachnoid space through
three apertures, one median and right
and left lateral (Fig. 53.7). A number
of extensions from the main cavity are
described. The largest of these are
two lateral recesses, one on either
side. Each lateral recess passes
laterally and opens into the
subarachnoid space at the lateral
aperture.
The Floor
Because of its shape, the floor of the
fourth ventricle is often called the
rhomboid fossa (Fig. 53.8). It is
divisible into an upper triangular part
formed by the posterior surface of the Fig. 53.8. Structures in the floor of the fourth ventricle.
pons; a lower triangular part formed
491
492
bounded laterally by the sulcus limitans. The region lateral to ventricle communicates with the subarachnoid space in the
the sulcus limitans is the vestibular area that overlies the region of the cerebello- medullary cistern. In the region of
vestibular nuclei. The vestibular area lies partly in the pons the lateral recess, the membrane is prolonged laterally and
and partly in the medulla. helps to form the wall of the recess.
The pontine part of the floor shows some features of interest The choroid plexuses of the fourth ventricle are similar in
in close relation to the sulcus limitans and the median eminence. structure to those of the lateral and third ventricles. They lie
The uppermost part of the sulcus limitans overlies an area that within the folds of pia mater that form the tela choroidea.
is bluish in colour and is called the locus coeruleus. (Deep to Each plexus (right or left) consists of a vertical limb lying
the locus coeruleus there is the nucleus coeruleus that extends next to the midline, and a horizontal limb extending into the
upwards into the tegmentum of the midbrain. It is regarded as lateral recess.
part of the reticular formation). Somewhat lower down, the
sulcus limitans is marked by a depression, the superior fovea.
At this level the median eminence shows a swelling, the facial
colliculus.
THE CEREBROSPINAL FLUID
The medullary part of the floor also shows some features of
interest in relation to the median eminence and the sulcus
limitans. The sulcus limitans is marked by a depression, the The cerebrospinal fluid (CSF) fills the subarachnoid space.
inferior fovea. Descending from the fovea, there is a sulcus It also extends into the ventricles of the brain, and into the
that runs obliquely towards the middle line. This sulcus divides central canal of the spinal cord. The CSF provides a fluid
the median eminence into two triangles. These are the cushion that protects the brain from injury. It probably also
hypoglossal triangle, medially; and the vagal triangle, helps to carry nutrition to the brain, and to remove waste
laterally. Between the vagal triangle (above) and the gracile products.
tubercle (below), there is a small area called the area postrema. CSF is formed by the choroid plexuses of the ventricles. The
Finally mention must be made of two terms often used in fluid formed in each lateral ventricle flows into the third
relation to the medulla. The lowest part of the floor of the ventricle through the interventricular foramen. From the third
fourth ventricle is called the calamus scriptorius, because of ventricle it passes through the aqueduct into the fourth
its resemblance to a nib. Each inferolateral margin of the ventricle. Here it passes through the median and lateral
ventricle is marked by a narrow white ridge or taenia. The apertures in the roof of this ventricle to enter the part of the
right and left taeniae meet at the inferior angle of the floor to subarachnoid space that forms the cerebello-medullary
form a small fold called the obex. The term obex is often used cistern. From here the fluid enters other parts of the
to denote the inferior angle itself. subarachnoid space. In passing from the posterior cranial
The Lateral Walls fossa into the upper (supratentorial) part of the cranial cavity
The upper part of each lateral wall is formed by the superior the CSF traverses the narrow interval between the free margin
cerebellar peduncle. The lower part is formed by the inferior of the tentorium cerebelli and the brainstem. It leaves the
cerebellar peduncle, and by the gracile and cuneate tubercles. subarachnoid space by entering the venous sinuses through
arachnoid villi.
The Roof Samples of CSF are often required for help in clinical
The roof of the fourth ventricle is tent-shaped and can be diagnosis. They are obtained most easily by lumbar
divided into upper and lower parts that meet at an apex (Fig. puncture. In this procedure a needle is introduced into the
53.7). The apex extends into the white core of the cerebellum. subarachnoid space through the interval between the third
The upper part of the roof is formed by the superior cerebellar and fourth lumbar vertebrae.
peduncles and the superior medullary velum. The inferior part
of the roof is devoid of nervous tissue in most of its extent. It
is formed by a membrane consisting of ependyma and a double Ventriculography
fold of pia mater that constitutes the tela choroidea of the The ventricles of the brain can be studied in living subjects
fourth ventricle. Laterally, on each side, this membrane reaches by taking radiographs after injecting a radio-opaque dye into
and fuses with the inferior cerebellar peduncles. The lower the ventricular system. The procedure is called
part of the membrane has a large aperture in it. This is the ventriculography. Parts of the ventricles can also be seen
median aperture of the fourth ventricle through which the using CT scans and magnetic resonance imaging.
BLOOD SUPPLY OF THE BRAIN
54 : Blood Supply of the Brain
The nervous system is richly supplied with blood.

Interruption of blood supply even for a short period can
result in damage to nervous tissue. It is interesting to note
that lymphatic vessels are not present in nervous tissue.
ARTERIES THAT SUPPLY THE BRAIN
The arteries that supply the brain are derived from the
internal carotid and vertebral arteries.
Internal carotid artery (Cerebral part)
After reaching the skull the internal carotid artery follows

a complicated course through the carotid canal, the
foramen lacerum, and the cavernous sinus. Finally, it
pierces the dura mater forming the roof of the cavernous
sinus, medial to the anterior clinoid process, and comes
into relationship with the brain. The artery turns
backwards to reach the anterior perforated substance of
the brain, and terminates here by dividing into the anterior
cerebral and middle cerebral arteries. Other branches
given off by the internal carotid artery in the intracranial
part of its course are shown in Figure 41.5. Two of these
branches may be noted. These are the anterior choroidal
artery, and the posterior communicating artery that take
part in supply of the brain. These branches are described
briefly below. Further details will be mentioned when we
take up the blood supply of different parts of the brain.
Anterior cerebral artery
We have seen that the anterior cerebral artery arises from
the internal carotid artery below the anterior perforated
substance, lateral to the optic chiasma (Figs 54.1 and 54.2).
From here it runs forwards and medially crossing above
the optic chiasma to reach the median longitudinal fissure.
Here the arteries of the two sides lie close together and
are united to each other by the anterior communicating
artery. The anterior cerebral artery now turns sharply to
reach the medial surface of the cerebral hemisphere. Here
it runs upwards to reach the genu of the corpus callosum
(Fig. 54.1B). It winds round the front of the genu and
Fig. 54.1. A. Initial parts of the anterior and middle cerebral
then runs backwards just above the body of the corpus
arteries (seen from below). B. Course of anterior cerebral
callosum, ending near its posterior part. The distribution artery (medial view). C. Course of middle cerebral artery
of the artery is considered below, along with that of the (lateral view).
middle cerebral and posterior cerebral arteries.
The anterior cerebral artery gives off a recurrent branch
(also called the artery of Heubner). This branch runs
493
494
Fig. 54.2. The circulus arteriosus and related structures.
backwards and laterally to enter the anterior perforated joining the posterior cerebral artery, thus helping to form an
substance (Fig. 54.2). arterial circle in relation to the base of the brain (See below).
It gives off some central branches that enter the cerebral
Middle cerebral artery
hemisphere and supply part of the thalamus.
After its origin from the internal carotid artery (just below the
anterior perforated substance), the middle cerebral artery runs
laterally on the inferior aspect of the cerebral hemisphere lying Anterior choroidal artery
deep within the stem of the lateral sulcus (Fig. 54.1A). Reaching This artery arises from the internal carotid artery near the
the superolateral surface of the hemisphere it runs backwards termination of the latter. It runs backwards in relation to the
deep within the posterior ramus of the lateral sulcus (Fig. uncus and the optic tract (Fig. 54.2). It ends in the choroid
54.1C). Along its course the artery gives off several branches plexus in the inferior horn of the lateral ventricle. This artery
to the brain. Their distribution is considered below along with also gives off branches to several parts of the brain including
that of the anterior and posterior cerebral arteries. the internal capsule.
Posterior communicating Artery Vertebral arteries

This artery arises from the internal carotid artery just before The vertebral artery is a branch of the subclavian artery. It
the termination of the latter (Fig. 54.2). The artery runs ascends up the neck passing through foramina transversaria
backwards crossing inferior to the optic tract, and ends by of the upper six cervical vertebrae, passes through the
suboccipital region and enters the upper part of the vertebral
canal. It then passes upwards to enter the cranial cavity
through the foramen magnum, and comes to lie lateral to the
lower part of the medulla oblongata. Continuing its ascent it
gradually passes forwards and medially over the medulla
and ends at the lower border of the pons by anastomosing
with the opposite vertebral artery to form the basilar artery
(Fig. 54.3).
The vertebral artery gives off several branches along its
course. The branches that take part in supplying the brain
are as follows.
1. Anterior and posterior spinal arteries
They are meant for supply of the spinal cord, but they also
give some branches to the medulla (Fig. 54.10).
Fig. 54.3. Arteries supplying the cerebellum.
Fig. 54.5. Course and distribution of the posterior
cerebral artery.
Fig. 54.4. Branches of the basilar artery. Some
branches of the vertebral artery are also shown.
Anterior inferior cerebellar artery
2. Posterior inferior cerebellar artery
This artery arises from the basilar artery near its lower end.
This is the largest branch of the vertebral artery. It first runs It runs backwards and laterally to reach the anterior part of
backwards in relation to the lateral aspect of the medulla, and the inferior surface of the cerebellum which it supplies (Fig.
then ramifies into branches over the posterior part of the inferior 54.3).
surface of the cerebellum (Fig. 54.3). Other branches of basilar artery
The basilar artery The basilar artery gives off some small pontine branches to
The basilar artery is formed by the union of the right and left the pons (Fig. 54.4). It also gives off the labyrinthine artery
vertebral arteries at the lower border of the pons. It ascends in that accompanies the facial nerve into the internal acoustic
the middle line, ventral to the pons, and ends at its upper border meatus to reach the internal ear.
by dividing into the right and left posterior cerebral arteries.
The branches of the basilar artery are as follows (Fig. 54.4). Circulus arteriosus
From figure 54.2 we see that some of the arteries supplying
Posterior cerebral artery the brain form an arterial circle that is present in relation to
The posterior cerebral artery is a terminal branch of the basilar the base of the brain (in the region of the interpeduncular
artery. It passes backwards winding round the midbrain to reach fossa). The anterior part of the circle is formed by the right
the tentorial surface of the cerebral hemisphere (Fig. 54.5). Near and left anterior cerebral arteries, and the anterior
its origin it is joined by the posterior communicating branch of
communicating artery that unites them. On either side the
the internal carotid artery. The posterior cerebral artery gives
ring is formed by the internal carotid artery and its posterior
off cortical and central branches to the cerebral hemisphere.
They are considered below along with those of the anterior and communicating branch. Posteriorly, the ring is completed
middle cerebral arteries. by the bifurcation of the basilar artery into the right and left
The posterior choroidal artery is a branch of the posterior posterior cerebral arteries. We have already noted that the
cerebral artery (Fig. 54.2). It supplies the choroid plexuses of posterior communicating artery joins the posterior cerebral
the lateral and third ventricles. It also supplies the lateral artery to complete the ring.
geniculate body. At this stage it may be noted that because of anastomoses
between the major arteries supplying the brain, blood supply
Superior cerebellar artery
of the area supplied by one artery can be taken over by
This artery arises from the basilar artery just proximal to the
another artery in the event of it becoming blocked. This
termination of the latter. It winds round the midbrain to reach
the superior surface of the cerebellum which it supplies (Fig. remark applies, however, only to the main arteries, and not
54.3). to their smaller branches (see below).
495
496
ARTERIAL SUPPLY OF
THE CEREBRAL CORTEX
The anterior, middle and posterior cerebral arteries give rise

