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MANUAL OF ANATOMY

PUBLISHED BY THE JOINT COMMITTEE OF HENRY FROWDE AND HODDER & STOUGHTON
AT THE OXFORD PRESS WAREHOUSE, 17 WARWICK SQUARE, LONDON, E.C-4

CUNNINGHAM'S MANUAL

OF

PRACTICAL ANATOMY

REVISED AND EDITED BY

ARTHUR ROBINSON

PROFESSOR OF ANATOMY I.V THE UNIVERSITY OF EDINBURGH

SEVEN tH EDITION 1

MEDICAL SCHOOI

VOLUME THIRD
HEAD AND NECK

WITH 233 ILLUSTRATIONS, MANY OF WHICH ARE COLOURED

WILLIAM WOOD AND COMPANY

EDINBURGH, GLASGOW, AND LONDON

HENRY FROWDE AND HODDER & STOUGHTON

1921

3 A

v.

Printed in Great Britain by R. & R. CLARK. LIMITED, Edinburgh.

1903;

3;v/ Edition, 1906.

'.*M EJitjpfb 1907.

:?A Editicn\ 191?.

' 6^/i Edition, 1914.

6M Edition, -2nd Impression. 1917.

6/// Edition, yd Impression, 1918.

7i*/j Edition, 1920.

7 /A Edition, -2nd Impression, 1921

34
CI

PREFACE TO
THE SEVENTH EDITION

IN this edition the general text has been revised, many new
figures, representing dissections, sections and radiographs,
have been introduced. The instructions for dissection have
been printed in a distinctive indented type ; in many cases
they have been rewritten and in some cases amplified.

The latter changes, together with the additional figures,

have caused so much increase of size that it has been deemed
advisable to publish the book in three volumes. Vol. I. :
Superior Extremity and Inferior Extremity ; Vol. II. : Thorax
and Abdomen ; Vol. III. : Head and Neck.

As was the case in previous editions, I am indebted to

Dr. E. B. Jamieson for many suggestions, for his invaluable
help in the revision of the text and for the preparation of
the Index.

My thanks are due to Dr. Robert Knox, to Major A. W.

Pirie and to Major T. Rankin for the use of radiographs,
which they very kindly prepared for me, and to Mr. J. T.
Murray for the new drawings of sections and dissections.

ARTHUR ROBINSON.
s.*^"

Oct, n, 1919.

CONTENTS

HEAD AND NECK.

PAGE

FACE AND FRONTAL REGION OF HEAD, ... 2

SIDE OF THE NECK, ...... 31

POSTERIOR TRIANGLE, ...... 32

THE SCALP AND THE SUPERFICIAL STRUCTURES OF THE

TEMPORAL REGION, . . . . .42

THE DISSECTION OF THE BACK, ..... 55

REMOVAL OF THE BRAIN, ...... 98

THE ANTERIOR PART OF THE NECK, . . . .120

PAROTID REGION, ....... 161

TEMPORAL AND INFRATEMPORAL REGIONS, . . .167

SUBMAXILLARY REGION, . . . . . .183

OTIC GANGLION AND TENSOR VELI PALATINI, . . .199

THE GREAT VESSELS AND NERVES OF THE NECK, . . 200

THYREOID GLAND TRACHEA (ESOPHAGUS, . . 227

SCALENE MUSCLES AND RECTUS LATERALIS, . .231

THE LATERAL PART OF THE MIDDLE CRANIAL FOSSA, . 234

THE ORBIT, ....... 242

PREVERTEBRAL REGION, . . ... . . 262

THE JOINTS OF THE NECK, ..... 269

MOUTH AND PHARYNX, . . . . . .277

CAROTID CANAL, . . . . . ... 299

NERVUS MAXILLARIS, . . . . . .300

NASAL CAVITIES, ....... 304

SPHENO - PALATINE GANGLION AND INTERNAL MAXILLARY .

ARTERY, ....... 317

THE LARYNX, . ... . . . . 322

THE TONGUE, ....... 346

vii

viii CONTENTS

ENCEPHALON THE BRAIN.

PAGE

BLOOD VESSELS OF THE BRAIN, ..... 376

THE BASE OF THE BRAIN, . . . . 389

THE CEREBRUM, ....... 396

VENTRICULUS LATERALIS, ..... 426

SEPTUM PELLUCIDUM FORNIX TELA CHORIOIDEA

VENTRICULI TERTII, ..... 440

THE THALAMI AND THE THIRD VENTRICLE, . . 445

THE MESENCEPHALON, . . . . . -451

BASAL GANGLIA OF THE CEREBRAL HEMISPHERES, . . 458

THE PARTS OF THE BRAIN WHICH LIE IN THE POSTERIOR

CRANIAL FOSSA, ...... 474

THE AUDITORY APPARATUS.

EXTERNAL EAR, ....... 506

MEMBRANA TYMPANI, ... . 509

MIDDLE EAR, TYMPANIC ANTRUM, AND AUDITORY TUBE, '. 510

OSSICULA AUDITUS, . . . . . - S 1 7

TUBA AUDITIVA, ...... 520

INTRAPETROUS PART OF THE FACIAL NERVE AND THE ACOUSTIC

NERVE, ..... 523

INTERNAL EAR, ....... 527

VESTIBULUM, ....... 527

CANALES SEMICIRCULARES OSSEI, .... 528

COCHLEA, . . . . . . -529

BULBUS OCULI.

GENERAL STRUCTURE OF THE EYEBALL, . . . 533

SCLERA, ........ 534

CORNEA, ...... -535

TUNICA VASCULOSA OCULI, ..... 536

RETINA, ........ 542

CORPUS VITREUM, ...... 543

LENS CRYSTALLINA, . . . . . . 545

CHAMBERS OF THE EYEBALL, ..... 546

INDEX . . 547
A GLOSSARY

OF THE

INTERNATIONAL (B.N.A.)
ANATOMICAL TERMINOLOGY

Frontalis

GENERAL TERMS.
TERMS INDICATING SITUATION AND DIRECTION.

Referring to the long axis of the body.

/Referring to the position of the long
^ axis of the body in the erect posture.
f Referring to the front and back of the
^ body or of the limbs.
^Referring to the anterior and posterior

aspects, respectively, of the body,

and to the flexor and extensor

^ aspects of the limbs, respectively.
f Referring to position nearer the head
I or the tail end of the long axis.
~\ Used only in reference to parts of
V. the head, neck, or trunk.
Used in reference to the head, neck,

and trunk. Equivalent to cranial

and caudal respectively.

( Used only in reference to the limbs.

Proximal nearer the attached end.

I Distal nearer the free end.
rUsed in reference to planes parallel
| with the sagittal suture of the
1 skull, i.e. vertical antero-posterior
I planes.

T Used in reference to planes parallel

j with the coronal suture of the skull,
I i.e. transverse vertical planes.

ix
Longitudinalis

Longitudina

Verticalis

Vertical

Anterior
Posterior

Ventral

Dorsal
Cranial

Anterior 'i
Posterior J
Ventral >

Dorsal J
Cranial ^

Caudal
Superior

Caudal J
Superior \

Inferior
Proximalis

Inferior J
Proximal \

Distalis

Distal j

Sagittalis

Sagittal
Frontal

GLOSSARY

Horizontalis

Medianus
Medialis

Lateralis
Intermedius

Superficialis

Profundus

Externus

Internus
Ulnaris

Radialis
Tibial

Horizontal

Median
Medial ^j

Lateral J
Intermediate

Superficial\
Deep /
External^

Internal
Ulnar \

Radial/
Tibial ^

Fibular FibularJ
Used in reference to planes at right

angles to vertical planes.

Referring to the median vertical

antero-posterior plane of the body.

Referring to structures relatively

nearer to or further away from the

median plane.

Referring to structures situated be-

tween more medial and more

lateral structures.
Referring to structures nearer to and

further away from the surface.

Referring, with few exceptions, to the

walls of cavities and hollow organs.

Not to be used as synonymous with

. medial and lateral.
Used in reference to the medial and

lateral borders of the forearm,

respectively.
Used in reference to the medial and

lateral borders of the leg, re-

spectively.

THE BONES.

B.N.A. TERMINOLOGY.

Vertebrae

Fovea costalis superior

P'ovea costalis inferior

Fovea costalis transversalis

Radix arcus vertebrae

Atlas

Fovea dentis
Epistropheus
Dens

Sternum

Corpus sterni
Processus xiphoideus
Incisura jugularis
Planum sternale

Ossa Granii.
Os frontale

Spina frontalis
Processus zygomaticus
Facies cerebralis
Facies frontalis
Pars orbitalis

OLD TERMINOLOGY.

Vertebras

Incomplete facet for head of rib,

upper
Incomplete facet for head of rib,

lower

Facet for tubercle of the rib

Pedicle

Atlas

Facet for odontoid process

Axis

Odontoid process

Sternum
Gladiolus
Ensiform process
Supra-sternal notch
Anterior surface

Bones of Skull.
Frontal

Nasal spine

External angular process

Internal surface
Frontal surface
Orbital plate
GLOSSARY

XI

B.N.A. TERMINOLOGY.

Os parietale

Lineae temporales
Sulcus transversus
Sulcus sagittalis

Os occipitale

Canal is hypoglossi
Foramen occipitale magnum
Canalis condyloideus
Sulcus transversus
Sulcus sagittalis
Clivus

Linea nuchse suprema

Linea nuchge superior
Linea nuchae inferior

Os sphenoidale

Crista infratemporalis

Sulcus chiasmatis

Crista sphenoidalis

Spina angularis

Lamina medialis processus ptery-

goidei
Lamina lateralis processus ptery-

goidei

Canalis pterygoideus [Vidii]

Fossa hypophyseos
Sulcus caroticus
Conchas sphenoidales
Hamulus pterygoideus
Canalis pharyngeus
Tuberculum sellae
Fissura orbitalis superior

Os temporale
Canalis facialis [Fallopii]
Hiatus canalis facialis
Vagina processus styloidei
Incisura mastoidea
Impressio trigemini
Eminentia arcuata

Sulcus sigmoideus
Fissura petrotympanica
Fossa mandibularis
Semicanalis tubae auditivse

Os ethmoidale

Labyrinthus ethmoidalis
Lamina papyracea
Processus uncinatus

OLD TERMINOLOGY.