to two sets of branches, cortical and central. The cortical
branches ramify on the surface of the cerebral hemispheres
and supply the cortex. The central branches supply structures
lying deep within the hemisphere.
Superolateral surface
The greater part of the superolateral surface of the cerebral
hemisphere is supplied by the middle cerebral artery (Fig.
54.6). The areas not supplied by this artery are as follows.
a. A strip half to one inch wide along the superomedial border
extending from the frontal pole to the parieto-occipital sulcus

is supplied by the anterior cerebral artery.
Fig. 54.8. Arteries supplying the orbital and tentorial

surfaces of the cerebral hemisphere.
b. The area belonging to the occipital lobe is supplied by the

posterior cerebral artery.
c. The inferior temporal gyrus (excluding the part adjoining
the temporal pole) is also supplied by the posterior cerebral
artery.
Medial surface
Fig. 54.6. Distribution of the anterior, posterior and
The main artery supplying the medial surface is the anterior
middle cerebral arteries on the superolateral surface of the
cerebral (Fig. 54.7). The part of this surface belonging to
cerebral hemisphere.
the occipital lobe is supplied by the posterior cerebral artery.
Inferior surface
The lateral part of the orbital surface is supplied by the
middle cerebral artery, and the medial part by the anterior
cerebral artery (Fig. 54.8).
The tentorial surface is supplied by the posterior cerebral
artery. The temporal pole is, however, supplied by the middle
cerebral artery (Fig. 54.8).
Additional points of interest
From the description given above it will be clear that the
main somatic motor and sensory areas are supplied by the
middle cerebral artery except in their uppermost parts (leg
areas) that are supplied by the anterior cerebral. The acoustic
area is supplied by the middle cerebral artery, and the visual
area by the posterior cerebral.
Fig. 54.7. Arteries supplying the medial surface of the

cerebral hemisphere.
ARTERIES SUPPLYING THE INTERIOR artery. The anterior part of the inferior surface is supplied by
OF THE CEREBRAL HEMISPHERE the anterior inferior cerebellar branches of the same artery.
The posterior part of the inferior surface is supplied by the
posterior inferior cerebellar branch of the vertebral artery.
Central or perforating arteries
Structures in the interior of the cerebral hemisphere are supplied
by central (or perforating) branches that arise from arteries lying
in relation to the base of the brain. They consist of six main
VENOUS DRAINAGE OF THE BRAIN
groups: anteromedial and posteromedial (that are median and
unpaired); right and left anterolateral; and right and left
posterolateral (Fig. 54.2). The veins draining the brain open into the dural venous
The arteries of the anteromedial group arise from the anterior sinuses (Fig. 54.9). These are the superior sagittal, inferior
cerebral and anterior communicating arteries. They enter the sagittal, straight, transverse, sigmoid, cavernous,
most medial part of the anterior perforated substance. The sphenoparietal, petrosal and occipital sinuses. Ultimately,
arteries of the anterolateral group are the so called striate the blood from all these sinuses reaches the sigmoid sinus
arteries. They arise mainly from the middle cerebral artery. that becomes continuous with the internal jugular vein.
Some of them arise from the anterior cerebral artery. The The venous drainage of individual parts of the brain is as
anterolateral group of perforating arteries enter the anterior follows.
perforated substance and divide into two sets, medial and lateral.
The medial striate arteries ascend through the lentiform
Veins of the Cerebral Hemisphere
nucleus. They supply this nucleus and also the caudate nucleus
and the internal capsule. The lateral striate arteries ascend
The veins of the cerebral hemisphere consist of two sets,
lateral to the lower part of the lentiform nucleus; they then turn
superficial and deep.
medially and pass through the substance of the lentiform nucleus
to reach the internal capsule and the caudate nucleus. One of Superficial veins
these lateral striate arteries is usually larger than the others. It The superficial veins drain into neighbouring venous sinuses.
is called Charcots artery, or artery of cerebral haemorrhage. The superior cerebral veins drain the upper parts of the
The posteromedial group of central arteries arise from the superolateral and medial surfaces, and end in the superior
posterior cerebral and posterior communicating arteries. They sagittal sinus. Some veins from the medial surface join the
enter the interpeduncular region. The central branches of the inferior sagittal sinus. Inferior cerebral veins drain the lower
posterolateral group arise from the posterior cerebral artery, part of the hemisphere. On the superolateral surface, they
as it winds around the cerebral peduncle. drain into the superficial middle cerebral vein that lies
superficially along the lateral sulcus and its posterior ramus.
Arterial Supply of the Brainstem
The posterior end of this vein is connected to the superior
Medulla
The medulla is supplied by various branches of
the vertebral arteries. These are the anterior and
posterior spinal arteries, the posterior inferior
cerebellar artery, and small direct branches.
Pons
The pons is supplied by branches from the basilar
artery.
Midbrain
The midbrain is supplied mainly by branches of
the basilar artery. These are the posterior cerebral
and superior cerebellar arteries and direct branches
from the basilar artery. Branches are also received
from the posterior communicating and anterior
choroidal arteries.
Arteries Supplying the Cerebellum

Fig. 54.9. Region of roof of third ventricle and floor of central part of
The superior surface of the cerebellum is supplied lateral ventricle seen from above after removing the corpus callosum
by the superior cerebellar branches of the basilar and parts above it. The deep veins are exposed.
497
498
sagittal sinus by the superior anastomotic vein; and to the basal veins, some veins from the occipital lobes, and some
transverse sinus by the inferior anastomotic vein. The from the corpus callosum.
superficial middle cerebral vein terminates in the cavernous The deep cerebral veins described above are responsible
sinus. Veins from the inferior surface of the cerebral hemisphere for draining the thalamus, the hypothalamus, the corpus
drain into the transverse, superior petrosal, cavernous and striatum, the internal capsule, the corpus callosum, the
sphenoparietal sinuses. Some may ascend to join the inferior septum pellucidum, and the choroid plexuses.
sagittal sinus.
Deep veins
The deep veins of the cerebral hemisphere are the two internal Veins of the cerebellum and brainstem
cerebral veins, that join to form the great cerebral vein (Fig.
54.9); and the two basal veins, that wind round the midbrain The veins from the upper surface of the cerebellum drain
to end in the great cerebral vein. Each internal cerebral vein into the straight, transverse, and superior petrosal venous
begins at the interventricular foramen, and runs backwards in sinuses. Veins from the inferior surface drain into the right
the tela choroidea, in the roof of the third ventricle. It has and left sigmoid, and inferior petrosal, sinuses, the occipital
numerous tributaries. One of these is the thalamostriate vein sinus and the straight sinus.
that lies in the floor of the lateral ventricle (between the The veins of the midbrain drain into the great cerebral vein
thalamus, medially, and the caudate nucleus, laterally). or into the basal vein. The pons and medulla drain into the
The great cerebral vein, formed by union of the two internal superior and inferior petrosal sinuses, the transverse sinus
cerebral veins, passes posteriorly beneath the splenium of the and the occipital sinus. Inferiorly, the veins of the medulla
corpus callosum, to end in the straight sinus. It receives the are continuous with the veins of the spinal cord.
INDEX
Index
Abdomen
regions of .................................................................... 224 Artery
wall of, anterior .......................................................... 230 alveolar, inferior ......................................................... 373
wall of, posterior ........................................................ 273 alveolar, posterior superior ........................................ 373
Abscess, lung ................................................................... 221 arch, palmar, deep ........................................................ 71
Acetabulum ................................................................ 82, 152 arch, palmar, superficial .............................................. 71
Achalasia cardia ............................................................... 220 auricular, deep ............................................................ 372
Achondroplasia .................................................................. 72 auricular, posterior ..................................................... 372
Adenoids .......................................................................... 422 axillary .................................................................... 20, 71
Aggar nasi ........................................................................ 420 brachial ................................................................... 37, 71
Air cells, mastoid ............................................................. 413 brachiocephalic .................................................. 206, 219
Ala, of sacrum .................................................................. 227 bronchial .................................................................... 207
Alae nasi ........................................................................... 334 carotid, common ................................ 207, 219,365, 438
Alveus ............................................................................... 481 carotid, external ................................................. 369, 438
Amelia ................................................................................ 72 carotid, internal ......................................... 368, 438, 493
Ampulla carpal ............................................................................ 57
hepatopancreatic ........................................................ 262 cerebellar, anterior inferior ........................................ 495
of rectum .................................................................... 287 cerebellar, posterior inferior ...................................... 495
Anastomosis cerebellar, superior .................................................... 495
around knee ................................................................ 128 cerebral, middle ................................................. 493, 494
around scapula ............................................................. 33 cerebral, posterior ...................................................... 495
cruciate ....................................................................... 122 cervical, transverse ...................................................... 32
portosystemic ............................................................. 309 choroidal, anterior ..................................................... 493
trochanteric ................................................................ 123 circumflex femoral, lateral ........................................ 114
Angina pectoris ................................................................ 222 circumflex femoral, medial ....................................... 114
Angiography .................................................................... 313 circumflex humeral, anterior ....................................... 22
Angiography, coronary .................................................... 221 circumflex humeral, posterior ..................................... 22
Angle circumflex iliac, deep ................................................ 239
acromial .......................................................................... 7 circumflex, of heart ................................................... 206
carrying ........................................................................ 69 colic, left .................................................................... 268
iridiocorneal ............................................................... 406 colic, middle .............................................................. 267
of rib ........................................................................... 170 colic, right .................................................................. 267
sternal ......................................................................... 169 communicating, anterior ........................................... 493
Annulus fibrosis ............................................................... 172 communicating, posterior .......................................... 494
Antrum, mastoid .............................................................. 413 conus, right ................................................................ 206
Antrum, pyloric ................................................................ 250 coronary, left .............................................................. 205
Aorta ................................................................................. 202 coronary, right ............................................................ 205
abdominal ........................................................... 204, 275 costocervical trunk .................................................... 376
arch of ................................................................ 204, 218 cystic .......................................................................... 266
ascending ........................................................... 202, 218 digital, of hand ............................................................. 58
branches of ................................................................. 205 dorsal carpal ................................................................. 56
descending ......................................................... 204, 218 dorsalis pedis ..................................................... 137, 160
Aponeurosis epigastric, inferior ..................................................... 239
epicranial .................................................................... 333 epigastric, superficial ................................................ 105
palatine ....................................................................... 417 epigastric, superior ............................................ 180, 239
plantar ........................................................................ 145 facial .................................................. 338, 369, 371, 438
Apparatus facial, transverse ........................................................ 338
lacrimal ....................................................................... 335 femoral ............................................................... 113, 160
Apparatus, biliary, extrahepatic ...................................... 261 gastric, left ................................................................. 265
Appendicitis ..................................................................... 310 gastric, right ............................................................... 266
Appendix, vermiform .............................................. 255, 305 gastric, short ............................................................... 266
Aqueduct, cerebral ........................................................... 488 gastroduodenal ........................................................... 266
Arachnoid mater .............................................................. 352 gastroepiploic, left ..................................................... 266
Arch gastroepiploic, right ................................................... 266
of foot, lateral ............................................................. 158 gluteal, inferior .......................................................... 121
of foot, medial ............................................................ 158 gluteal, superior ................................................. 122, 285
of foot, transverse ...................................................... 159 hepatic ........................................................................ 265
palmar, .......................................................................... 71 ileocolic ...................................................................... 267
plantar ........................................................................ 160 iliac, common .................................................... 278, 306
pubic ............................................................................. 82 iliac, external ...................................................... 278, 306
vertebral ..................................................................... 166 iliac, internal ...................................................... 278, 284
zygomatic ................................................................... 321 iliac, superficial circumflex ...................................... 105
Areola ................................................................................. 24 iliolumbar ................................................................... 285
infraorbital ................................................................. 373
intercostal, anterior .................................................... 180
499
500
Artery (continued) Artery (continued)
intercostal, posterior .................................................. 179 suprascapular ......................................................... 22, 33
intercostal, superior ................................................... 179 supratrochlear .............................................................. 38
interosseous, anterior ................................................... 56 temporal, superficial .......................................... 338, 374
interosseous, common ................................................. 56 testicular ..................................................................... 276
interosseous, posterior ................................................. 57 thoracic, internal ....................................... 180, 207, 218
interventricular, anterior ............................................ 206 thoracic, lateral ............................................................ 22
interventricular, posterior .......................................... 206 thoracic, superior ................................................. 22, 207
labial ........................................................................... 371 thoracoacromial ........................................................... 22
lingual ................................................................. 369, 370 thyrocervical trunk ..................................................... 376
lumbar ........................................................................ 277 thyroid, inferior .......................................................... 376
marginal, left of heart ................................................ 206 thyroid, superior ........................................................ 369
maxillary ............................................................ 339, 372 tibial, anterior .................................................... 136, 160
meningeal, accesory ................................................... 372 tibial, posterior ................................................... 144, 160
meningeal, middle ..................................................... 372 tonsillar ....................................................................... 371
mesenteric, inferior .................................................... 267 trunk, coeliac ............................................................. 265
mesenteric, superior ................................................... 266 trunk, costocervical ................................................... 179
metacarpal .................................................................... 57 trunk, pulmonary ............................................... 202, 218
musculophrenic .................................................. 180, 239 tympanic, anterior ...................................................... 372
nasal, lateral ............................................................... 371 ulnar ........................................................................ 56, 71
obturator ..................................................................... 284 ulnar collateral, superior .............................................. 38
obturator, abnormal ........................................... 164, 284 uterine ......................................................................... 284
occipital ...................................................................... 371 vaginal ........................................................................ 284
of brain ....................................................................... 493 vertebral ..................................................................... 375
of brain, central .......................................................... 496 vesical, inferior .......................................................... 284
of brain, perforating ................................................... 496 vesical, superior ......................................................... 284
of hand ......................................................................... 57 Ascites .............................................................................. 309
of head and neck ........................................................ 365 Asthma, bronchial ............................................................ 221
of sinuatrial node ....................................................... 206 Atrium of heart
ophthalmic ................................................................. 369 left ............................................................................... 197
ovarian ........................................................................ 277 right ............................................................................ 196
palatine ascending ..................................................... 371 Auricle, of ear .................................................................. 408
palatine, greater ......................................................... 373 Axilla .................................................................................. 20
palatine, lesser ............................................................ 373
palmar ........................................................................... 57
palmar carpal ............................................................... 56 Barium meal ..................................................................... 313
pancreaticoduodenal, inferior ................................... 267 Barium swallow ............................................................... 220
pancreaticoduodenal, superior .................................. 266 Bladder
pericardiophrenic ....................................................... 180 gall ...................................................................... 262, 311
peroneal ...................................................................... 145 urinary ................................................................ 289, 304
pharyngeal, ascending ....................................... 369, 370 Blind spot ......................................................................... 407
plantar, lateral .................................................... 149, 160 Body
plantar, medial ................................................... 149, 160 carotid ........................................................................ 433
popliteal .............................................................. 127, 160 ciliary .......................................................................... 405
princeps pollicis ........................................................... 56 geniculate, lateral ...................................... 387, 477, 486
profunda brachii .......................................................... 37 geniculate, medial ...................................................... 477
profunda femoris ................................................ 114, 160 perineal ............................................................... 247, 288
pudendal, internal ..................................... 122, 248, 284 trapezoid ..................................................................... 470
pudendal, superficial external ................................... 105 Bone