Parietal

Temporal ridges
Groove for lateral sinus
Groove for sup. long, sinus

Occipital

Anterior condyloid foramen

Foramen magnum
Posterior condyloid foramen
Groove for lateral sinus
Groove for sup. long, sinus
Median part of upper surface of

basi-occipital
Highest curved line
Superior curved line
Inferior curved line

Sphenoid

Pterygoid ridge
Optic groove
Ethmoidal crest
Spinous process
Internal pterygoid plate

External pterygoid plate

Vidian canal
Pituitary fossa
Cavernous groove
Sphenoidal turbinal bones
Hamular process
Pterygo-palatine canal
Olivary eminence
Sphenoidal fissure

Temporal Bone

Aqueduct of Fallopius

Hiatus Fallopii

Vaginal process of tympanic bone

Digastric fossa

Impression for Gasserian ganglion

Eminence for sup. semicircular

canal

Fossa sigmoidea
Glaserian fissure
Glenoid cavity
Eustachian tube

Ethmoid
Lateral mass
Os planum
Unciform process

Xll

GLOSSARY

B.N.A. TERMINOLOGY.

Os lacrimale

Hamulus lacrimalis
Crista lacrimalis posterior

Os nasale

Sulcus ethmoidalis

Maxilla

Facies anterior
Fades infra-temporalis
Sinus maxillaris
Processus frontalis
Processus zygomaticus
Canales alveolares
Canalis naso-lacrimalis
Os incisivum
Foramen incisivum

Os palatinum

Pars perpendicularis
Crista conchalis
Crista ethmoidalis
Pars horizontalis

Os zygomaticum
Processus temporalis
Processus fronto-sphenoidalis
Foramen zygomatico-orbitale
Foramen zygomatico-faciale

Mandibula
Spina mentalis
Linea obliqua
Linea mylohyoidea
Incisura mandibulae
Foramen mandibulare
Canalis mandibulse
Protuberantia mentalis

OLD TERMINOLOGY.

Lachrymal Bone
Hamular process
Lachrymal crest

Nasal Bone

Groove for nasal nerve

Superior Maxillary Bone

Facial or external surface

Zygomatic surface
Antrum of Highmore
Nasal process
Malar process
Posterior dental canals
Lacrimal groove
Premaxilla
Anterior palatine foramen

Palate Bone
Vertical plate
Inferior turbinate crest
Superior turbinate crest
Horizontal plate

Malar Bone

Zygomatic process
Frontal process
Tempora-malar canal
Malar foramen

Inferior Maxillary Bone

Genial tubercle or spine
External oblique line
Internal oblique line
Sigmoid notch
Inferior dental foramen
Inferior dental canal
Mental process

The Skull as a Whole.

Ossa suturarum

Foveolse granular es (Pacchioni)

Fossa pterygo-palatina

Canalis pterygo-palatinus

Foramen lacerum

Choanse

Fissura orbitalis superior

Fissura orbitalis inferior

Wormian bones
Pacchionian depressions
Spheno-maxillary fossa
Posterior palatine canal
Foramen lacerum medium
Posterior nares
Sphenoidal fissure
Spheno-maxillary fissure

GLOSSARY

Xlll

Upper Extremity.

B.N.A. TERMINOLOGY. OLD TERMINOLOGY.

Clavicula

Tuberositas coracoidea
Tuberositas costalis

Scapula

Incisura scapularis
Angulus lateralis
Angulus medialis

Humerus

Sulcus intertubercularis
Crista tuberculi majoris
Crista tuberculi minoris
Facies anterior medialis
Fades anterior lateralis
Margo medialis
Margo lateralis
Sulcus nervi radialis
Capitulum

Epicondylus medialis
Epicondylus lateralis

Ulna

Incisura semilunaris
Incisura radialis
Crista interossea
Facies dorsalis
Facies volaris
Facies medialis
Margo dorsalis
Margo volaris

Radius

Tuberositas radii
Incisura ulnaris
Crista interossea
Facies dorsalis
Facies volaris
Facies lateralis
Margo dorsalis
Margo volaris

Carpus

Os naviculare
Os lunatum
Os triquetrum
Os multangulum majus
Os multangulum minus
Os capitatum
Os hamatum
Clavicle

Impression for conoid ligament

Impression for rhomboid ligament

Scapula

Supra-scapular notch
Anterior or lateral angle
Superior angle

Humerus

Bicipital groove

External lip

Internal lip
Internal surface
External surface
Internal border
External border
Musculo-spiral groove
Capitellum
Internal condyle
External condyle

Ulna

Greater sigmoid cavity

Lesser sigmoid cavity
External or interosseous border
Posterior surface
Anterior surface
Internal surface
Posterior border
Anterior border

Radius

Bicipital tuberosity

Sigmoid cavity

Internal or interosseous border

Posterior surface

Anterior surface

External surface

Posterior border

Anterior border

Carpus
Scaphoid
Semilunar
Cuneiform
Trapezium
Trapezoid
Os magnum
Unciform

XIV

GLOSSARY

Lower

B.N.A. TERMINOLOGY.
Os coxae

Linea glutsea anterior

Linea glutaea posterior
Linea terminalis
Spina ischiadica
Incisura ischiadica major
Incisura ischiadica minor
Tuberculum pubicum
Ramus inferior oss. pubis
Ramus superior oss. pubis
Ramus superior ossis ischii
Ramus inferior oss. ischii
Pecten ossis pubis
Facies symphyseos

Pelvis

Pelvis major

Pelvis minor

Apertura pelvis minoris superior

Apertura pelvis minoris inferior

Linea terminalis

Femur

Fossa trochanterica
Linea intertrochanterica
Crista intertrochanterica
Condylus medialis
Condylus lateralis
Epicondylus medialis
Epicondylus lateralis
Tibia

Condylus medialis
Condylus lateralis
Eminentia intercondyloidea
Tuberositas tibiae
Malleolus medialis

Fibula

Malleolus lateralis
Apex capituli fibulae

Extremity.

OLD TERMINOLOGY.
Innominate Bone
Middle curved line
Superior curved line
Margin of inlet of true pelvis
Spine of the ischium
Great sacro-sciatic notch
Lesser sacro-sciatic notch
Spine of pubis
Descending ramus of pubis
Ascending ramus of pubis
Body of ischium
Ramus of ischium
Pubic part of ilio-pectineal line
Symphysis pubis

Pelvis

False pelvis

True pelvis

Pelvic inlet

Pelvic outlet

Margin of inlet of true pelvis

Femur

Digital fossa

Spiral line

Post, intertrochanteric line

Inner condyle

Outer condyle

Inner tuberosity
Outer tuberosity

Tibia

Internal tuberosity
External tuberosity
Spine
Tubercle
Internal malleolus

Fibula

External malleolus
Styloid process

Bones of the Foot.

Talus

Calcaneus

Tuber calcanei

Processus medialis tuberis calcanei

Processus lateralis tuberis calcanei

Os cuneiforme primum

Os cuneiforme secundum

Os cuneiforme tertium

Astragalus
Os calcis

Tuberosity of

Inner

Outer

Inner cuneiform
Middle cuneiform.
Outer cuneiform.

GLOSSARY xv

THE LIGAMENTS.

Ligaments of the Spine.

B. N.A. TERMINOLOGY. OLD TERMINOLOGY.

Lig. longitudinale anterius Anterior common ligament

Lig. longitudinale posterius Posterior common ligament

Lig. flava Ligamenta subflava

Membrana tectoria Posterior occipito-axial ligament

Articulatio atlanto-epistrophica Joint between the atlas and the axis

Lig. alaria .Odontoid or check ligaments

Lig. apicis dentis Suspensory ligament

The Ribs.

Lig. capituli costse radiatum Anterior costo- vertebral or stellate

ligament

Lig. sterno-costale interarticulare Interarticular chondro-sternal liga-

ment

Lig. sterno-costalia radiata Anterior and posterior chondro-

sternal ligament

Lig. costoxiphoidea Chondro-xiphoid ligaments

The Jaw.

Lig. temporo-mandibulare External lateral ligament of the jaw

Lig. spheno-mandibulare Internal lateral ligament of the jaw

Lig. stylo-mandibulare Stylo-maxillary ligament

Upper Extremity.

Lig. costo-claviculare Rhomboid ligament

Labrum glenoidale Glenoid ligament

Articulatio radio-ulnaris proximalis Superior radio-ulnar joint

Lig. collaterale ulnare Internal lateral ligament of elbow

joint

Lig. collaterale radiale External lateral ligament

Lig. annulare radii Orbicular ligament

Chorda obliqua Oblique ligament of ulna

Articulatio radio-ulnaris distalis Inferior radio-ulnar joint

Discus articularis Triangular fibre-cartilage

Recessus sacciformis Membrana sacciformis

Lig. radio-carpeum volare Anterior ligament of the radio-

carpal joint

Lig. radio-carpeum dorsale Posterior ligament of the radio-

carpal joint
Lig. collaterale carpi ulnare Internal lateral ligament of the

wrist joint
VOL. Ill b

XVI

GLOSSARY

B.N.A. TERMINOLOGY.
Lig. collaterale carpi radiale

Articulationes intercarpse
Lig. accessoria volaria

Lig. capitulorum (oss. metacar-

palium) transversa
Lig. collateralia

OLD TERMINOLOGY.

External lateral ligament of the

wrist joint
Carpal joints
Palmar ligaments of the metacarpo-

phalangeal joints
Transverse metacarpal ligament

Lateral phalangeal ligaments

The Lower Extremity.

Lig. arcuatum

Lig. sacro-tuberosum

Processus falciformis
Lig. sacro-spinosum
Labrum glenoidale
Zona orbicularis
Ligamentum iliofemorale
Lig. ischio-capsulare
Lig. pubo-capsulare
Lig. popliteum obliquum
Lig. collaterale fibulare
Lig. collaterale tibiale
Lig. popliteum arcuatum
Meniscus lateralis
Meniscus medialis
Plica synovialis patellaris
Plicae alares

Articulatio tibio-fibularis
Lig. capituli fibulae

Syndesmosis tibio-fibularis

Lig. deltoideum

Lig. talo-fibulare anterius

Lig. talo-fibulare posterius

Lig. calcaneo-fibulare
Lig. talo-calcaneum laterale
Lig. talo-calcaneum mediale

Lig. calcaneo-naviculare plantare

Lig. talo-naviculare

Pars calcaneo-navicularis^ lig.

J-bifur-
Pars calcaneo-cuboidea J catum

Subpubic ligament

Great sacro-sciatic ligament

Falciform process

Small sacro-sciatic ligament

Cotyloid ligament
Zonular band

Y-shaped ligament

Ischio-capsular band

Pubo-femoral ligament

Ligament of Winslow

Long external lateral ligament

Internal lateral ligament

Arcuate popliteal ligament

External semilunar cartilage

Internal semilunar cartilage

Lig. mucosum

Ligamenta alaria

Superior tibio-fibular articulation

Anterior and posterior superior

tibio-fibular ligaments

Inferior tibio-fibular articulation

Internal lateral ligament of ankle

Anterior fasciculus of external

lateral ligament

Posterior fasciculus of external

lateral ligament

Middle fasciculus of external lateral

ligament

External calcaneo-astragaloid liga-

ment

Internal calcaneo-astragaloid liga-

ment

Inferior calcaneo-navicular ligament

Astragalo-scaphoid ligament

Superior calcaneo- scaphoid liga-

ment

Internal calcaneo-cuboid ligament

GLOSSARY

XVII

THE MUSCLES.