pulmonary, left ........................................................... 202 calcaneus ...................................................................... 96
pulmonary, right ......................................................... 202 capitate ......................................................................... 16
radial ....................................................................... 55, 71 carpal ............................................................................ 15
radialis indicis .............................................................. 56 clavicle ........................................................................... 4
rectal, inferior ............................................................ 248 coccyx ......................................................................... 228
rectal, middle ............................................................. 284 cuboid ........................................................................... 97
rectal, superior ........................................................... 268 cuneiform, intermediate .............................................. 99
recurrent, anterior ulnar ............................................... 56 cuneiform, lateral ......................................................... 99
recurrent, interosseous ................................................. 57 cuneiform, medial ........................................................ 99
recurrent, posterior ulnar ............................................. 56 femur ............................................................................ 84
recurrrent, radial .......................................................... 56 fibula ............................................................................ 92
renal ............................................................................ 276 frontal ......................................................................... 318
sacral, lateral .............................................................. 285 hamate .......................................................................... 16
sacral, median ............................................................ 278 hip ................................................................................. 79
scapular, dorsal .......................................................... 376 humerus .......................................................................... 9
sphenopalatine ........................................................... 373 hyoid ........................................................................... 332
splenic ........................................................................ 266 ilium ............................................................................. 79
subclavian ......................................... 207, 219, 374, 438 incus ........................................................................... 410
subcostal ..................................................................... 180 ischium ......................................................................... 81
submental ................................................................... 371 lunate ............................................................................ 15
superficial palmar ........................................................ 56 malleus ....................................................................... 410
supraduodenal ............................................................ 266 mandible ..................................................................... 330
INDEX
Bone (continued) Buergers disease ............................................................. 162
manubrium sterni ....................................................... 168 Bulb, olfactory ................................................................. 479
metacarpal .................................................................... 16 Bulla ethmoidalis ............................................................. 421
metatarsal ..................................................................... 99 Bursa
navicular ....................................................................... 97 olecranon ...................................................................... 76
occipital ..................................................... 318, 322, 325 radial ............................................................................. 48
of foot ........................................................................... 96 subacromial .................................................................. 76
of hand ......................................................................... 15 ulnar .............................................................................. 47
of head and neck ........................................................ 315
of lower limb ................................................................ 78 Caecum .................................................................... 254, 305
of thorax ..................................................................... 165 Caesarean section ............................................................ 312
of upper limb .................................................................. 4 Canal
palatine ....................................................................... 322 adductor ...................................................................... 107
parietal ........................................................................ 318 alimentary .................................................................. 225
patella ........................................................................... 89 anal ............................................................. 257, 288, 311
phalanges of foot ......................................................... 99 carotid ................................................................ 325, 328
phalanges of hand ........................................................ 16 cervicoaxillary ........................................................ 20, 74
pisiform ........................................................................ 15 condylar, anterior ....................................................... 326
premaxilla ................................................................... 322 condylar, posterior ............................................. 326, 328
pubis ............................................................................. 81 femoral ....................................................................... 163
radius ............................................................................. 11 hypoglossal ................................................ 326, 328, 329
rib, angle of ................................................................ 170 inguinal ..................................................... 231, 234, 304
rib, atypical ................................................................ 170 nasolacrimal ............................................................... 320
rib, eleventh ............................................................... 171 optic ........................................................... 320, 327, 328
rib, false ...................................................................... 170 pudendal ..................................................................... 247
rib, first ....................................................................... 170 pyloric ........................................................................ 250
rib, floating ................................................................ 170 sacral .......................................................................... 227
rib, movements of ...................................................... 174 semicircular ................................................................ 414
rib, second .................................................................. 170 spiral ........................................................................... 414
rib, tenth ..................................................................... 171 Capitulum ............................................................................. 9
rib, true ....................................................................... 170 Capsule, renal .................................................................. 271
rib, twelfth .................................................................. 171 Capsule, internal ...................................................... 457, 482
rib, typical .................................................................. 169 anterior limb ............................................................... 457
sacrum ........................................................................ 227 genu ............................................................................ 457
scaphoid ....................................................................... 15 posterior limb ............................................................. 457
scapula ............................................................................ 6 retrolentiform part ..................................................... 458
scapula, winging of ...................................................... 75 sublentiform part ....................................................... 458
sphenoid ............................................ 320, 321, 322, 323 Caput medusae ......................................................... 307, 310
stapes .......................................................................... 410 Cardiac arrest ................................................................... 222
sternum ....................................................................... 168 Cardiac transplantation ................................................... 222
talus .............................................................................. 97 Cardiospasm ..................................................................... 220
temporal ............................................................. 320, 325 Cartilage
tibia ............................................................................... 90 arytenoid .................................................................... 425
trapezium ...................................................................... 15 corniculate .................................................................. 425
trapezoid ....................................................................... 16 cricoid ........................................................................ 425
triquetral ....................................................................... 15 cuneiform ................................................................... 425
ulna ............................................................................... 13 of epiglottis ................................................................ 425
vertebra, body of ........................................................ 166 of larynx ..................................................................... 424
vertebra, eleventh thoracic ........................................ 168 thyroid ........................................................................ 424
vertebra, first thoracic ............................................... 168 Cauda equina ................................................................... 353
vertebra, lamina of ..................................................... 166 Cavity
vertebra, lumbar ......................................................... 226 abdominal ................................................................... 223
vertebra, pedicle of .................................................... 166 cranial ................................................................. 317, 350
vertebra, spine of ....................................................... 166 glenoid ............................................................................ 6
vertebra, tenth thoracic .............................................. 168 nasal .................................................................... 329, 419
vertebra, twelfth thoracic .......................................... 168 oral .............................................................................. 416
vertebra, typical ......................................................... 166 peritoneal .................................................................... 295
vertebral column ........................................................ 165 pleural ......................................................................... 192
vomer .......................................................................... 323 thoracic ....................................................................... 185
Brain, gross anatomy ....................................................... 444 tympanic ..................................................................... 409
Bronchi ............................................................................. 221 Cerebellum
intrapulmonary ........................................................... 189 connections of ............................................................ 465
principal ............................................................. 187, 218 cortex of ..................................................................... 449
Bronchiectasis .................................................................. 221 gross anatomy ............................................................ 448
Bronchiole ........................................................................ 189 nuclei of ..................................................................... 449
Bronchitis ......................................................................... 221 peduncles of ....................................................... 449, 465
Bronchography ................................................................. 221 structure of ................................................................. 449
Cerebral hemisphere
gross anatomy ............................................................ 450
gyri of ......................................................................... 451
lobes of ....................................................................... 450
501
502
Cerebral hemisphere(Continued) Crest
poles of 450 ampullary ................................................................... 416
sulci of ........................................................................ 451 frontal ......................................................................... 326
Cerebrospinal fluid .......................................................... 492 infratemporal .............................................................. 324
Cheeks .............................................................................. 334 intertrochanteric ........................................................... 86
Chiasma, optic ......................................................... 386, 486 obturator ....................................................................... 81
Cholangiography .............................................................. 313 occipital, external ...................................................... 318
Cholecystectomy .............................................................. 311 Crest (continued)
Cholecystitis ..................................................................... 311 occipital, internal ....................................................... 328
Cholecystography ............................................................ 313 palatine ....................................................................... 323
Cholelithiasis ................................................................... 311 pubic ............................................................................. 81
Choroid ............................................................................. 405 supinator ....................................................................... 13
Circulus arteriosus ........................................................... 495 urethral ....................................................................... 291
Cisterna chyli ................................................................... 282 urethral, interureteric ................................................. 291
Claw hand .......................................................................... 74 Cretinism .......................................................................... 441
Cleft, pudendal ................................................................. 245 Crista galli ........................................................................ 326
Clitoris .............................................................................. 245 Crista terminalis ............................................................... 196
Club foot ............................................................................ 72 Cryptorchidism ................................................................ 308
Club hand ........................................................................... 72 Cubital fossa ...................................................................... 40
Cochlea ............................................................................. 414 Cuff, rotator ....................................................................... 66
Colitis ............................................................................... 310 Cupola .............................................................................. 416
Colliculuc seminalis ........................................................ 291 Cyst
Colon branchial ..................................................................... 443
ascending ........................................................... 255, 305 pseudopancreatic ....................................................... 312
descending ......................................................... 256, 305 thyroglossal ................................................................ 443
sigmoid ............................................................... 257, 305 Cystocoele ........................................................................ 313
transverse ........................................................... 256, 305
Colporraphy ..................................................................... 313 Dens, of axis .................................................................... 316
Colpotomy ........................................................................ 313 Diabetes mellitis .............................................................. 311
Column Diaphragm ........................................................................ 220
anal ............................................................................. 288 oral .............................................................................. 346
renal ............................................................................ 271 pelvic ......................................................... 247, 283, 307
vertebral ..................................................................... 306 urogenital ........................................................... 244, 245
Commissures of brain ...................................................... 483 Diaphragm, pelvic ........................................................... 247
anterior ....................................................................... 484 Diaphragma sellae ........................................................... 351
corpus callosum ......................................................... 484 Disc
habenular .................................................................... 484 intervertebral ............................................. 166, 171, 307
hippocampal ............................................................... 484 optic ............................................................................ 407
Computed tomography .................................................... 313 Diverticulum
Conchae, nasal ................................................................. 420 allantoic ...................................................................... 307
Conjunctiva ...................................................................... 334 ilei ............................................................................... 310
fornix of ...................................................................... 335 Meckels ............................................................. 307, 310
ocular .......................................................................... 335 Dorsum nasi ..................................................................... 334
Connexus, interthalamic .................................................. 490 Dorsum sellae ................................................................... 327
Conus medullaris ............................................................. 355 Duct
Cord bile .............................................................................. 262
spermatic ............................................................ 105, 234 cystic .......................................................................... 261
spinal .......................................................................... 354 ejaculatory .................................................................. 292
Cornea ...................................................................... 334, 405 frontonasal .................................................................. 421