Muscles of the Back.

Superficial.

B.N.A. TERMINOLOGY.
Levator scapulae

OLD TERMINOLOGY.
Levator anguli scapulae

Muscles of the Chest.

Serratus anterior Serratus magnus

Muscles of Upper Extremity.

Biceps brachii

Lacertus fibrosus
Brachialis
Triceps brachii

Caput mediale

Caput laterale
Pronator teres

Caput ulnare
Brachio-radialis
Supinator

Extensor carpi radialis longus

Extensor carpi radialis brevis
Extensor indicis proprius
Extensor digiti quinti proprius
Abductor pollicis longus
Abductor pollicis brevis
Extensor pollicis brevis
Extensor pollicis longus
Lig. carpi transversum
Lig. carpi dorsale
Biceps

Bicipital fascia
Brachialis anticus
Triceps

Inner head

Outer head
Pronator radii teres

Coronoid head
Supinator longus
Supinator brevis
Extensor carpi radialis longior
Extensor carpi radialis brevior
Extensor indicis
Extensor minimi digiti
Extensor ossis metacarpi pollicis
Abductor pollicis
Extensor primi internodii pollicis
Extensor secundi internodii pollicis
Anterior annular ligament
Posterior annular ligament

Muscles of Lower Extremity.

Tensor fasciae latae

Canalis adductorius (Hunteri)

Trigonum femorale (fossa Scarpce

major)

Canalis femoralis
Annulus femoralis
M. quadriceps femoris

Rectus femoris

Vastus lateralis

Vastus intermedius

Vastus medialis

M. articularis genu
Tibialis anterior

Tensor fasciae femoris

Hunter's canal
Scarpa's triangle

Crural canal
Crural ring
Quadriceps

Rectus femoris

Vastus externus

Crureus

Vastus internus

Subcrureus
Tibialis anticus

xviii GLOSSARY

B.N.A. TERMINOLOGY. OLD TERMINOLOGY.

Tendo calcaneus Tendo Achillis

Tibialis posterior Tibialis posticus

Quadratus plant* Accessorius

Lig. transversum cruris Upper anterior annular ligament

Lig. cruciatum cruris Lower anterior annular ligament

Lig. laciniatum Internal annular ligament

Retinaculum musculorum pero- "\

nseorum superius

T> .. . V External annular ligament

Retinaculum musculorum pero- I

nseorum inferius

Axial Muscles.
Muscles of the Back.

Serratus posterior superior Serratus posticus superior

Serratus posterior inferior Serratus posticus inferior

Splenius cervicis Splenius colli

Sacro-spinalis Erector spinse

Ilio-costalis Ilio-costalis

Lumborum Sacro-lumbalis

Dorsi Accessorius

Cervicis Cervicalis ascendens

Longissimus Longissimus

Dorsi Dorsi

Cervicis Transversalis cervicis

Capitis Trachelo-mastoid

Spinalis Spinalis

Dorsi Dorsi

Cervicis Colli

Capitis Capitis

Semispinalis Semispinalis

Dorsi Dorsi

Cervicis Colli

Capitis Complexus

Multifidus Multifidus spinse

Muscles of Head and Neck.

Epicranius Occipito-frontalis

Galea aponeurotica Epicranial aponeurosis

Procerus Pyramidalis nasi

Pars transversa (nasalis) Compressor naris

Pars alaris (nasalis) Dilatores naris

Auricularis anterior Attrahens aurem

Auricularis posterior Retrahens aurem

Auricularis superior Attollens aurem

Orbicularis oculi Orbicularis palpebrarum

Pars lacrimalis Tensor tarsi
GLOSSARY

xix

B.N.A. TERMINOLOGY.
Triangularis
Quadratus labii superioris

Caput zygomaticum

Caput infraorbitale

Caput angulare
Zygomaticus
Caninus

Quadratus labii inferioris

Mentalis
Platysma
Sterno-thyreoid
Thyreo-hyoid

OLD TERMINOLOGY.
Depressor anguli oris

Zygomaticus minor

Levator labii superioris

Levator labii superioris alaeque nasi

Zygomaticus major

Levator anguli oris

Depressor labii inferioris

Levator menti

Platysma myoides

Sterno-thyroid

Thyro-hyoid

Muscles and Fascia of the Orbit.

Fascia bulbi Capsule of Tenon

Septum orbitale Palpebral ligaments

Rectus lateralis Rectus externus

Rectus medialis Rectus internus

Muscles of the Tongue.

Genio-glossus Genio-hyo-glossus

Longitudinalis superior Superior lingualis

Longitudinalis inferior Inferior lingualis

Transversus linguae Transverse fibres

Verticalis linguae Vertical fibres

Pharyngo-palatinus
M. uvulae

Levator veli palatini

Tensor veli palatini
Glosso-palatinus

Muscles of the Pharynx.

Palato-pharyngeus
Azygos uvulae
Levator palati
Tensor palati
Palato-glossus

Deep Lateral Muscles of Neck.

Scalenus anterior Scalenus anticus

Scalenus posterior Scalenus posticus

Longus capitis Rectus capitis anticus major

Rectus capitis anterior Rectus capitis anticus minor

Transversus thoracis
Diaphragma

Crus mediale "j

Crus intermedium >-
Crus laterale J
Arcus lumbo - costalis

(Halleri)
Arcus lumbo - costalis
(Halleri)

Muscles of Thorax.

Triangularis sterni
Diaphragm

Crura and origins from arcuate

ligaments

medialis Ligamentum arcuatum internum

lateralis

Ligamentum arcuatum externum

XX

GLOSSARY

Muscles of the Abdomen.

B.N.A. TERMINOLOGY.

Ligamentum inguinale (Pouparti)

Ligamentum lacunare (Gimbernati)
Fibrse intercrurales
Ligamentum inguinale reflexum

(Collesi)
Annulus inguinalis subcutaneus

Crus superius

Crus inferius

Falx aponeurotica inguinalis

M. transversus abdominis
Linea semicircularis (Douglasi)
Annulus inguinalis abdominalis

OLD TERMINOLOGY.
Poupart's ligament
Gimbernat's ligament
Intercolumnar fibres
Triangular fascia

External abdominal ring

Internal pillar

External pillar
Conjoined tendon
Transversalis muscle
Fold of Douglas
Internal abdominal ring

Perineum and Pelvis.

Transversus perinei superficialis

M. sphincter urethrae membranacese
Diaphragma urogenitale

Fascia diaphragmatis urogenitalis

superior
Fascia diaphragmatis urogenitalis

inferior

Arcus tendineus fasciae pelvis

Ligamenta puboprostatica

Fascia diaphragmatis pelvis superior

Fascia diaphragmatis pelvis inferior

Transversus perinei
Compressor urethrse
Deep transverse muscle and sphinc-
ter urethrse
Deep layer of triangular ligament

Superficial layer of the triangular

ligament

White line of pelvis

Anterior and lateral true ligaments

of bladder

Visceral layer of pelvic fascia

Anal fascia
THE NERVOUS SYSTEM.

Medulla Spinalis.

Fasciculus anterior proprius (Flech-

sig)

Fasciculus lateralis proprius

Nucleus dorsalis
Pars thoracalis
Sulcus intermedius posterior
Columnse anteriores, etc.
Fasciculus cerebro-spinalis anterior
Fasciculus cerebro-spinalis lateralis

(pyramidalis)

Fasciculus cerebello-spinalis
Fasciculus a ntero- lateralis super-
ficialis

Spinal Cord.

Anterior ground or basis bundle

Lateral ground bundle

Clarke's column
Dorsal part of spinal cord
Paramedian furrow
Anterior grey column
Direct pyramidal tract
Crossed pyramidal tract

Direct cerebellar tract

Gowers' tract

GLOSSARY

xxi

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XX11

GLOSSARY
Brain.

B.N.A. TERMINOLOGY.

Rhombencephalon

Ernmentia medialis

Ala cinerea

Ala acustica

Nucleus nervi abducentis

ISuclei n. acustici

Fasciculus longitudinalis medialis

Corpus trapezoideum

Incisura cerebelli anterior

Incisura cerebelli posterior

Sulcus horizontalis cerebelli

Lobulus centralis

Folium vermis

Tuber vermis

Lobulus quadrangularis

Brachium conjunctivum cerebelli

Lobulus semilunaris superior

Lobulus semilunaris inferior

Cerebrum

Pedunculus cerebri
Colliculus superior
Colliculus inierior
Aqueductus cerebri

Foramen interventriculare

Hypothalamus

Sulcus hypothalamicus

Massa intermedia

Fasciculus thalamo-mammillaris
Pars opercularis

Thalamus

Pallium

Gyri transitivi

Fissura cerebri lateralis

Gyrus temporalis superior

Gyrus temporalis medius

Gyrus temporalis inferior

Sulcus centralis (Rolandi)

Sulcus temporalis superior

Sulcus temporalis medius

Sulcus circularis

Sulcus temporalis inferior

Gyrus fusiformis

Sulcus interparietalis

Sulcus corporis callosi

Sulcus cinguli

Fissura hippocampi

Gyrus cinguli

OLD TERMINOLOGY.

Eminentia teres

Trigonum vagi

Trigonum acusticum

Nucleus of 6th nerve

Auditory nucleus

Posterior longitudinal bundle

Corpus trapezoides

Semilunar notch (of cerebellum)

Marsupial notch
Great horizontal fissure

Lobus centralis

Folium cacuminis

Tuber valvulae

Quadrate lobule

Superior cerebellar peduncle

Postero-superior lobule

Postero-inferior lobule

Crus cerebri

Anterior corpus quadrigeminum

Posterior corpus quadrigeminum
Iter e tertio ad quartum ventri-

culum, or aqued. of Sylvius

Foramen of Monro
Subthalmic region
Sulcus of Monro
Middle commissure
Bundle of Vicq d'Azyr
Pars basilaris
Optic thalamus
Cortex cerebri
Annectant gyri
Fissure of Sylvius
First temporal gyrus
Second temporal gyrus
Third temporal gyrus
Fissure of Rolando
Parallel sulcus
Second temporal sulcus
Limiting sulcus of Reil
Occipito-temporal sulcus
Occipito-temporal convolution
Intraparietal sulcus
Callosal sulcus
Calloso-marginal fissure
Dentate fissure
Callosal convolution

GLOSSARY

xxni
B.N.A. TERMINOLOGY.
Stria terminalis
Trigonum collaterale
Hippocampus
Digitationes hippocampi
Fascia dentata hippocampi
Columna fornicis
Septum pellucidum
Inferior cornu
Commissura hippocampi
Nucleus lentiformis
Pars frontalis capsulae internae
Pars occipitalis capsulse internse
Radiatio occipito-thalamica
Radiatio corporis callosi

Pars frontalis

Pars occipitalis

OLD TERMINOLOGY.
Tsenia semicircularis
Trigonum ventriculi
Hippocampus major
Pes hippocampi
Gyrus dentatus
Anterior pillar of fornix
Septum lucidum

Descending horn of lateral ventricle

Lyra

Lenticular nucleus
Anterior limb (of internal capsule)
Posterior limb (of internal capsule)
Optic radiation
Radiation of corpus callosum

Forceps minor

Forceps major

Membranes of Brain.