Cornu, sacral .................................................................... 228 hepatic ................................................................ 259, 261
Cornua, of hyoid bone ..................................................... 332 hepatic, common ................................................ 259, 261
Corona glandis ................................................................. 243 lactiferous ..................................................................... 24
Coronary bypass surgery ................................................. 222 lymphatic, right .......................................................... 212
Corpora cavernosa of penis ............................................. 243 nasolacrimal ....................................................... 336, 422
Corpus callosum ...................................................... 458, 484 of cochlea ................................................................... 414
genu of ........................................................................ 458 pancreatic, accesory ................................................... 263
rostrum of ................................................................... 458 pancreatic, main ......................................................... 263
splenium of ................................................................ 458 parotid ........................................................................ 338
trunk of ....................................................................... 458 semicircular ................................................................ 414
Corpus luteum .................................................................. 294 submandibular ........................................................... 345
Cortex cerebral ................................................................. 455 thoracic ....................................................................... 211
acoustic area ............................................................... 456 vitellointestinal .......................................................... 307
arterial supply ............................................................ 496 Ductus venosus ................................................................ 261
functional areas of ..................................................... 456 Ductus deferens .............................................. 234, 242, 292
motor area .................................................................. 456 Duodenum ................................................................ 251, 305
premotor area ............................................................. 456 Dura mater ....................................................................... 351
sensory area ................................................................ 456 Dysphagia ........................................................................ 220
visual area .................................................................. 456 Dyspnoea .......................................................................... 221
Cranium ............................................................................ 317
INDEX
Ear Follicle
internal ....................................................................... 413 Graafian ...................................................................... 293
middle ......................................................................... 409 ovarion ....................................................................... 293
ossicles of ................................................................... 410 Foot ................................................................................... 130
Ectopia cordis .................................................................. 219 Foot drop .......................................................................... 163
Efffusion, pleural ............................................................. 220 Foot, flat ........................................................................... 159
Effusion, pericardial ........................................................ 222 Foramen
Empyema .......................................................................... 220 caecum ....................................................................... 326
Endocarditis ..................................................................... 221 caecum, of tongue ...................................................... 347
Endocranium .................................................................... 351 epiploicum ......................................................... 296, 298
Endometrium ................................................................... 294 Foramen (continued)
Enteritis ............................................................................ 310 infraorbital ......................................................... 319, 320
Ependyma ......................................................................... 488 interventricular ........................................................... 488
Epididymis ....................................................................... 241 jugular ............................................... 325, 326, 328, 329
duct of ........................................................................ 242 lacerum ............................................................... 325, 327
Epithalamus ..................................................................... 477 magnum .............................................................. 325, 328
Erbs paralysis .................................................................... 74 mental ......................................................................... 331
Erbs point .......................................................................... 74 obturator ....................................................................... 83
Exomphlos ....................................................................... 307 of Langer ...................................................................... 24
Eyeball .............................................................................. 404 ovale ................................................................... 324, 328
Eyelids .............................................................................. 334 ovale, patent ............................................................... 221
palatine, greater ......................................................... 323
Face .......................................................................... 334, 336 palatine, lesser ............................................................ 323
dangerous area of ....................................................... 439 rotundum ............................................................ 327, 328
Falx cerebelli .................................................................... 351 sacral .......................................................................... 227
Falx cerebri ...................................................................... 351 sciatic, greater .............................................................. 84
Fascia sciatic, lesser ................................................................ 84
buccopharyngeal ........................................................ 423 spinosum ............................................................ 324, 328
clavipectoral ................................................................. 19 stylomastoid ....................................................... 325, 328
cremasteric ................................................................. 234 transversarium ............................................................ 167
cribriform ................................................................... 105 Fornix ............................................................................... 481
deep cervical .............................................................. 365 Fossa
obturator ............................................................. 247, 284 acetabular ..................................................................... 83
pelvic .......................................................................... 284 coronoid ......................................................................... 9
pharyngobasilar .......................................................... 423 cranial, anterior .......................................................... 326
pretracheal .................................................................. 365 cranial, middle ................................................... 326, 327
prevertebral ................................................................ 365 cranial, posterior ........................................................ 328
renal ............................................................................ 271 digastric ...................................................................... 331
spermatic, external ..................................................... 234 for gall bladder ........................................................... 259
spermatic, internal ..................................................... 234 hyaloid ........................................................................ 407
thoracolumbar .................................................... 231, 273 hypophyseal ....................................................... 327, 352
transversalis ............................................................... 231 iliac ....................................................................... 81, 224
Fasciae latae ..................................................................... 105 incisive ....................................................................... 331
Fenestra cochleae ............................................................. 412 incudis ........................................................................ 412
Fenestra vestibuli ............................................................. 412 infraspinous .................................................................... 6
Filum terminale ................................................................ 353 infratemporal ...................................................... 321, 339
Fimbria ............................................................................. 481 ischiorectal ................................................. 247, 288, 311
Fissure jugular ........................................................................ 325
choroid ....................................................................... 488 lacrimal ....................................................................... 319
for ligamentum teres .......................................... 258, 259 malleolar ....................................................................... 92
for ligamentum venosum ........................................... 259 mandibular ......................................................... 321, 325
orbital, inferior ........................................................... 320 olecranon ........................................................................ 9
orbital, superior ......................................... 320, 327, 328 ovalis .......................................................................... 197
palpebral ..................................................................... 334 ovarian ........................................................................ 293
pterygomaxillary ........................................................ 324 popliteal ...................................................................... 125
squamotympanic ........................................................ 325 pterygoid .................................................................... 323
transverse, of brain .................................................... 491 radial ............................................................................... 9
Fistula rhomboid .................................................................... 491
branchial ..................................................................... 443 sublingual ................................................................... 331
fascal .......................................................................... 307 submandibular ........................................................... 331
urinary ........................................................................ 307 supraspinous .................................................................. 6
Fluid cerebrospinal .......................................................... 352 temporal ..................................................................... 321
Fold trochanteric .................................................................. 86
aryepiglottic ............................................................... 426 trochlear ..................................................................... 319
fimbriated ................................................................... 348 Fovea, pterygoid .............................................................. 331
glossoepiglotic, .......................................................... 348 Fovea centralis ................................................................. 406
palatoglossal ....................................................... 348, 417 Frenulum
palatopharyngeal ........................................................ 417 linguae ........................................................................ 348
sublingual ........................................................... 348, 417 of penis ....................................................................... 243
vestibular .................................................................... 426 Frenulum linguae ............................................................. 416
Vocal ........................................................................... 426 Fundus, of stomach .......................................................... 250
503
504
Gall bladder .................................................................... 306 Hiatus, sacral ................................................................... 228
Ganglion Hippocampal formation ................................................... 480
autonomic ................................................................... 302 Hippocampus ................................................................... 481
aorticcorenal ............................................................... 217 Hydrocele ......................................................................... 308
aorticorenal ................................................................ 282 Hymen .............................................................................. 246
cervicothoracic ........................................................... 217 Hyperparathyroidism ....................................................... 441
coeliac ................................................................ 217, 282 Hypochondrium ............................................................... 224
dorsal nerve root ........................................................ 355 Hypoparathyroidism ........................................................ 441
genicular ..................................................................... 393 Hypophysis cerebri .......................................................... 429
impar .......................................................................... 303 Hypothalamus .................................................................. 475
otic .............................................................................. 397 Hysterectomy ................................................................... 312
pterygopalatine .......................................................... 395
sacral .......................................................................... 503 Ileum ................................................................................ 253
spinal .......................................................................... 355 Indusium griseum ............................................................ 480
spiral ........................................................................... 414 Infundibulum
submandibular ........................................................... 396 ethmoidal .................................................................... 421
sympathetic ................................................................ 401 Infundibulum of right ventricle ....................................... 197
trigeminal ................................................................... 390 Intestine ............................................................................ 304
Gastritis ............................................................................ 310 large ............................................................................ 254
Gastroscopy ...................................................................... 310 small ........................................................................... 251
Girdle Iris ............................................................................. 334, 406
pectoral ........................................................................... 4
shoulder .......................................................................... 4 Jejunum ........................................................................... 253
Gland Joint
bulbourethral .............................................................. 245 acromioclavicular ........................................................ 65
lacrimal ............................................................... 335, 404 ankle ........................................................................... 156
mammary ...................................................................... 24 atlantoaxial ................................................................. 356
parathyroid ......................................................... 432, 441 atlantooccipital .......................................................... 326
parotid ................................................................ 337, 437 atlanto-occipital ................................................. 316, 357
pineal .......................................................................... 431 calcaneocuboid .......................................................... 158
prostate ....................................................................... 292 carpometacarpal ........................................................... 70
sublingual ................................................................... 345 costochondral ............................................................. 174
submandibular ................................................... 344, 437 costotransverse ........................................................... 173
suprarenal ................................................................... 272 costovertebral ............................................................. 173
thyroid ....................................................... 431, 437, 441 elbow ............................................................................ 67
vestibular, greater ...................................................... 246 hip ............................................................................... 152
Globus pallidus ................................................................ 479 humero-radial ............................................................... 67
Goitre ................................................................................ 441 humero-ulnar ................................................................ 68
Goitre, toxic ..................................................................... 441 intercarpal .................................................................... 70
Groove interchondral .............................................................. 174
atrioventricular ........................................................... 195 interphalangeal ............................................................. 70
carotid ........................................................................ 327 intertarsal ................................................................... 158
costal .......................................................................... 170 intervertebral .............................................................. 171
infraorbital ................................................................. 320 knee ............................................................................ 154
interventricular ........................................................... 195 lumbosacral ................................................................ 282
lacrimal ....................................................................... 320 manubriosternal ................................................. 168, 173
mylohyoid .................................................................. 331 metacarpophalangeal ................................................... 70
obturator ....................................................................... 82 midcarpal ..................................................................... 70
radial ......................................................................... 9, 41 of lower limb .............................................................. 152

of sternum .................................................................. 173
Haemorrhoids ................................................ 289, 310, 311 of thorax ..................................................................... 171
Haemothorax .................................................................... 220 of upper limb ................................................................ 65
Hare lip ............................................................................. 442 pubic symphysis ................................................ 229, 282
Heart ................................................................................. 194 radioulnar ..................................................................... 69
apex of ........................................................................ 194 sacroiliac .................................................................... 229
borders of ................................................................... 195 shoulder ........................................................................ 66
conducting system of ................................................. 199 sternoclavicular .................................................... 65, 169
grooves of ................................................................... 195 talocalcaneonavicular ................................................ 158
surface projection of .................................................. 201 tarsal, transverse ........................................................ 158
surfaces of .................................................................. 194 temporomandibular .................................................... 342
Heart disease, ischaemic ................................................. 222 temporo-mandibular .................................................. 321
Helicotrema ...................................................................... 415 tibiotalar ..................................................................... 158
Hemianopia ...................................................................... 439 wrist .............................................................................. 69
Hepatitis ........................................................................... 311 xiphisternal ........................................................ 168, 173
Hernia
femoral ....................................................................... 163 Kidney ..................................................................... 269, 312
inguinal ...................................................................... 308 Klumpkes paralysis .......................................................... 74
inguinal, direct ........................................................... 308 Kyphosis ........................................................................... 219
inguinal, indirect ........................................................ 308
physiological .............................................................. 307 Labium majus ................................................................. 245
Hiatus semilunaris ........................................................... 421 Labium minus .................................................................. 245
INDEX
Labrum Ligament (continued)
acetabular ................................................................... 152 popliteal, arcuate ........................................................ 155
glenoidal ....................................................................... 66 popliteal, oblique ....................................................... 155
Labyrinth pubofemoral ............................................................... 152
bony ............................................................................ 413 radiocarpal, dorsal ....................................................... 69
membranous ............................................................... 413 radiocarpal, palmar ...................................................... 69
Lacrimal sacroiliac .................................................................... 229
canaliculi .................................................................... 336 sacrospinous ............................................................... 229
caruncle ...................................................................... 335 sacrotuberous ............................................................. 229
papilla ......................................................................... 335 sphenomandibular ..................................................... 343
punctum ..................................................................... 335 spring .......................................................................... 158
sac ............................................................................... 336 sternoclavicular ............................................................ 65
Lacus lacrimalis ............................................................... 335 stylomandibular ................................................. 343, 365
Laparoscopy ..................................................................... 309 suspensory of breast .................................................... 24
Laparotomy ...................................................................... 309 suspensory, of lens ..................................................... 407
Larynx ...................................................................... 424, 443 talocalcaneal, interosseous ........................................ 158
Lemniscus talofibular, anterior .................................................... 156
medial ......................................................................... 463 talofibular, posterior .................................................. 156
posterior column-medial ........................................... 463 tibionavicular ............................................................. 157
spinal .......................................................................... 463 tibiotalar ..................................................................... 157
Lens .................................................................................. 407 transverse humeral ....................................................... 66
Ligament triangular, left ............................................................ 258
alar .............................................................................. 357 triangular, right .......................................................... 258
anococcygeal .............................................................. 247 ulnocarpal, dorsal ........................................................ 69
apical .......................................................................... 357 ulnocarpal, palmar ....................................................... 69
arcuate, lateral ............................................................ 177 umbilical, lateral ........................................................ 239
arcuate, medial ........................................................... 177 umbilical, median ...................................................... 290
arcuate, median .......................................................... 177 vestibular .................................................................... 426
bifurcate ..................................................................... 158 vocal ........................................................................... 426
broad ........................................................................... 293 Ligamentum denticulatum .............................................. 353
calcaneofibular ........................................................... 156 Ligamentum flavum ........................................................ 357
capsular ................................ See under individual joints Ligamentum patellae ....................................................... 155
collateral, fibular ........................................................ 155 Ligamentum teres ............................................................ 261
collateral, radial ..................................................... 68, 69 Ligamentum venosum ..................................................... 261
collateral, tibial .......................................................... 155 Limen nasi ........................................................................ 420
collateral, ulnar ...................................................... 68, 69 Line
connecting vertebrae .................................................. 172 anterior oblique ............................................................. 11
coracoacromial ............................................................. 65 arcuate .................................................................. 81, 236
coracoclavicular ........................................................... 65 gluteal, anterior ............................................................ 80
coracohumeral .............................................................. 66 gluteal, inferior ............................................................ 80
costoclavicular ............................................................. 65 gluteal, posterior .......................................................... 80
costotransverse ........................................................... 173 Holdens ..................................................................... 105
cruciate, anterior ........................................................ 155 intertrochanteric ........................................................... 86
cruciate, posterior ...................................................... 156 linea terminalis ............................................................ 85
deltoid ......................................................................... 157 midclavicular ............................................................. 224
falciform ............................................................. 258, 260 mylohyoid .................................................................. 331
gastrophrenic .............................................................. 297 nuchal, inferior .......................................................... 318
gastrosplenic ...................................................... 264, 297 nuchal, superior ......................................................... 318
glenohumeral ................................................................ 66 pectinate ..................................................................... 288
iliofemoral .................................................................. 152 pectineal ....................................................................... 81
inguinal .............................................................. 105, 230 spiral ............................................................................. 86
inguinal, reflected part .............................................. 231 supracondylar ............................................................... 87
interclavicular .............................................................. 65 temporal ..................................................................... 320
ischiofemoral ............................................................. 152 trapezoid ......................................................................... 4
lacunar ........................................................................ 230 white of Hilton ........................................................... 288
lienorenal ............................................................ 264, 297 Linea alba ................................................................. 224, 230
longitudinal, anterior ................................................. 357 Linea aspera ....................................................................... 86
of acetabulum ............................................................. 152 Liver ................................................................. 258, 305, 311
of ankle joint .............................................................. 156 Lumbar puncture ..................................................... 307, 353
of atlas, transverse ..................................................... 357 Lung ......................................................................... 188, 221
of head of femur ........................................................ 152 Lymph node
of larynx ..................................................................... 425 aortic, lateral ...................................................... 298, 299
of ovary ...................................................................... 293 axillary .......................................................................... 23
of ovary, suspensory .................................................. 293 buccal ......................................................................... 433
of uterus, round .......................................................... 295 cervical, deep ............................................................. 433
palpebral ..................................................................... 335 cervical, superficial ................................................... 433
pectineal ..................................................................... 230 coeliac ........................................................................ 298
plantar calcaneocuboid .............................................. 158 gastroepiploic, right ................................................... 300
plantar calcaneonavicular .......................................... 158 hepatic ........................................................................ 300
plantar, long ............................................................... 158 iliac connon ................................................................ 299
plantar, short .............................................................. 158 iliac external ............................................................... 299
505
506
Muscle(continued)
adductor brevis ........................................................... 111
Lymph node continued)
adductor hallucis ........................................................ 148
iliac internal ............................................................... 299
adductor longus ........................................................... 111
inferior mesenteric ..................................................... 298
adductor magnus ........................................................ 112
inguinal, deep ............................................................. 105
adductor pollicis .......................................................... 51
inguinal,, superficial .................................................. 104
anconeus ....................................................................... 62
jugulodigastric ........................................................... 433
anterior vertebral ........................................................ 361
juguloomohyoid ......................................................... 433
articularis genu .......................................................... 110
occipital ...................................................................... 433
biceps brachii ............................................................... 35
of abdomen ................................................................. 298
biceps femoris ............................................................ 127
of head and neck ........................................................ 433
brachialis ...................................................................... 36
of pelvis ...................................................................... 298
brachioradialis ............................................................. 58
of thorax ..................................................................... 212
buccinator .................................................................. 337
pancreaticoduodenal .................................................. 300
bulbospongiosus ........................................................ 245
pancreaticosplenic ..................................................... 300
coccygeus ................................................................... 283
parotid ........................................................................ 433
constrictor, inferior .................................................... 423
pyloric ........................................................................ 300
constrictor, middle ..................................................... 423
retroaortic ................................................................... 298
constrictor, superior ................................................... 423
retroauricular .............................................................. 433
coracobrachialis ........................................................... 35
submandibular ........................................................... 433
dartos .......................................................................... 241
superior mesenteric .................................................... 298
deep of back ............................................................... 362
Lymph trunk
deltoid ........................................................................... 29
intestinal ..................................................................... 298
diaphragm .................................................................. 177
lumbar ........................................................................ 298
digastric ...................................................................... 346
erector spinae ............................................................. 362
Macula lutea ........................................................... 406, 484
extensor carpi radialis brevis ...................................... 59
Magnetic resonance imaging .......................................... 314
extensor carpi radialis longus ...................................... 59
Malleolus
extensor carpi ulnaris .................................................. 61
lateral ............................................................................ 92
extensor digitorum ....................................................... 60
medial ........................................................................... 91
extensor digitorum brevis .......................................... 133
Mammography ................................................................... 72
extensor digitorum longus ......................................... 131
Meatus
extensor hallucis longus ............................................ 131
acoustic, external ............................................... 321, 409
extensor indicis ............................................................ 63
acoustic, internal ........................................................ 328
extensor pollicis brevis ................................................ 63
of nasal cavity ............................................................ 420
extensor pollicis longus ............................................... 63
Mediastinum ............................................................ 185, 222
extensosr digiti minimi ................................................ 60
Medulla
flexor carpi radialis ...................................................... 43
gross anatomy ............................................................ 444
flexor carpi ulnaris ....................................................... 44
internal structure ................................................ 446, 467
flexor digiti minimi ..................................................... 50
Membrana tectoria ........................................................... 357
flexor digiti minimi brevis ........................................ 147
Membrane
flexor digitorum accessorius ..................................... 146
atlanto-occipital, anterior .......................................... 357
flexor digitorum brevis .............................................. 145
atlanto-occipital, posterior ........................................ 357
flexor digitorum longus ............................................. 141
basilar, of ear .............................................................. 414
flexor digitorum profundus ......................................... 46
obturator ....................................................................... 83
flexor digitorum superficialis ...................................... 44
perineal ....................................................................... 244
flexor hallucis brevis ................................................. 147
thyrohyoid .................................................................. 425
flexor hallucis longus ................................................ 141
tympanic ..................................................................... 410
flexor pollicis brevis .................................................... 50