Cisterna cerebello-medullaris
Cisterna interpeduncularis
Granulationes arachnoideales
Tela chorioidea ventriculi tertii
Tela chorioidea ventriculi quarti

Cisterna magna
Cisterna basalis
Pacchionian bodies
Velum interpositum
Tela choroidea inferior

Cerebral Nerves.

N. oculomotorius
N. trochlearis
N trigeminus

Ganglion semilunare (Gasseri)

N. naso-ciliaris

N. maxillaris

N. meningeus (medius)

N. zygomaticus

Rami alveolares superiores pos-

teriores

Rami alveolares superiores medii

Rami alveolares superiores an-

teriores

Ganglion spheno-palatinum

N. palatinus medius

N. mandibularis

Nervus spinosus

N. alveolaris inferior
N. abducens
N. facialis
N. intermedius
N. acusticus

Third nerve

Fourth nerve

Fifth nerve

Gasserian ganglion
Nasal nerve

Superior maxillary nerve

Recurrent meningeal nerve
Temporo-malar nerve
Posterior superior dental

Middle superior dental

Anterior superior dental

Meckel's ganglion
External palatine nerve
Inferior maxillary nerve
Recurrent nerve
Inferior dental

Sixth nerve

Seventh nerve

Pars intermedia of Wrisberg

Eighth or auditory nerve

XXIV

GLOSSARY

B.N.A. TERMINOLOGY.

Ganglion superius
N. recurrens
Ganglion jugulare
Ganglion nodosum
Plexus oesophageus anterior 1
Plexus oesophageus posterior J
Nervus accessorius
Ramus internus

Ramus externus

OLD TERMINOLOGY.
Jugular ganglion of Qth nerve
Recurrent laryngeal nerve
Ganglion of root ^ ,
Ganglion of trunk j fva g us

Plexus guise

Spinal accessory

Accessory portion of spinal

accessory nerve
Spinal portion

Spinal Nerves.

Rami posteriores

Rami anteriores

N. cutaneus colli

Nn. supraclaviculares anteriores

Nn. supraclaviculares medii

Nn. supraclaviculares posteriores

N. dorsalis scapulae

Nn. intercosto-brachiales

N. thoracalis longus

N. thoraco-dorsalis

N. cutaneus brachii medialis

N. cutaneus brachii lateralis

Fasciculus lateralis
Fasciculus medialis
N. cutaneus antibrachii lateralis

N. cutaneus antibrachii medialis

Ramus volaris

Ramus ulnaris
N. cutaneus antibrachii dorsalis

N. axillaris

N. interosseus volaris

Ramus palmaris N. mediani

Nn. digitales volares proprii

Ramus dorsalis manus
Ramus cutaneus palmaris

N. radialis

N. cutaneus brachii posterior

N. cutaneus antibrachii dorsalis

Posterior primary divisions
Anterior primary divisions
Superficial cervical nerve
Suprasternal nerves
Supraclavicular nerves
Supra-acromial nerves
Nerve to the rhomboids
Intercosto-humeral nerve
Nerve of Bell
Long subscapular nerve
Lesser internal cutaneous nerve
Cutaneous branch of circumflex

nerve

Outer cord (of plexus)

Inner cord
Cutaneous branch of musculo-cuta-

neous nerve

Internal cutaneous nerve

Anterior branch
Posterior branch
External cutaneous branch of mus-

culo-spiral
Circumflex nerve
Anterior interosseous
Palmar cutaneous branch of the

median nerve
Collateral palmar digital branches

of median nerve
Dorsal cutaneous branch of ulnar

nerve
Palmar cutaneous branch of ulnar

nerve
Musculo-spiral nerve

Internal cutaneous branch of

musculo-spiral nerve
External cutaneous branches of
musculo-spiral nerve

GLOSSARY

XXV
B.N.A. TERMINOLOGY.

N. radialis (contd.)
Ramus superficialis
N. interosseus dorsalis

Nn. digitales dorsales

N. ilio-hypogastricus

Ramus cutaneus lateralis

Ramus cutaneus anterior

N. genito-femoralis

N. lumbo-inguinalis

N. spermaticus externus

N. cutaneus femoris lateralis

N. femoralis
N. saphenus

Ramus infrapatellaris

N. ischiadicus

N. peronaeus communis

Ramus anastomoticus pero-

naeus

N. peronaeus superficialis

N. peronaeus profundus
N. tibialis

N. cutaneus surae medialis

N. suralis

N. plantaris medialis
N. plantaris lateralis
N. pudendus

OLD TERMINOLOGY.

Musculo-spiral nerve (contd.)

Radial nerve

Posterior interosseous nerve

Dorsal digital nerves
Ilio-hypogastric nerve

Iliac branch of ilio-hypogastric

nerve

Hypogastric branch of ilio-

hypogastric nerve
Genito-crural nerve

Crural branch of genito-crural

nerve
Genital branch of genito-crural

nerve

External cutaneous nerve

Anterior crural nerve
Long saphenous nerve

Patellar branch of long saph-

enous nerve
Great sciatic nerve
External popliteal nerve

Nervus communicans fibularis

Musculo-cutaneous nerve

Anterior tibial nerve

Internal popliteal nerve

Nervus communicans tibialis

Short saphenous nerve
Internal plantar
External plantar
Pudic nerve

THE HEART- AND BLOOD VESSELS.

Heart.

Atrium

Auricula cordis
Incisura cordis
Trabeculae carneae
Tuberculum intervenosum
Sulcus longitudinalis anterior
Sulcus coronarius
Limbus fossae ovalis
Valvula venae cavae
Valvula sinus coronarii
Auricle

Auricular appendix

Notch at apex of heart

Columnae carneae

Intervenous tubercle of Lower

Anterior interventricular groove

Auriculo-ventricular groove

Annulus ovalis

Eustachian valve

Valve of Thebesius

XXVI

GLOSSARY

Arteries.

B.N.A. TERMINOLOGY.
Sinus aortae
A. profunda linguae
A. maxillaris externa
A. alveolans inferior
Ramus meningeus accessorius
A. buccinatoria
A. alveolaris superior posterior
Aa. alveolares superiores anteriores
Ramus carotico-tympanicus
A. chorioidea
A. auditiva interna
Kami ad pontem

A. pericardiaco-phrenica

Rami intercostales (A. mammaria

interna)

Truncus thyreo-cervicalis
A. transversa scapulae
A. intercostalis suprema
A. transversa colli
A. thoracalis suprema
A. thoraco-acromialis
A. thoracalis lateralis
A. circumflexa scapulae
A. profunda brachii
A. collateralis radialis
A. collateralis ulnaris superior
A. collateralis ulnaris inferior
Ramus carpeus volaris
Ramus carpeus dorsalis
Aa. metacarpeae dorsales
A. volaris indicis radialis
Arcus volaris superficialis
Arcus volaris profundus
A. interossea dorsalis
A. interossea recurrens

A. interossea volaris

Ramus carpeus dorsalis

Ramus carpeus volaris

Aa. digitales volares communes

Aa. digitales volares propriae

Arteriae intestinales

A. suprarenalis media
A. hypogastrica
A. umbilicalis
A. pudenda interna
A epigastrica inferior

OLD TERMINOLOGY.
Sinuses of Valsalva
Ranine artery
Facial artery
Inferior dental artery
Small meningeal artery
Buccal artery
Posterior dental artery
Anterior superior dental arteries
Tympanic branch of int. carotid
Anterior choroidal artery
Auditory artery
Transverse arteries (branches of

Basilar artery)

Arteria comes nervi phrenici

Anterior intercostal arteries

Thyroid axis

Suprascapular artery
Superior intercostal

Transversalis colli

Superior thoracic artery

Acromio-thoracic artery

Long thoracic artery

Dorsalis scapulae

Superior profunda

Anterior branch of superior profunda

Inferior profunda

Anastomotica magna

Anterior radial carpal

Posterior radial carpal

Dorsal interosseous arteries

Radialis indicis

Superficial palmar arch

Deep palmar arch

Posterior interosseous artery

Posterior interosseous recurrent

artery

Anterior interosseous artery

Posterior ulnar carpal
Anterior ulnar carpal
Palmar digital arteries
Collateral digital arteries
Intestinal branches of sup. mesen-

teric

Middle capsular artery

Internal iliac artery
Obliterated hypogastric
Internal pudic artery
Deep epigastric artery

GLOSSARY
XXVll

. B.N.A. TERMINOLOGY.
A. spermatica externa
Aa. pudendse externse

A. circumflexa femoris medialis

A. circumflexa femoris lateralis

A. germ suprema

A. genu superior lateralis

A. genu superior medialis

A. genu media

A. genu inferior lateralis

A, genu inferior medialis

A. malleolaris anterior lateralis

A. malleolaris anterior medialis

A. peronaea

Ramus perforans

A. malleolaris posterior lateralis

A. malleolaris posterior medialis
Kami calcanei laterales
Rami calcanei mediales
A. plantaris medialis
A. plantaris lateralis
Aa. metatarseae plantares
Aa. digitales plantares

OLD TERMINOLOGY.

Cremasteric artery

Superficial and deep external pudic

arteries

Internal circumflex artery

External circumflex artery
Anastomotica magna
Superior external articular artery
Superior internal articular artery
Azygos articular artery
Inferior external articular artery
"Inferior internal articular artery
External malleolar artery
Internal malleolar artery
Peroneal artery

Anterior peroneal artery

Posterior peroneal artery
Internal malleolar artery
External calcanean artery
Internal calcanean artery
Internal plantar artery
External plantar artery
Digital branches
Collateral digital branches

Veins.