tympanic, secondary .................................................. 414
flexor pollicis longus ................................................... 47
vestibular, of ear ........................................................ 414
gastrocnemius ............................................................ 139
Meninges .......................................................................... 351
gemelli ........................................................................ 120
Meningocoele ................................................................... 306
genioglossus ............................................................... 348
Meningomyelocoele ......................................................... 306
geniohyoid .................................................................. 346
Meniscus, of knee joint ................................................... 156
gluteus maximus ........................................................ 117
Mesencephalon ................................................................ 455
gluteus medius ........................................................... 118
Mesentery ........................................................ 254, 296, 305
gluteus minimus ......................................................... 119
Mesocolon
gracilis ........................................................................ 110
sigmoid ....................................................................... 297
hyoglossus .................................................................. 348
transverse ................................................................... 297
hypothenar .................................................................... 49
Mesovarium ..................................................................... 293
iliacus ......................................................................... 108
Metathalamus ................................................................... 477
infrahyoid ................................................................... 360
Midbrain
infraspinatus ................................................................. 29
gross anatomy ............................................................ 445
intercostal ................................................................... 174
internal structure ................................................ 447, 471
intercostal, external ................................................... 174
Miners elbow .................................................................... 76
intercostal, innermost ................................................ 174
Mons pubis ....................................................................... 246
intercostal, internal .................................................... 174
Muscle
interossei, dorsal of hand ............................................ 51
abductor digiti minimi ......................................... 49, 146
interossei, palmar ......................................................... 51
Abductor hallucis ....................................................... 146
interosseus, of foot ..................................................... 148
abductor pollicis brevis ............................................... 49
ischiocavernosus ........................................................ 245
abductor pollicis longus .............................................. 63
INDEX
Muscle(continued) Muscle(continued)
lateral vertebral .......................................................... 360 rectus, lateral .............................................................. 403
latissimus dorsi ............................................................ 27 rectus, medial ............................................................. 403
levator ani ................................................................... 283 rectus, superior ........................................................... 403
levator palpebrae superioris ...................................... 404 rhomboideus major ...................................................... 28
levator prostate ........................................................... 283 rhomboideus minor ...................................................... 27
levator scapulae ........................................................... 27 salpingopharyngeus ................................................... 423
levatores costarum ..................................................... 176 sartorius ...................................................................... 109
longus capitis ............................................................. 361 scalenus anterior ........................................................ 360
longus colli ................................................................. 361 scalenus medius ......................................................... 360
lumbrical, of foot ....................................................... 146 scalenus posterior ...................................................... 361
lumbrical, of hand ........................................................ 49 semimembranosus ...................................................... 126
masseter ...................................................................... 341 semispinalis capitis .................................................... 363
mylohyoid .................................................................. 346 semitendinosus ........................................................... 125
oblique, superior ........................................................ 403 serratus anterior ........................................................... 19
oblique,inferior .......................................................... 403 serratus posterior inferior .......................................... 176
obliquus capitis inferior ............................................ 364 serratus posterior superior ......................................... 176
obliquus capitis superior ........................................... 364 soleus .......................................................................... 140
obliquus externus abdominis .................................... 231 sphincter ani externus ................................................ 247
obliquus internus abdominis ..................................... 232 sphincter urethrae .............................................. 244, 292
obturator externus ...................................................... 120 sphincter vesicae ........................................................ 292
obturator internus ...................................................... 119 splenius capitis .......................................................... 362
occipitofrontalis ......................................................... 333 stapedius ..................................................................... 412
of face ......................................................................... 336 sternocleidomastoid ................................................... 359
of larynx ..................................................................... 427 sternocostalis ...................................................... 174, 175
of neck ........................................................................ 359 sternohyoid ................................................................. 360
of tongue .................................................................... 348 sternothyroid .............................................................. 360
omohyoid ................................................................... 360 styloglossus ................................................................ 348
opponens digiti minimi ............................................... 50 stylohyoid ................................................................... 346
opponens pollicis ......................................................... 50 stylopharyngeus ......................................................... 423
orbicularis oculi ......................................................... 336 subclavius ..................................................................... 18
orbicularis oris ........................................................... 336 subcostales ................................................................. 174
palatoglossus .............................................................. 348 suboccipital ................................................................ 363
palatopharyngeus ....................................................... 423 subscapularis ................................................................ 30
palmaris brevis ............................................................. 49 supinator ....................................................................... 62
papillary of heart ........................................................ 197 suprahyoid .................................................................. 345
pectineus ..................................................................... 111 supraspinatus ............................................................... 29
pectoralis major ........................................................... 17 temporalis ................................................................... 341
pectoralis minor ........................................................... 18 tensor fasciae latae ..................................................... 108
perinei, deep transverse ............................................. 245 tensor tympani ........................................................... 412
perinei, superficial transverse ................................... 245 teres major .................................................................... 30
perinei, transverse, superficial .................................. 245 teres minor ................................................................... 30
Peroneus brevis .......................................................... 135 thenar ............................................................................ 49
Peroneus longus ......................................................... 134 thyrohyoid .................................................................. 360
peroneus tertius .......................................................... 133 tibialis anterior ........................................................... 130
piriformis .................................................................... 119 tibialis posterior ......................................................... 142
plantaris ...................................................................... 139 transversus abdominis ............................................... 233
platysma ............................................................... 17, 359 trapezius ....................................................................... 26
popliteus ..................................................................... 140 triceps ........................................................................... 41
prevertebral ................................................................ 361 vastus intermedius ............................................. 109, 110
pronator quadratus ....................................................... 48 vastus lateralis ............................................................ 109
pronator teres ............................................................... 42 vastus medialis ................................................... 109, 110
psoas major ................................................................ 107 Musculi pectinati ............................................................. 196
psoas minor ................................................................ 107 Myasthenia gravis ............................................................ 222
pterygoid, lateral ........................................................ 341 Myocardial infarction ...................................................... 222
pterygoid, medial ....................................................... 342 Myocarditis ...................................................................... 221
puborectalis ................................................................ 283 Myometrium .................................................................... 294
pubovaginalis ............................................................. 283 Myxoedema ...................................................................... 441
pupillae, dilator .......................................................... 406
pupillae, sphincter ..................................................... 406 Nares, external ............................................................... 334
pyramidalis ................................................................. 235 Nerve
quadratus femoris ...................................................... 120 abducent ............................................................. 389, 440
quadratus lumborum .................................................. 274 accessory .................................................................... 399
quadriceps femoris ..................................................... 109 accessory, cranial ....................................................... 441
rectus abdominis ........................................................ 235 accessory, cranial part ............................................... 399
rectus capitis anterior ................................................ 361 accessory, spinal ................................................ 438, 441
rectus capitis lateralis ................................................ 361 accessory, spinal part ........................................... 28, 399
rectus capitis posterior major .................................... 364 alveolar, inferior ................................................. 340, 393
rectus capitis posterior minor .................................... 363 ansa cervicalis ............................................................ 384
rectus femoris ..................................................... 109, 110 auricular, greater ........................................................ 383
rectus, inferior ............................................................ 403 auricular, posterior ..................................................... 394
507
508
Nerve (continued) Nerve (continued)
auriculotemporal ....................................... 340, 392, 438 peroneal, superficial ................................. 101, 138, 161
autonomic ................................................................... 214 phrenic ....................................................... 213, 385, 439
axillary .................................................................... 31, 75 plantar, lateral .................................................... 102, 161
buccal ......................................................................... 340 plantar, medial ................................................... 102, 161
cardiac ........................................................................ 215 pudendal .................................................... 123, 248, 286
cervical ....................................................................... 382 radial .......................................................... 39, 54, 72, 76
cervical, dorsal rami of .............................................. 382 rectal, inferior ............................................................ 249
chorda tympani .......................................... 341, 394, 411 saphenous ........................................................... 101, 115
cochlear ...................................................................... 396 scapular, dorsal ............................................................ 28
cranial ......................................................................... 385 sciatic ........................................................ 123, 160, 163
cranial, nuclei of ........................................................ 385 splanchnic .......................................................... 217, 286
cutaneous of thigh ..................................................... 115 splanchnic, greater ..................................................... 303
cutaneous of thigh, lateral ................................. 116, 282 splanchnic, lesser ....................................................... 303
cutaneous of thigh, posterior ..................................... 123 splanchnic, lowestr .................................................... 303
cutaneous, of arm ......................................................... 33 splanchnic, pelvic ...................................................... 303
cutaneous, of calf ....................................................... 101 subcostal .................................................... 100, 101, 237
cutaneous, of foot ...................................................... 101 supraclavicular ..................................................... 33, 384
cutaneous, of forerm .................................................... 33 suprascapular ............................................................... 31
cutaneous, of gluteal region ...................................... 101 sural .................................................................... 101, 150
cutaneous, of hand ....................................................... 34 sympathetic ............................................... 214, 216, 441
cutaneous, of leg ........................................................ 101 sympathetic trunk .............................................. 401, 439
cutaneous, of lower limb ........................................... 100 temporal, deep ............................................................ 340
cutaneous, of sole ...................................................... 102 thoracic, first .............................................................. 183
cutaneous, of thigh ............................................ 100, 101 thoracic, long ............................................................... 75
cutaneous, perforating ............................................... 123 thoracic, second ......................................................... 183
cutaneous, transverse of neck ................................... 383 tibial ................................................................... 150, 161
digital of hand .............................................................. 52 to obturator internus .................................................. 123
digital, of foot ............................................................ 150 to pectineus ................................................................ 115
dorsal, of penis ........................................................... 249 to piriformis ............................................................... 123
facial .......................................................... 393, 438, 440 to popliteus ................................................................. 150
femoral .............................................. 115, 160, 163, 282 to quadratus femoris .................................................. 123
frontal ......................................................................... 390 trigeminal ........................................................... 389, 440
genitofemoral ............................................. 116, 238, 285 trochlear ............................................................. 388, 440
glossopharyngeal ...................................... 396, 438, 441 ulnar ........................................................... 39, 53, 72, 75
gluteal, inferior .......................................................... 123 vagus ................................ 215, 257, 302, 398, 438, 441
gluteal, superior ......................................................... 123 vestibular .................................................................... 396
hypoglossal ......................................................... 400, 441 vestibulocochlear ............................................... 396, 441
iliohypogastric .................................. 100, 101, 237, 282 Nipple ................................................................................. 24
ilioinguinal ................................................ 100, 238, 282 Node
intercostal ................................................................... 236 atrioventricular ........................................................... 199
intercostal, lower ........................................................ 182 sinuatrial ..................................................................... 199
intercostal, typical ..................................................... 182 Nose, external .................................................................. 334
intercostobrachial ................................................ 33, 183
lacrimal ....................................................................... 390 Oesophagus ............................................ 209, 218, 220, 428
laryngeal, external ...................................................... 398 abdominal part ........................................................... 250
laryngeal, internal ...................................................... 398 Omentum
laryngeal, recurrent ............................................ 215, 398 greater ......................................................................... 296
laryngeal, superior ..................................................... 398 lesser .......................................................... 259, 260, 296

lingual ........................................................ 340, 392, 438 Orbit ................................................................ 317, 319, 402
lumbar ........................................................................ 280 Organ
lumbosacral trunk ...................................................... 285 spiral of Corti ............................................................. 415
mandibular ................................................ 340, 392, 438 Orifice
maxillary .................................................................... 391 aortic ........................................................................... 198
median ....................................................... 38, 52, 71, 75 atrioventricular ................................................... 194, 197
musculocutaneous .................................................. 38, 71 pulmonary .................................................................. 198
nasociliary .................................................................. 390 urethral, internal ........................................................ 291
obturator ............................................ 100, 116, 282, 285 Otoliths ............................................................................. 416
occipital, greater ........................................................ 382 Ovary ................................................................................ 293
occipital, lesser .......................................................... 383 Ovulation .......................................................................... 294
oculomotor ......................................................... 387, 440
of thoracic wall .......................................................... 182 Pain, referred ................................................................. 440
of thoracic, ventral rami of ........................................ 182 Palate
of thorax ..................................................................... 213 bony ............................................................................ 322
olfactory ............................................................. 386, 439 cleft ............................................................................. 442
ophthalmic ................................................................. 390 hard ............................................................................. 417
optic ........................................................... 386, 439, 486 soft .............................................................................. 417
parasympathetic ......................................................... 214 Pancreas ........................................................... 263, 306, 311
perineal ....................................................................... 249 Pancreatitis ....................................................................... 312
peroneal, common .............................................. 161, 163
peroneal, deep ........................................... 101, 137, 161
INDEX
Papilla Plexus
duodenal, major ......................................................... 253 aortic ........................................................................... 302
duodenal, minor ......................................................... 253 brachial ......................................................................... 23
of tongue .................................................................... 347 brachial, postfixed ....................................................... 74
sublingual ........................................................... 348, 416 brachial, prefixed ......................................................... 74
Parallelogram, Morrisons ............................................... 270 cardiac, deep .............................................................. 214
Pathway cardiac, superficial .................................................... 214
cortico-ponto-cerebellar ............................................ 460 cervical ....................................................................... 383
for hearing .................................................................. 487 choroid ............................................................... 353, 491
for smell ..................................................................... 487 coeliac ................................................................ 282, 302
for taste ....................................................................... 487 hypogastric, inferior .................................................. 302
olfactory ..................................................................... 480 hypogastric, superior ................................................. 302
posterior column-medial lemniscus .......................... 463 intermesenteric ........................................................... 302
secretomotor to sublingual gland .............................. 395 lumbar ........................................................................ 281
secretomotor to submandibular gland ....................... 395 myenteric .................................................................... 302
spinocerebellar ........................................................... 464 oesophageal ................................................................ 214
spinothalamic ............................................................. 463 of Auerbach ................................................................ 302
visual ......................................................... 387, 439, 484 of Meissner ................................................................. 302
Pecten ............................................................................... 288 patellar ........................................................................ 115
Pecten pubis ....................................................................... 81 pharyngeal .................................................................. 398
Pectoral region ................................................................... 17 pulmonary .................................................................. 214
Pelvimetry ........................................................................ 307 renal ............................................................................ 217
Pelvis sacral .......................................................................... 286
apertures of .................................................................. 85 submucous ................................................................. 302
as a whole ..................................................................... 85 subsartorial ................................................................. 115
brim of .......................................................................... 85 vesical ......................................................................... 302
cavity of ........................................................................ 85 Plexus (venous)
false .............................................................................. 85 basilar ......................................................................... 379
greater ........................................................................... 85 pampiniform ...................................................... 234, 279
inlet of .......................................................................... 85 pterygoid .................................................................... 380
lesser ............................................................................. 85 rectal ........................................................................... 285
renal ............................................................................ 270 vertebral ..................................................................... 356
true ................................................................................ 85 Pneumonectomy ............................................................... 221
Penis ................................................................................. 243 Pneumonia ....................................................................... 221
bulb of ................................................................ 244, 245 Pneumonitis ..................................................................... 221
corpora cavernosa of .................................................. 243 Pneumothorax .................................................................. 220
corpus of ..................................................................... 243 Pons
corpus spongiosum of ................................................ 243 gross anatomy ............................................................ 445
crura of ....................................................................... 245 internal structure ................................................ 447, 470
glans of ....................................................................... 243 Porta hepatis ..................................................................... 259
root of ......................................................................... 245 Pouch
Pericarditis ....................................................................... 222 Morissons .................................................................. 309
Pericardium ...................................................................... 199 of Doughlas ............................................... 288, 294, 309
Perineum .......................................................................... 241 rectouterine ............................................... 288, 294, 298
Peritoneum ............................................................... 295, 309 rectovesical ............................................... 287, 290, 298
sac of, greater ............................................................. 296 vesicouterine ...................................................... 294, 298
sac of, lesser ............................................................... 296 Prepuce ............................................................................. 243
sac, lesser ................................................................... 297 Process
Pes planus ......................................................................... 159 acromion ..................................................................... 6, 7
Peyers patches ................................................................ 253 alveolar of maxilla ..................................................... 322
Pharynx ............................................................................ 422 articular, of vertebra .................................................. 167
laryngeal part of ......................................................... 422 clinoid, anterior .................................................. 326, 352
nasal part of ................................................................ 422 clinoid, posterior ................................................ 327, 352
oral part of .................................................................. 422 condylar, of mandible ................................................ 331
Phocomelia ......................................................................... 72 coracoid ...................................................................... 6, 7
Pia mater .......................................................................... 352 coronoid ............................................................... 13, 331
Piles .......................................................................... 289, 310 mastoid ....................................................................... 321
Pineal body ....................................................................... 431 odontoid ..................................................................... 316
Plantar aponeurosis ............................................................ 49 olecranon ...................................................................... 13
Plate palatal ......................................................................... 322
cribriform of ethmoid ................................................ 326 pterygoid ............................................................ 321, 323
horizontal, of palatine ................................................ 322 spinous of vertebra .................................................... 166
perpendicular, of palatine bone ................................. 323 styloid, of fibula ........................................................... 92
pterygoid, lateral ........................................................ 324 styloid, of radius .......................................................... 12
tarsal ........................................................................... 335 styloid, of temporal bone ........................................... 321
tympanic ..................................................................... 325 styloid, of ulna ............................................................. 13
Pleura ........................................................................ 190, 220 transverse of vertebra ................................................ 166
Pleurisy ............................................................................. 220 uncinate, of pancreas ................................................. 263
Pleuritis ............................................................................ 220 xiphoid ....................................................................... 168
Processus vaginalis .................................................. 242, 308
Promontory, of ear ........................................................... 412
509
510
Promontory, sacral ........................................................... 227 Septum primum defect .................................................... 221
Prosencephalon ................................................................ 455 Septum secundum defect ................................................ 221
Prostate ............................................................................. 312 Sheath
Prostatectomy ................................................................... 312 carotid ........................................................................ 365
Pterion .............................................................................. 321 femoral ....................................................................... 163
Ptosis ................................................................................ 440 fibrous flexor ........................................................ 47, 145
Pudendum ........................................................................ 245 rectus .......................................................................... 235
Pupil ................................................................................. 334 synovial, of hand .................................................... 47, 64
Putamen ............................................................................ 479 Sigmoidoscopy ................................................................. 310
Pyelography ...................................................................... 313 Sinus
Pyramid, renal .................................................................. 270 carotid ........................................................................ 432
Pyramid, of ear ................................................................. 412 coronary ...................................................................... 207
lactiferous ..................................................................... 24
Raynauds disease ............................................................ 74 of epididymis ............................................................. 242
Recess of pericardium, oblique ............................................. 199
epitympanic ................................................................ 409 of pericardium, transverse ......................................... 199
sphenoethmoidal ....................................... 330, 420, 422 prostatic ...................................................................... 291
Rectocoele ........................................................................ 313 renal ............................................................................ 270
Rectum ............................................................. 257, 287, 311 tonsillar ....................................................................... 422
Region Sinus (venous)
infratemporal .............................................................. 339 cavernous ........................................................... 378, 439
inguinal ...................................................................... 224 meningeal, middle ..................................................... 379
lumbar ........................................................................ 224 occipital ...................................................................... 378
olfactory ..................................................................... 479 petrosal, inferior ......................................................... 379
submandibular ........................................................... 344 petrosal, superior ....................................................... 379
temporal ..................................................................... 339 sagittal, inferior .......................................................... 378
umbilical .................................................................... 224 sagittal, superior ........................................................ 378
Reticular formation .......................................................... 473 sigmoid ....................................................................... 378
Retina ............................................................................... 406 sphenoparietal ............................................................ 379
bipolar cells of ........................................................... 406 straight ........................................................................ 378
central region of of .................................................... 406 transverse ................................................................... 378
cones of ...................................................................... 406 Sinus (paranasal)
ganglion cells of ......................................................... 406 ethmoidal ............................................................ 330, 422
rods of ......................................................................... 406 frontal ................................................................. 329, 437
Retinaculum maxillary ............................................................ 329, 422
extensor of wrist .......................................................... 64 sphenoidal .......................................................... 329, 422
flexor of wrist ............................................................... 48 Sinus, intracranial
flexor, of ankle ........................................................... 143 cavernous ................................................................... 352
of ankle, extensor ....................................................... 134 occipital ...................................................................... 352
of ankle, peroneal ...................................................... 134 petrosal, superior ....................................................... 352
patellar ........................................................................ 155 sagittal, inferior .......................................................... 351
Retinal quadrants ............................................................. 484 sagittal, superior ........................................................ 351
Rhombencephalon ........................................................... 455 straight ........................................................................ 351
Ridge Sinusitis ............................................................................ 443
supracondylar ................................................................. 9 Skull ................................................................................. 317
Rima glottidis .................................................................. 426 Space
Ring epidural ...................................................................... 353
anorectal ..................................................................... 283 forearm, of Parona ....................................................... 76
femoral ....................................................................... 163 midpalmar .................................................................... 76