V. cordis magna

V. obliqua atrii sinistri

Lig. venae cavae sinistrre

Vv. cordis minimae

Sinus ti'ansversus

Confluens sinuum

Plexus basilaris

Sinus sagittalis superior

Sinus sagittalis inferior

Spheno-parietal sinus

V. cerebri internae

V. cerebri magna

V. terminalis

V. basalis

V. transversa scapulas

V. thoraco-acromialis

Vv. transversae colli

V. thoracalis lateralis

V. azygos
V. hemiazygos

V. hemiazygos accessoria

V. hypogastrica

V. epigastrica inferior

V. saphena magna

V. saphena parva

Great cardiac vein

Oblique vein of Marshall
Vestigial fold of Marshall
Veins of Thebesius
Lateral sinus
Torcular Herophili
Basilar sinus

Superior longitudinal sinus

Inferior longitudinal sinus
Sinus alae parvae
Veins of Galen
Vena magna Galeni
Vein of the corpus striatum
Basilar vein
Suprascapular vein
Acromio-thoracic vein
Transversalis colli veins
Long thoracic vein
Vena azygos major
Vena azygos minor inferior
Vena azygos minor superior
Internal iliac vein
Deep epigastric vein
Internal saphenous vein
External saphenous vein

xxviii GLOSSARY

Lymphatics.

B.N.A. TERMINOLOGY. OLD TERMINOLOGY.

Cisterna chyli Receptaculum chyli

THE VISCERA.
Digestive Apparatus.

Arcus glosso-palatinus Anterior pillar of fauces

Arcus pharyngo-palatinus Posterior pillar of fauces

Gl. lingualis anterior Gland of Nuhn

Ductus submaxillaris Wharton's duct

Gl. parotis accessoria Socia parotidis

Ductus parotideus (Stenonis) Stenson's duct

Dentes praemolares Bicuspid teeth

Dens serotinus Wisdom tooth

Papillae vallatse Circumvallate papillae

Recessus pharyngeus Lateral recess of pharynx

Tela submucosa Pharyngeal aponeurosis

Plicae circulares Valvulae conniventes

Gl. intestinales Crypts of Lieberkuhn

Valvula coli Ileo-caecal valve

Columnae rectales Columns of Morgagni

Plicae transversales recti Valves of Houston

Valvula spiralis Valves of Heister

Noduli lymphatici aggregati Peyer's patches

(Peyeri)

Intestinum jejunum Jejunum

Intestinum ileum Ileum

Noduli lymphatici lienales Malpighian corpuscles

(Malpighii)
'

Respiratory Apparatus.
Larynx

Prominentia laryngea Adam's apple

Incisura thyreoidea superior Superior thyroid notch

M. ary-epiglotticus Aryteno-epiglottidean muscle

M. vocalis Internal thyro-arytenoid muscle

M. thyreo-epiglotticus Thyro-epiglottidean muscle

Appendix ventriculi laryngis Laryngeal sac

Plica vocalis True vocal cord

Plica ventricularis False vocal cord

Ligamentum ventriculare Superior thyro-arytenoid ligament

Ligamentum vocale Inferior thyro-arytenoid ligament

Glottis Glottis vera

Rima vestibuli Glottis spuria

Cartilage thyreoidea Thyroid cartilage

GLOSSARY

XXIX

B.N.A. TERMINOLOGY.
Membrana hyo-thyreoidea
Cartilage corniculata (Santorini)
Tuberculum epiglotticum
Pars intermembranacea (rimae

glottidis)
Pars intercartilaginea (rimae

glottidis)
Conus elasticus (membranaa

elasticas larynges)
Glandula thyreoidea
Glomus caroticum
Nose

Concha nasalis suprema (Santorini)

Concha nasalis superior
Concha nasalis media
Concha nasalis inferior

OLD TERMINOLOGY.
Thyro-hyoid membrane
Cartilage of Santorini
Cushion of epiglottis
Glottis vocalis

Glottis respiratoria
Crico-thyroid membrane

Thyroid gland
Intercarotid gland or .body
Highest turbinate bone
Superior turbinate bone
Middle turbinate bone
Inferior turbinate bone

Urogenital Apparatus.

Corpuscula renis

Paradidymis

Appendix testis

Ductus deferens

Gl. urethrales

Glandula bulbo-urethralis (Cowperi)

Folliculi oophori vesiculosi

Cumulus oophorus

Tuba uterina

Epoophoron

Appendices vesiculosi

Ductus epoophori longitudinalis

Orificium internum uteri

Orificium externum

Processus vaginalis

Glandula magna vestibuli

Malpighian corpuscles

Organ of Giraldes

Hydatid of Morgagni (male)

Vas deferens

Glands of Littre

Cowper's gland

Graafian follicles
Discus proligerus

Fallopian tube

Parovarium

Hydatids of Morgagni (female)

Gartner's duct

Internal os (of uterus)

External os

Canal of Nuck

Bartholin's gland

Peritoneum.

Bursa omentalis
Foramen epiploicum
Lig. phrenico-colicum
Excavatio recto-uterina (cavum

Douglasi)
Lig. gastro-lienale

Lesser peritoneal sac

Foramen of Winslow
Costo-colic ligament
Pouch of Douglas

Gastro-splenic omentum

SENSE ORGANS.
The Eye.

Sclera

Lamina elastica anterior (Bowmani)

Sclerotic coat
Bowman's membrane

XXX
GLOSSARY

B.N.A. TERMINOLOGY.

Lamina elastica posterior (Des-

cemeti)

Spatia anguli iridis

Angulus iridis
Zonula ciliaris
Septum orbitale
Fascia bulbi

Commissura palpebrarum lateralis

Commissura palpebrarum medialis
Tarsus superior
Tarsus inferior
Lig. palpebrale mediale
Raphe palpebralis lateralis
Tarsal glands

OLD TERMINOLOGY.
Descemet's membrane

Spaces of Fontana
Irido-corneal junction
Zonule of Zinn
Palpebral ligament
Capsule of Tenon
External canthus
Internal canthus
Superior tarsal plate
Inferior tarsal plate
Internal tarsal ligament
External tarsal ligament
Meibomian glands

The Ear.

Canalis semicircularis lateralis

Ductus reuniens
Ductus cochlearis
Recessus sphericus
Recessus ellipticus
Paries jugularis
Paries labyrinthica
Fenestra vestibuli

Fenestra cochleae
Paries mastoidea

Antrum tympanicum
Paries carotica
Processus lateralis
Processus anterior

External semicircular canal

Canalis reuniens
Membranous cochlea
Fovea hemispherica
Fovea hemi-elliptica
Floor of tympanum
Inner wall

Fenestra ovalis

Fenestra rotunda
Posterior wall

Mastoid antrum
Anterior wall

Processus brevis (of malleus)

Processus gracilis

Anterior View of the Skull (Norma frontalis), showing the bones

and the muscular attachments.

1. M. orbicularis oculi, upper frontal

attachment (corrugator super-

cilii).

2. M. orbicularis oculi, lower

frontal attachment.

3. M. orbicularis oculi (tensor

tarsi), lacrimal attachment.

4. M. orbicularis oculi, maxillary

attachment.

5. M. quadratus labii superioris,

angular part.
6. M. quadratus labii superioris,

infra-orbital part.

7. M. quadratus labii superioris,

zygomatic part.

8. M. zygomaticus, on zygomatic

bone.

9. M. caninus, on maxilla.

10. M. nasalis, pars transversa.

11. M. incisivus labii superioris.

T2. M. nasalis, pars alaris.

13. M. depressor septi.

14. Symphysis of mandible.

15. M. mentalis, on body of mandible.

16. M. quadratus labii inferioris, on

body of mandible.

17. M. platysma, on body of mandible.

1 8. M. triangularis, on body of

mandible.

19. M. buccinator, on alveolar pro-

cesses of maxilla and mandible.

20. M. masseter, insertion, on ramies

of mandible.

21. M. sterno-mastoid, .on mastoid

process of temporal bone.

22. M. temporalis, insertion, on ramus

of mandible.

23. Maxilla.

24. M. rnasseter, origin, on zygomatic

and temporal bones.

25. Zygomatic bone.

26. Lacrimal bone.

27. Squamous part of temporal bone,

and origin of M. temporalis.

28. Great wing of sphenoid bone,

and origin ofM. temporalis.

29. Parietal bone, and origin of

M. temporalis.

30. Temporal line, and iipper limit

of origin of M. temporalis on
frontal and parietal bones.

31. M. procerus, on nasal bone.

32. Nasal bone.

33. Frontal bone.

16 ' 15 14

Anterior View of the Skull (Norma frontalis), showing the bones and the
muscular attachments.

24 23 22 21

Lateral View of the Skull (Norma lateralis), showing the bones and the
muscular attachments.

Lateral View of the Skull (Norma lateralis), showing the bones

and the attachments of muscles.

1. Coronal suture.

2. Frontal bone.

3. Great wing of sphenoid bone, and

origin of temporal muscle.

4. Zygomatic bone.

5 . M . orbicularis oculi , upper fron tal

origin (corrugator supercilii\

6. M. orbicularis oculi, lower frontal

origin.

7. M. orbicularis oculi (tensor

tarsi), lacrimal attachment.

8. M. procerus, on nasal bone.

9. M. orbicularis oculi, maxillary

origin.
10. M. quadratus labii superioris,

angular part.
n. M. quadratus labii superioris,

infra-orbital part, on maxilla

and zygoma tic bone.

12. M. quadratus labii inferioris,

zygomatic part, on zygomatic

bone.

13. M. zygomaticus, on zygomatic

bone.

14. M. caninus, on maxilla.

15. M. nasalis, pars transversa.

16. M. nasalis, pars alaris.

17. M. depressor septi.

1 8. M. incisivus labii superioris, on

maxilla.

19. M. incisivus labii inferioris, on

maxilla.

20. M. mentalis, on body of mandible.

21. M. quadratus labii inferioris, on

body of mandible.
22. M. triangularis, on body of

mandible.

23. M. platysma, on body of man-

dible.

24. M. buccinator, on alveolar pro-

cesses of maxilla and mandible.

25. M. masseter, insertion on ramus

of mandible.

26. M. temporalis, insertion on

coronoid process of mandible.

27. M. masseter, origin on zygomatic

and temporal bones.

28. M. stylo-glossus, on styloid pro-

cess of temporal bone.

29. M. stylo-hyoid, on styloid process

of temporal bone.

30. M. auricularis posterior, on post-

auditory part of squamous

portion of temporal bone.

31. M. longissimus capitis, on mastoid

portion of -temporal bone.

32. M. sterno-mastoid, on mastoid

part of temporal bone and

squamous part of occipital bone.

33. M. splenius capitis, on mastoid

part of temporal bone and

squamous part of occipital bo?ie.

34. M. trapezius, on superior nuchal

line of occipital bone.

35. M. occipito frontalis, occipital

part, on superior nuchal line
of occipital bone.

36. Squamous par.t of occipital bone.

37. Lambda.

38. Squamous part of temporal bone,

and origin of M. temporalis.

39. Parietal bone.

40. Inferior temporal line, and upper

limit of origin ofM. temporalis

on parietal and frontal bones.

41. Superior temporal line, and upper

attachment of temporal apo-

MANUAL

OF

PRACTICAL ANATOMY.

HEAD AND NECK.

THE dissectors of the Head and Neck begin work as soon

as the subject is brought into the room. During the first
three days, whilst the body is in the lithotomy posture, they
dissect the face, the anterior part of the eyelids, the superficial
part of the nose, and the anterior part of the scalp. During
the following five days, when the body is lying on its back,
they dissect the posterior triangle, and complete the dissection
of the scalp.

It is only by dissecting the face at this period, whilst

the parts are in good condition, that the dissector can
gain any satisfactory idea of its component parts ; and it is
essential that the contents of the posterior triangle, which
is such an important surgical region, should be displayed
before the dissector of the arm has disturbed its posterior
boundary.

The first day should be devoted to the examination of the

anterior part of the frontal region of the head and the face,
the study of the surface anatomy of the ocular appendages,
the reflection of the skin and the cleaning of the superficial
muscles of the face and anterior part of the scalp. On the
second day the dissectors should display the superficial
surface of the parotid gland ; they should also find and
clean the superficial vessels and nerves, and trace them to

VOL. Ill 1

2 HEAD AND NECK

their terminations. On the third day the superficial muscles

must be reflected, and the deeper vessels and nerves must
be exposed and cleaned, and the auricle should be examined
and dissected. On the fourth day the body is placed upon
its back, and the dissectors should commence the dissection
of the posterior triangle of the neck they must complete
that part of the dissection jn three days. On the seventh
day they should complete the examination of the scalp.
The eighth day should be devoted to a final study of the
brachial plexus, in association with the dissectors of the upper
extremity.

FACE AND FRONTAL REGION OF HEAD.

The dissectors should commence the study of the face and

frontal region by an examination of the bony prominences
and ridges in the area to be dissected.

In the centre of the facial area is the prominent outer

portion of the nose, consisting of a lower mobile part, formed
mainly by skin and cartilage, and an upper rigid portion,
formed by the nasal bones and the frontal processes of
the maxillae. At the sides of the nose are the sockets
for the eyeballs, each of which is bounded above by the
supra-orbital margin of the frontal bone and below by the
orbital margins of the maxilla and the zygomatic bone
(O.T. malar). The supra- and infra-orbital margins meet
laterally in the region of the cheek bone (zygomatic). From
the posterior part of the zygomatic bone, the zygomatic
arch, formed partly by the zygomatic and partly by the
temporal bone, extends barkwards to the ear. Above the
zygomatic arch is the region of the temporal fossa, which
is bounded superiorly by the temporal line. The line
terminates anteriorly in the lateral part of the supra-orbital
margin. Above the medial part of the supra-orbital margin
the superciliary arch can be felt, and at a higher level,
above the lateral part of the supra-orbital margin, lies the
frontal tuberosity. The region above the nose and between
the medial ends of the superciliary arches is the glabella.

Below the zygomatic arch lies the ramus of the mandible,

covered by the masseter muscle ; and extending forwards
from the lower end of the ramus is the body of the mandible.
A line dropped vertically through the junction of the medial
FACE AND FRONTAL REGION OF HEAD 3

third with the lateral two-thirds of the supra-orbital margin,

will cut through the supra-orbital notch of the frontal bone,
the infra-orbital foramen of the maxilla, and the mental foramen
of the mandible, all three of which may be felt if firm pressure
is made in the proper situations. The first, which lies in the
supra-orbital margin, transmits the supra-orbital vessels and
nerve. The second is placed about half an inch below the
infra-orbital jnargjn ; it transmits the infra-orbital vessels and
nerve. The third lies midway between the second premolar
tooth of the mandible and the lower border of the mandible ;
it transmits the mental branches of the inferior alveolar vessels
andjierve.

After the bony points of the region have been studied,

the surface anatomy of the ocular appendages should be
examined. Under this head are included (i) the eyebrows ;
(2) the eyelids; (3) the conjunctiva.

The eyebrows are two curved tegumentary projections

placed over the supra-orbital arches of the frontal bone ; they
intervene between the forehead above and the ocular regions
below. The short stiff hairs which spring from the eyebrows
have a lateral inclination.

'The eyelids (palpebrae) are the semilunar curtains provided

for the protection of each eyeball. The upper lid is the
longer and much the more movable of the two. When the
eye is open, the margins of the two lids are slightly concave
and the interval between them, rima palpebrarum, is elliptical
in outline. When the eye is closed, and the margins of the
lids are in apposition, the rima palpebrarum is reduced to a
nearly horizontal line. Owing to the greater length and
mobility of the upper lid, the rima, in the closed condition, is
placed at the level of the lower border of the cornea, which
is the transparent front part of the eyeball.

At the extremities of the rima palpebrarum the eyelids

meet and form the palpebral commissures. Immediately
lateral to the medial commissure the rima expands into a
small triangular space, called the locus lacrimalis. If the
dissector now examines the free margins of the lids he will
note that, to the lateral side of the lacus lacnmalis, they
are flat, and that in each lid the cilia or eyelashes project
from the anterior border, whilst the tarsal glands open,
by a series of minute apertures, along the posterior border,
a distinct interval intervening between the cilia and the

4 HEAD AND NECK

mouths of the glands. On the other hand, the small

portion of the margin of each eyelid which bounds the
lacus lacrimalis is more horizontal in direction and some-
what rounded. It is destitute both of eyelashes and of tarsal
glands. At the very point where the eyelashes in each eyelid
cease, and the palpebral margin becomes rounded, a small
eminence, with a central perforation, will be seen. The

Margin of the upper eye

lid, with openings of
ducts of tarsal glands

Papilla lacrimalis, with

punctum lacrimale on
the summit

Plica semilunaris

Caruncula lacrimalis
Papilla lacrimalis

Opening of tarsal gland

Tarsal gland
shining through the
conjunctiva

FIG. i. Eyelid slightly everted to show the Conjunctiva (enlarged).

eminence is the papilla lacrimalis, whilst the perforation, called

the punctum lacrimale, is the mouth of a lacrimal duct, which
conveys away the tears. Endeavour to pass a bristle into
each of the orifices. The upper duct at first ascends, whilst
the lower one descends, and then both run horizontally to the
lacrimal sac, which lies in a depression in the medial wall of
the orbit.

The conjunctiva is the membram ies the deep

surfaces of the lids. It is reflected f;om i^-m on to the

FACE AND FRONTAL REGION OF HEAD 5

anterior aspect of the eyeball. At the margins of the lids it

is continuous with the skin, whilst, through the puncta lacri-
malia and the lacrimal ducts, it becomes continuous with
the lining membrane of the lacrimal sac. The line of re-
flection of the conjunctiva from each of the eyelids on to the
eyeball is termed a fornix conjunctiva. Owing to the greater
vertical extent of the upper lid, the conjunctival recess
between the upper lid and the eyeball is larger than that
behind the lower lid. The conjunctiva is loosely connected
with the eyelids on the one hand, and with the sclera, or-
white part of the eyeball, on the other. Over the cornea the
membrane becomes thinned down to a mere epithelial cover-
ing, which forms the epithelium of the cornea.

In connection with the conjunctiva, the plica semilunaris

and the caruncula lacrimalis must be examined. The
caruncula is the reddish, fleshy -looking elevation which
occupies the centre of the lacus lacrimalis. From its surface
a few minute hairs project. The plica semilunaris is of interest
because it is the rudimentary representative, in the human eye,
of the membrana nictitans, or third eyelid, found in many
animals. It is a small vertical fold of conjunctiva, which is
placed immediately to the lateral side of the caruncula, and it
slightly overlaps the eyeball at that point (Fig. i).

Dissection. Distend the eyelids slightly by placing a little

tow or cotton wool, steeped in preservative solution, in the con-
junctival sac ; then stitch the margins of the lids together.
Distend the cheeks and lips slightly by placing tow or cotton
wool, steeped in preservative solution, in the vestibule of the
mouth that is, between the cheeks and lips externally and the
teeth and gums internally ; then stitch the red margins of the
lips together.

Reflect the skin by means of three incisions, a median longi-

tudinal and two transverse. Commence the median incision
midway between the root of the nose and the external occipital
protuberance, carry it forwards to the forehead and then down-
wards along the median line of the forehead, the nose and the
lips, to the tip of the chin. Commence the upper horizontal
incision at the level of the rima palpebrarum ; carry it laterally
from the longitudinal incision to the medial commissure, then
round the margins of the rima to the lateral commissure, and,
finally, backwards to the ear. The lower horizontal incision
should run from the angle of the mouth to the posterior border
of the ramus of the mandible. Reflect the upper and middle
flaps and leave them attached posteriorly. Reflect the lower
flap downwards to the lower border of the mandible. Note,
whilst reflecting the skin, that many of the superficial fibres of
the facial muscles are implanted into its deep surface. It is

HEAD AND NECK

those fibres which tend to displace the margins of wounds of the

face, and necessitate the application of numerous and firmly
tied sutures in order to secure quick and accurate union. Whilst
reflecting the skin the dissector must be careful to keep his knife
playing against its deep surface ; otherwise he is certain to
injure the sphincter muscle of the eyelids, and the superficial
extrinsic muscles of the ear which lie in the temporal region.

After the skin is reflected, clean the superficial muscles.

That which will first attract attention is the orbicularis oculi,
around the orbit. Above the orbicularis oculi is the frontal
belly of the epicranial muscle. To the medial side of the orbi-
cularis oculi lie the muscles of the nose. Below the eye the
muscles of the upper lip pass downwards to the orbicularis oris
and the mouth. Passing forwards and upwards, over the posterior
part of the lower border of the mandible, are the upper and
posterior fibres of the platysma, and more medially are the
muscles of the lower lip (Fig. 2).

Commence with the orbicularis oculi (O.T. orbicularis palpe-

brarum), which lies in and around the region of the eyelids.
Pull the eyelids laterally and note a prominent cord-like band
which extends from the frontal process of the maxilla to the
medial commissure, where it becomes continuous with both
eyelids ; it is the medial palpebral ligament (O.T. internal tarsal
ligament). A somewhat similar band, the lateral palpebral
raphe (O.T. external tarsal ligament), extends from the lateral
commissure to the zygomatic bone. After the medial palpebral
ligament has been recognised, clean first the thicker orbital part
of the orbicularis oculi, which covers the superficial bony
boundaries of the orbit, and then the thinner palpebral portion,
which lies in the eyelids. The palpebral part is not only thin
but also pale, and its fibres, in each eyelid, sweep in gentle curves
from the medial palpebral ligament to the lateral palpebral
raphe, gaining attachment to both.