inguinal, superficial ........................................... 105, 230 perineal, deep ............................................................. 244
perineal, superficial ................................................... 244
Saccule ............................................................................. 414 peritoneal, around liver ............................................. 260
Salpingitis ........................................................................ 312 pulp ............................................................................... 76
Scala tympani ................................................................... 414 quadrangular ................................................................ 30
Scala vestibuli .................................................................. 414 subarachnoid .............................................................. 352
Scalp ................................................................................. 333 subdural ...................................................................... 352
Scapular region .................................................................. 29 subhepatic .......................................................... 260, 309
Sciatica ............................................................................. 162 subphrenic .......................................................... 260, 309
Sclera ................................................................................ 405 supraclavicular ........................................................... 365
Scoliosis ........................................................................... 219 suprasternal ................................................................ 365
Scrotum .................................................................... 241, 308 thenar ............................................................................ 76
Segments triangular ...................................................................... 30
bronchopulmonary ..................................................... 189 Sphincter
spinal .......................................................................... 355 ampullae ..................................................................... 263
renal ............................................................................ 271 anal, external .............................................................. 288
Sella turcica ..................................................................... 327 anal, internal .............................................................. 288
Seminal vesicle ................................................................ 292 choledochus ............................................................... 262
Septum pancreaticus ............................................................... 263
interatrial .................................................................... 194 Spina bifida ...................................................................... 306
interventricular ................................................... 194, 199 Spina bifida occulta ......................................................... 306
orbital ......................................................................... 335
INDEX
Spine Tract .................................................................................. 458
illiac, anterior inferior ................................................. 80 corticonuclear ............................................................ 460
illiac, anterior superior ................................................ 80 corticospinal ............................................................... 458
illiac, posterior inferior ................................................ 80 geniculocalcarine ....................................................... 486
illiac, posterior superior .............................................. 80 iliotibial ...................................................................... 105
ischial ........................................................................... 81 olfactory ..................................................................... 479
mental ......................................................................... 331 olivospinal .................................................................. 460
of scapula ....................................................................... 6 optic .................................................................... 387, 486
of sphenoid ................................................................. 324 reticulospinal .............................................................. 460
Spleen .............................................................. 264, 306, 312 rubrospinal ................................................................. 459
Splenectomy ..................................................................... 312 spinocerebellar, dorsal ............................................... 465
Splenomegaly ................................................................... 312 spinocerebellar, ventral .............................................. 465
Splenovenography ........................................................... 312 spino-olivary .............................................................. 464
Spondylolisthesis ............................................................. 306 spinotectal .................................................................. 464
Sternal puncture ............................................................... 219 tectospinal .................................................................. 459
Stomach .................................................................... 250, 304 vestibulospinal ........................................................... 460
Stria Tredelenberg sign ............................................................. 119
olfactory ..................................................................... 479 Trendelenburg test ........................................................... 162
terminalis ............................................................ 474, 480 Triangle
medullaris thalami ..................................................... 474 anal ..................................................................... 241, 247
medullares .................................................................. 491 anterior ............................................................... 358, 364
Subthalamic region .......................................................... 477 carotid ................................................................ 359, 364
Sulcus digastric .............................................................. 358, 364
chiasmaticus ............................................................... 326 femoral ....................................................................... 106
intertubercular ................................................................ 9 muscular ............................................................. 359, 365
preauricular .................................................................. 81 posterior ............................................................. 358, 364
sigmoid ....................................................................... 328 submental ........................................................... 358, 364
terminalis .................................................................... 196 suboccipital ................................................................ 365
terminalis, of tongue .................................................. 347 urogenital ........................................................... 241, 244
transverse ................................................................... 328 Trigone of urinary bladder .............................................. 290
tympanic ..................................................................... 410 Trunk
Sustentaculum tali ............................................................. 96 lumbosacral ........................................................ 281, 285
Symphysis menti .............................................................. 331 sympathetic ....................................... 217, 303, 401, 439
Syndactyly .......................................................................... 72 thyrocervical ................................................................ 32
Syndrome Trunk, lymphatic
carpal tunnel ................................................................. 75 bronchomediastinal, left ............................................ 212
Horners ...................................................................... 441 bronchomediastinal, right ......................................... 212
scalene .......................................................................... 74 jugular, left ................................................................. 212
scalenus anticus ........................................................... 74 jugular, right .............................................................. 212
thoracic outlet ............................................................ 219 subclavian, left ........................................................... 211
subclavian, right ........................................................ 212
Taenia thalami ................................................................ 474 Tubal pregnancy .............................................................. 312
Tapetum ............................................................................ 458 Tube
Tarsus ............................................................................... 335 auditory ..................................................... 324, 409, 413
Teeth ................................................................................. 418 uterine ................................................................. 294, 312
Tegmen tympani ...................................................... 325, 327 Tuber omentale ................................................................ 263
Tela choroidea ................................................. 353, 488, 490 Tubercle
Telencephalon .................................................................. 455 adductor ........................................................................ 87
Tendon, conjoint .............................................................. 231 anterior, of calcaneus ................................................... 97
Tennis elbow ...................................................................... 73 articular ...................................................................... 325
Tentorium cerebelli .......................................................... 351 conoid ............................................................................. 4
Testis ......................................................................... 241, 308 deltoid ............................................................................. 4
mediastinum ............................................................... 242 dorsal, of radius ........................................................... 12
rete .............................................................................. 242 greater ............................................................................. 9
Thalamus .......................................................................... 474 infraglenoid .................................................................... 6
Thorax, walls of ............................................................... 174 lesser ............................................................................... 9
Thromboangitis obliterans .............................................. 162 of iliac crest .................................................................. 80
Thymus ............................................................ 185, 210, 222 of talus .......................................................................... 97
Thyroidectomy ................................................................. 441 peroneal ........................................................................ 96
Thyrotoxicosis .................................................................. 441 pubic ............................................................................. 81
Tongue .............................................................................. 347 quadrate ........................................................................ 86
Tonsil supraglenoid ............................................................... 6, 7
lingual ......................................................................... 347 Tuberculum sellae ............................................................ 327
palatine .............................................. 422, 424, 437, 443 Tuberosity
pharyngeal .......................................................... 422, 443 deltoid ............................................................................. 9
tubal ............................................................................ 422 gluteal ........................................................................... 87
Trabeculae carnae ............................................................ 197 iliac ............................................................................... 81
Trachea .................................................... 186, 218, 220, 428 ischial ........................................................................... 81
Tracheostomy ........................................................... 220, 443 maxillary .................................................................... 322
of cuboid ...................................................................... 99
of navicular .................................................................. 97
511
512
Tuberosity (continued) Vein (continued)
of ulna .......................................................................... 13 of face ......................................................................... 338
radial .............................................................................. 11 of hand ......................................................................... 34
tibial ............................................................................. 90 of lower limb .............................................................. 102
Tunica vaginalis ............................................................... 241 of thoracic wall .......................................................... 181
Tunnel, carpal .............................................................. 16, 48 of upper limb ................................................................ 34
Tunnel,carpal ..................................................................... 47 ophthalmic, inferior ................................................... 379
Tympanum ....................................................................... 409 ophthalmic, superior .................................................. 379
Ultrasonography ............................................................ 313 ovarian ........................................................................ 279
Umbilicus ................................................................. 225, 307 perforating .................................................................. 104
Urachus ............................................................................ 307 phrenic, inferior ......................................................... 279
Ureter ....................................................... 272, 289, 306, 312 popliteal ...................................................................... 160
Urethra ............................................................................. 291 portal .......................................................................... 269
female ......................................................................... 292 pulmonary .................................................................. 207
male ............................................................................ 291 renal ............................................................................ 279
membranous part ....................................................... 291 retromandibular ......................................................... 380
penile part .................................................................. 291 saphenous, great ................................................. 102, 160
prostatic part .............................................................. 291 saphenous, long ......................................................... 102
sphincters of ............................................................... 292 saphenous, short ................................................ 102, 160
spongiose part ............................................................ 291 saphenous, small ........................................................ 102
Uterus ....................................................................... 294, 312 splenic ........................................................................ 269
Utricle ............................................................................... 414 subclavian .......................................................... 377, 438
Utricle, prostatic ............................................................. 291 subcostal ..................................................................... 182
Uvula ................................................................................ 417 suprarenal; .................................................................. 279
Vagina ...................................................................... 295, 313 temporal, superficial .................................................. 380
Vaginal examination ........................................................ 313 testicular ..................................................................... 279
Vallecula ........................................................................... 348 thoracic, internal ........................................................ 181
Valve thyroid, inferior .......................................................... 380
anal ............................................................................. 288 thyroid, middle ........................................................... 380
aortic ........................................................................... 198 thyroid, superior ........................................................ 380
mitral .......................................................................... 198 umbilical .................................................................... 261
of coronary sulcus ...................................................... 196 varicose ...................................................................... 162
of inferior vena cava .................................................. 196 vertebral ..................................................................... 381
pulmonary .................................................................. 198 Vena cava
tricuspid ..................................................................... 198 inferior ................................................................ 278, 306
Varices, oesophageal ................................................ 220, 310 superior ............................................................... 207, 219
Varicocele ......................................................................... 308 Venae cordis minimae .................................................... 196
Vasectomy ........................................................................ 309 Ventricle of heart
Vault, of skull ................................................................... 317 left ............................................................................... 197
Vein Ventricles, of brain
auricular, posterior ..................................................... 380 fourth .......................................................................... 491
axillary .......................................................................... 23 lateral .......................................................................... 488
azygos ......................................................................... 181 Vertebra
azygos system of ........................................................ 181 atlas ............................................................................ 315
basilic ........................................................................... 35 axis ............................................................................. 316
brachiocephalic, left .......................................... 209, 219 cervical, seventh ........................................................ 317
brachiocephalic, right ........................................ 209, 219 typical cervical ........................................................... 315
cardiac, great .............................................................. 207 Vestibule
cardiac, middle .......................................................... 207 aortic ........................................................................... 197

cardiac, small ............................................................. 207 bulbs of ....................................................................... 246
cephalic ........................................................................ 34 of ear ........................................................................... 414
cervical, deep ............................................................. 381 of female genitalia ..................................................... 245
facial ........................................................................... 379 of larynx ..................................................................... 426
facial, common .......................................................... 379 of mouth ..................................................................... 416
femoral ............................................................... 115, 160 of nose ........................................................................ 420
hemiazygos ................................................................. 181 Villi
hemiazygos, accesssory ............................................. 181 arachnoid .................................................................... 353
hepatic ................................................................ 269, 279 Visual field ....................................................................... 484
iliac, common .................................................... 279, 306 Vntricles, of brain
iliac, external ...................................................... 279, 306 third ............................................................................ 490
iliac, internal ...................................................... 280, 285 Volkmanns ischaemic contracture ................................... 73
intercostal, posterior .................................................. 182 Vulva ................................................................................ 245
intercostal, superior ................................................... 182 Wall, abdominal ..................................................... 230, 273
jugular, anterior ......................................................... 381
jugular, external ................................................. 380, 438
jugular, internal .................................................. 377, 438
lingual ......................................................................... 379
lumbar ........................................................................ 279
maxillary .................................................................... 380
median cubital ............................................................. 35
occipital ...................................................................... 381

Essentials of Anatomy, 2nd Edition

Caricato da

Informazioni sul documento

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

Essentials of Anatomy, 2nd Edition

Caricato da

Copyright:

Formati disponibili

ESSENTIALS OF ANATOMY

JAYPEE BROTHERS MEDICAL PUBLISHERS (P) LTD.

First Edition: 2002

2008 INDERBIR SINGH

Preface to the First Edition

1. Some Descriptive Terms --------------------------------------------------------------------------- 2

PART 2: LOWER EXTREMITY

9. Bones of the Lower Limb ------------------------------------------------------------------------- 78

16. Bones and Joints of the Thorax ---------------------------------------------------------------- 165

PART 4: ABDOMEN AND PELVIS

23. Introduction to the Abdomen: Bones and Joints -------------------------------------------- 223

35. Bones of the Head and Neck ------------------------------------------------------------------- 315

PART 6: CENTRAL NERVOUS SYSTEM

48. Gross Anatomy of the Brain ------------------------------------------------------------------- 444

Index ------------------------------------------------------------------------------------------------------ 499

PART 1:UPPER EXTREMITY

1 : Some Descriptive Terms

For convenience of description the human body is divided

part of the head (and includes the region of the forehead,

Fig. 1.3. Scheme showing median and paramedian planes.

SOME DESCRIPTIVE TERMS

2 : Bones of the Upper Extremity

Fig. 2.3. Right clavicle seen from below.

Fig. 2.4. Right clavicle, showing attachments, seen from above.

Fig.2.5. Right clavicle showing attachments, seen from below.

The greater part of the scapula consists of a flat triangular

cavity that articulates with the head of the humerus. The

The acromion is continuous with the lateral end of the spine.

The coracoid process is shaped like a bent finger. The root

Some Attachments on the Scapula

Fig. 2.13. Right humerus showing attachments, seen

18. The capsular ligament of the shoulder joint is attached

Fig. 2.14. Upper end of right humerus, showing

The radius is a long bone

prominent ridge is called the dorsal

Attachments on the Radius

end of the medial margin of the

THE SKELETON OF THE

The skeleton of the hand consists of

The Trapezoid Bone

The Capitate Bone

THE METACARPAL BONES Attachments on the Skeleton of the Hand

THE PECTORAL REGION

Origin (Fig. 3.3):

Fig. 3.2. Attachments of the

Fig. 3.5. Schematic diagram to show the position of

The axilla is the region of the armpit. The

humerus in the region of the

THE AXILLARY ARTERY

The axillary artery is a continuation of the subclavian

Fig. 3.8. Some muscles related to the axillary artery

Fig. 3.10. Branches of the axillary artery.

Fig. 3.11. Axillary lymph nodes seen from the front

The first part of the artery

THE BRACHIAL PLEXUS

Basic Plan of the Brachial Plexus

The basic plan of the brachial plexus is shown in

THE MAMMARY GLANDS

Fig. 3.14. Schematic vertical section through

Fig. 3.15. Scheme to show the lymphatic drainage of the breast.

4 : The Back and Scapular Region

Movements of the scapula

The scapula is held in position by muscles attached to it and its position

body (Fig. 4.1). Rotation is described