Next clean the orbicularis oris, which surrounds the mouth,

and take care not to injure the other muscles of the lips which
blend with the margins of the orbicularis oris. Attempt to
define the depressor septi nasi which springs from the middle of
the upper border of the orbicularis oris and is inserted into the
lower part of the septum of the nose (Fig. 2) .

After the two orbicular muscles have been cleaned, turn to

the frontal belly of the epicranius, which lies above the orbicu-
laris oculi. Its fibres run upwards and backwards from the
orbicularis oculi, with which it blends, to the tendinous sheet
called the galea aponeurotica, which covers the vertex of the
skull and connects the frontal belly with the occipital belly
of the muscle. The edge of the knife must be kept parallel
with the fibres of the muscle, and as the cleaning proceeds avoid
injuring the branches of the supra-orbital nerve and artery
which pierce the muscle. From the medial margin of the frontal
belly of the epicranius trace a small bundle of muscle fibres,
called the procerus, downwards to the dorsum of the nose, and
at the same time secure the supra -trochlear nerve and the
frontal branch of the ophthalmic artery which pierce the muscle
at the medial part of the upper margin of the orbit. Below the
procerus secure the angular head of the quadratus labii superioris,
a muscular slip which springs from the frontal process of the

FACE AND FRONTAL REGION OF HEAD 7

maxillary bone, and trace it downwards to the orbicularis oris,

but avoid injury to the angular vein which lies on its super-
ficial surface. Medial to the angular head of the quadratus
labii superioris find and clean the pars transversa of the musculus
nasalis, which lies across the lower part of the bridge of the
nose. Below the pars transversa it may be possible to dis-
play the pars alaris which passes from the maxilla tJ5 the ala of
the nose.

Now turn to the lower border of the mandible and clean the
platysma, a broad thin sheet of muscle which ascends from the
neck. Its anterior fibres are inserted into the anterior part of
the lower border of the mandible. The posterior fibres ascend
across the mandible, then they turn forwards to the angle of
the mouth, as the risoritis. Above and in front of the risorius
find the zygomaticus, a slender muscle which descends from
the zygomatic bone to the angle of the mouth, where it blends
with the orbicularis oris. Now follow the angular vein down-
wards and backwards. At the lower margin of the orbit it
becomes the anterior facial vein ; follow that vein downwards
and backwards to the point where it disappears under cover of
the zygomaticus. Below and in front of the anterior facial
vein the terminal part of the external maxillary artery may be
found on the superficial surface of the quadratus labii superioris,
but it may lie deep to that muscle. After the anterior facial
vein has been cleaned, in the area indicated, raise the lower
fibres of the orbicularis oculi and reflect them towards the
palpebral fissure ; then clean the infra - orbital head of the
quadratus labii superioris, a flat and fairly wide muscle which
springs from the lower margin of the orbit, under cover of
the orbicularis oculi, and descends to the upper lip, where
it blends with the orbicularis oris. Lateral to the infra-
orbital head, the small zygomatic head of the quadratus labii
superioris may be found. It descends from the zygomatic
bone and blends with the lower part of the lateral border of
the infra-orbital head. After the zygomatic head has been
cleaned turn to the lower lip region and clean the triangu-
laris. It springs from the mandible above the insertion of the
anterior part of the platysma and passes upwards to the angle
of the mouth, where it blends with the orbicularis oris. Anterior
to the triangularis, and on a deeper plane, find and clean the
quadralus labii inferioris. It springs from the mandible under
cover of and anterior to the triangularis and ascends to the
orbicularis oris, with which it blends. After the muscles
mentioned have been defined proceed to the detailed study of
their positions and attachments.

Orbicularis Oculi. The orbicular muscle of the eyelids,

on each side, consists of a thick orbital portion which covers
the superficial bony boundaries of the orbit, and a thinner
and paler palpebral part which lies in the eyelids.

The orbital portion of the muscle extends upwards to the

forehead, laterally to the temporal region and downwards into
the cheek. Its fibres are relatively dark and coarse. They
all take origin medially from the medial part of the palpebral

8 HEAD AND NECK

ligament, the adjoining part of the frontal bone, and the

frontal process of the maxilla, and they sweep laterally round
the margin of the orbit in the form of a series of con-
centric loops. The upper fibres blend with the frontal belly
of the epicranius, and the lower fibres overlap the upper
parts of the muscles of the upper lip. Some of the fibres
spring from the nasal part of the frontal bone and terminate
in the skin of the eyebrow.

The palpebral part consists of fibres which sweep in

gentle curves from the medial palpebral ligament to the
lateral palpebral raphe, to both of which they are attached.
Peripherally they blend with the orbital part, and they form
a continuous layer of uniform thickness, except near the free
margins, where, close to the bases of the eyelashes, there is
a more pronounced fasciculus, termed the ciliary bundle.
Some of the fibres of the palpebral portion pass from the
deep surface of the medial palpebral ligament to the lacrimal
bone ; they constitute the pars lacrimalis^ which will be
described when the eyelids are dissected (see p. 29).

The orbicularis oculi is supplied by the facial nerve.

It closes the eyelids and compresses them against the eye-
ball. The pars lacrimalis helps to force the lacrimal secretion
from the lacrimal sac into the naso-lacrimal duct. Those
fibres of the orbital part of the muscle which spring from
the nasal process of the frontal bone and terminate in the
skin of the eyebrow pull the eyebrow towards the median
plane, and throw the skin of the central part of the fore-
head into vertical folds ; they were at one time described as
a separate muscle which was called the corrugator supercilii.

Musculus Epicranius (O.T. Occipito - Frontalis). The

epicranius is a quadricipital muscle possessing two occipital
heads, the occipitales muscles, and two frontal heads, the
frontales muscles ; they are all inserted into an intermediate
aponeurosis, the galea aponeurotica (O.T. epicranial aponeur-
osis), which extends from the frontal to the occipital region
(p. 50). The lower part of each frontal head blends with the
orbicularis oculi, and from its medial border a small muscular
bundle, known as the musculus procerus (O.T. pyramidalis
nasi\ descends to the dorsum of the nose. At present only
the frontalis and the procerus have been displayed (Fig. 2).

The Frontalis becomes apparent immediately above the

upper border of the orbicularis oculi. As it is cleaned care

FACE AND FRONTAL REGION OF HEAD 9

should be taken to avoid injury to the branches of the supra-

orbital nerve which pierce it. It has little or no attachment
to bone. Below, its fibres either blend with the fibres of the
orbicularis oculi or they are attached to the skin of the eye-
brows. Above, they terminate in the galea aponeurotica, in the
region of the coronal suture. The lateral border is attached
to the temporal ridge by aponeurotic fibres, and the medial
border blends with its fellow of the opposite side for a short
distance above the root of the nose. Above the union the
medial fibres of opposite sides diverge, and below it they pass
downwards over the nasal bones as the proceral muscles.
The frontalis pulls the scalp forwards. ItJs^ supplied by the
Musculus Procerus (O.T. Pyramidalis Nasi). The proceral
muscles are often absent; when present, each springs from
the lower and medial part of the corresponding frontalis.
It descends over the nasal bone and ends on the dorsum
of the nose, where some of its fibres blend with the trans-
verse part of the nasalis and others are inserted into the skin.
\t 4$ glipplied by the facial nerve.

Along the lower and medial border of the orbicularis oculi

will be found the muscles of the nose and the upper lip.

The proper muscles of the nose are the musculus nas_alj

and_the_muscuhiS- depressor sejpti, but the rjrocerus alsojuay.
Uejooked upon as_ p5rtlv__a^agjJLjiiu^
hj^a^pjj-h^jRi^

Musculus Nasalis. The musculus nasalis consists of two

parts, the pars transversa (O.T. compressor nan's) and the
pars alaris (O.T. dilator nan's). The pars transversa springs
from the root of the frontal process of the maxilla, passes
across the cartilaginous part of the nose, above the ala, and
ends in an aponeurosis which connects it with its fellow of
the opposite side. The pars alaris springs from the maxilla,
at the side of the lower part of the anterior nasal aperture,
and it terminates in the posterior part of the ala and the
mobile part of the septum of the nose. The nasalis is partly
concealed by the angular head of the quadratus labii superioris.

The transverse part, acting with its fellow of the opposite

side, depresses the dorsum of the nose and compresses its
sides. The pars alaris dilates the nostril of the same side.
Both parts are supplied by the facial nerve.

Musculus Depressor Septi Nasi. The depressor of the

to HEAD AND NECK

nasal septum is frequently difficult to display. It springs

from the superficial fibres of the upper part of the orbicularis
oris, and is inserted into the anterior part of the septum of
the nose. It depresses the septum and reduces the antero-
posterior diameter of the anterior nasal aperture. The name
indicates the action of the muscle, which is supplied by the
facial nerve.

The Muscles of the Mouth and Cheeks. The muscles of

this group form two layers, a superficial and a deep. Those
of the superficial group are the orbicularis oris, quadratus
labii superioris, zygomaticus, triangularis, risorius, quadratus
labii inferioris ; those of the deeper group are the buccinator,
caninus, incisivus superior and inferior, and the mentalis.
All, with the exception of the orbicularis oris, are bilateral.
Only the members of the superficial group are at present
displayed ; the deeper muscles will be dissected after the
superficial vessels and nerves have been cleaned and studied.
Orbicularis Oris. The orbicularis oris is the sphincter
muscle of the oral aperture. It lies in the substance of the
lips, and consists of a deeper layer of fibres which are arranged
in concentric ellipsoidal rings, and a series of superficial fibres
into which all the other muscles of the lips and cheeks con-
verge. The details of its formation cannot be understood
until the attachments of the other muscles have been studied
(see p. 21). It is supplied by the facial nerve.

Musculus Quadratus Labii Superioris. The quadratus

labii superioris possesses three heads a zygomatic, an infra-
orbital, and an angular.

The zygomatic head (O.T. zygomaticus minor] springs

from the anterior part of the facial surface of the zygomatic
bone, under cover of the lower lateral part of the orbicularis
oculi. It runs downwards and forwards, and either joins
the infra-orbital head or is inserted into the lateral part of the
upper portion of the orbicularis oris and into the adjacent
part of the skin of the upper lip.

The infra -orbital head (O.T. levator labii superioris

proprius) arises from the whole length of the infra-orbital
border, under cover of the orbicularis oculi. It is inserted
into the upper lateral part of the orbicularis oris and the
skin of the upper lip (Fig. 2).

The angular head (O.T. levator labii superioris alceque

nasi] springs from the frontal process of the maxilla. It

FACE AND FRONTAL REGION OF HEAD n

broadens as it descends, and it is inserted into the ala of the

nose and into the upper part of the orbicularis oris.

The quadratus labii superioris raises the upper lip, and its

Frontalis

Orbicularis oculi

M. quadratus labii superioris,

angular head

M. nasalis, pars transversa

M. quadratus labii superioris,
infra-orbital head

M. zygomaticus
M. caninus
Risorius

Orbicularis oris

Orbicularis oris

M. quadratus labii inferioris

M. triangularis

Platysma

FIG. 2. The Facial Muscles.

angular head elevates the ala of the nose. It is supplied

by the facial nerve.

Musculus Zygomaticus. The zygomaticus (O.T. zygo-

maticus major) is a comparatively long, slender muscular
band which springs from the facial surface of the zygomatic
bone, under cover of the lower lateral fibres of the orbicularis

12 HEAD AND NECK

oculi and to the lateral side of the zygomatic head of the

quadratus labii superioris. Its fibres pass downwards and
medially to the angle of the mouth, where some blend with
the orbicularis oris and others are inserted into the skin. It
pulls the angle of the mouth upwards and backwards. It is
supplied by the facial nerve.

The Risorius. When well developed the risorius muscle

consists partly of some of the uppermost fibres of the platysma
muscle of the neck, which bend forwards and medially to the
angle of the mouth, and partly of additional fibres which
spring from the fascia over the masseter muscle and the
parotid gland. Both groups of fibres blend with the fibres
of the orbicularis oris at the angle of the mouth. The
risorius depresses the angle of the mouth and draws it back-
wards. It is supplied by the facial nerve.

Musculus Triangularis. The triangularis (O.T. depressor

anguli oris) springs from the oblique line on the lateral surface
of the body of the mandible. Its fibres converge as they
pass forwards and upwards, and, at the angle of the mouth,
they blend with the orbicularis oris, in which some of them
curve past the angle and terminate in the substance of the
upper lip (Figs. 2, 3). It depresses the angle of the
mouth, and is supplied by the facial nerve.

Musculus Quadratus Labii Inferioris (O.T. Depressor Labii

Inferioris). The quadrate muscle of the lower lip springs
from the lower part of the superficial surface of the mandible,
between the mental tubercle and the mental foramen, its
posterior border being overlapped by the triangularis. The
fibres pass upwards and medially, some to blend with the
orbicularis oris and others to gain attachment to the skin of
the lower lip. It depresses the lower lip, and is supplied by
the facial nerve.

Platysma. Only the upper part of the broad, flat,

quadrangular subcutaneous muscle of the neck is at present
visible. The posterior fibres ascend over the lower border
of the ramus and the posterior part of the lower border of
the body of the mandible, and they have already been seen
taking part in the formation of the risorius. The anterior
fibres gain direct insertion into the anterior part of the lower
border of the body of the mandible. The latter attach-
ment is the only bony attachment which the muscle possesses,
all its other attachments being either to fascia or to skin.

FACE AND FRONTAL REGION OF HEAD 13

It helps to depress the mandible and is supplied by the

facial nerve.

Dissection. Cut through the posterior half of the platysma

along the lower border of the mandible ; detach the risorius
from the fascia on the masseter ; then turn the risorius and the
detached part of the platysma towards the angle of the mouth.
Whilst doing that be careful to avoid injuring the branches of
the vessels and nerves of the face (Figs. 4, 5, 15).

As soon as the platysma and the risorius are reflected search

below the level of the ear for branches of the great auricular

- M. quaclratus labii superioris,

caput angulare

M. quadratus labii
superioris, caput
infraorbitale

M. caninus
M. triangularis

M. quadratus labii inferioris

FIG. 3. Diagram of the Orbicularis Oris Muscle.

The fibres which enter it from the buccinator are not represented.

nerve which ascend over the lower part of the parotid gland,
Some of them pierce the parotid and terminate in its substance,
others end in the skin of the masseteric region.

Find the anterior facial vein and the external maxillary artery
at the lower and anterior angle of the masseter, as they cross
the lower border of the mandible. Clean them at that point,
but do not trace them towards their terminations at present.

At the posterior border of the mandible note the deep fascia

over the superficial surface of the parotid gland; it is called
the parotid fascia. It ascends from the fascia of the neck,
and is attached above to the zygomatic arch. Note also that
at the anterior border of the parotid the parotid fascia blends
with the fascia on the superficial surface of the masseter
muscle. Cut through the fascia covering the parotid gland
immediately anterior to the ear, extending the incision from
the zygoma above to the angle of the mandible below ; then

14 HEAD AND NECK

raise the fascia from the gland, dissecting carefully forwards,

upwards, and downwards. As the extremities and the anterior
border of the gland are approached, look carefully for nerves
and vessels which emerge from beneath them, and also for
the duct of the gland, which appears from under cover of the
anterior border about a finger's breadth below the zygoma.
The duct has thick walls, is of considerable size, and is easily
recognised. It runs forwards across the masseter and turns
round the anterior border of the muscle, bending at right angles
to its original course. It pierces, in turn, the fascia covering
the buccinator muscle, the buccinator muscle itself and the
mucous membrane of the mouth ; and it opens into the vestibule
of the mouth, on a small papilla, opposite the second molar tooth
of the maxilla. Above the duct and below the zygomatic arch
find (i) the accessory parotid, a small detached part of the parotid
which lies a short distance in front of the anterior border of the
main mass of the gland ; (2) the transverse facial vessels ; and
(3) the zygomatic branches of the facial nerve. Below the duct
find the buccal and the mandibular branches of the facial nerve.
At the upper end of the parotid seek for the superficial temporal
vessels. Posterior to them lies the auriculo-temporal branch
of the third division of the trigeminal nerve, and anterior to
them, the temporal branches of the facial nerve. From the
lower extremity of the gland emerge (i) the cervical branch of
the facial nerve, (2) the posterior facial vein (O.T. anterior
division of the temporo-maxillary vein), and (3) a tributary of
the external jugular vein (Fig. 15).

Follow the temporal branch of the facial nerve upwards and

forwards to the frontal belly of the epicranius and the upper
part of the orbicularis oculi. As the temporal branch is cleaned
the anterior part of the strong temporal fascia will be exposed.
It is attached to the upper border of the zygomatic arch, the
posterior border of the zygomatic bone, and the temporal line
on the frontal bone. Springing from it, above the posterior part
of the zygoma, is the anterior muscle of the auricle, and at a
higher level the superior muscle of the auricle. Attempt to define
both the muscles and the branches which pass to them from the
temporal division of the facial nerve. A short distance behind
a prominent tubercle, which can be felt on the posterior border
of the zygomatic bone, the zjgomatico -temporal branch of the
rnflvill a ry division -oi- the, trigeminal nerve pierces the temporal
fasciaLand communicates with the temporal branch of the facial
nerve. An attempt should be made to secure the zygomatico-
temporal nerve and to define the connection.

Further dissection is required before the zygomatic buccal

and mandibular branches of the facial nerve can be traced to
their terminations. As the dissection proceeds the deeper
muscles of the face, branches of the trigeminal nerve and the
internal maxillary artery will be exposed, whilst at the same time
the externally maxillary artery and its branches and the anterior
facial vein and its tributaries must be cleaned.

Follow the upper zygomatic branches of the facial nerve

forwards to their termination in the lateral part of the orbicu-
laris oculi, then reflect that muscle towards the median plane
and under cover of it, emerging from the zygomatic bone,
find the zygorgQlico-facial branch of the maxillary division of

FACE AND FRONTAL REGION OF HEAD 15

the trigeminal nerve. It^communicates with one of the zygomatic

twigs of the lacial nerve. Next follow the lower zygomatic
bTanches of the facial nerve forwards to the zygomaticus muscle,
and note that one of the twigs supplies it ; then detach the
zygomaticus from its origin, turn it down to the angle of the
mouth. When that has been done detach the zygomatic and
infra-orbital parts of the quadratus labii superioris from their
origins and turn them downwards. Now follow the anterior facial
vein and the external maxillary artery forwards and upwards
to the nose, and secure the branches of the artery. Some of the
smaller branches pass backwards, but the main branches, the
inferior and superior labial, pass forwards into the lower and
upper lips respectively, where they lie deep to the orbicularis
oris against the mucous membrane. Beyond the angle of the
mouth the lateral nasal branch arises, and the continuation of
the external maxillary artery beyond that branch is called the
angular artery.

After the external maxillary artery and its branches have

been cleaned follow the lower zygomatic branches of the facial
nerve forwards through the fat exposed by the reflection of the
zygomaticus and the quadratus labii superioris, and secure their
connections with the terminal branches of the infra-orbital
branch of the maxillary division of the trigeminal nerve, which
issues through the infra-orbital foramen accompanied by the
infra-orbital branch of the internal maxillary artery. The
interlacement of the zygomatic branches of the facial nerve
with the infra-orbital nerve constitutes the infra-orbital plexus.
From the infra-orbital plexus branches ascend to the lower
eyelid, other branches descend to the upper lip, and still others
pass medially to the nose. After the branches of the infra-
orbital plexus have been displayed clean the buccal branch of
the facial nerve. Follow it through the pad of fat called the
suctorial pad which lies on the buccinator muscle. Secure,
if possible, its junction with the buccinator branch of the
mandibular division of the trigeminal nerve, which issues from
under cover of the middle of the anterior border of the
masseter muscle, and follow its branches of supply to the
buccinator muscle. It may be necessary to cut through the
anterior border of the masseter to secure the buccinator branch
of the mandibular nerve. Next detach the triangularis from the
angle of the mouth and turn it downwards to its insertion,
secure the twig it receives from the mandibular branch of the
facial n prw j and display the union "of that branch with the
mental branch of the alveolar division of the trigeminal nerve,
which issues through tEe "mental foramen, under cover of the
triangularis and below the second lower premolar tooth. Secure
also a twig from the mandibular branch of the facial nerve which
supplies the quadratus labii inferioris. Accompanying the
mandibular nerve deep to the triangularis there is, usually, a
definite branch of the external maxillary artery which used to be
called the inferior labial. Finally, reflect the posterior part of
the platysma below the mandible to display the cervical branch
of the facial nerve, which issues from the lower part of the
parotid gland to supply the platysma and to communicate
with the upper branch of a cutaneous nerve called the nervus
cutaneus colli. Do not follow it to its termination at present

1 6 HEAD AND NECK

(see p. 122). After the various structures mentioned have been

cleaned proceed to the study of the anterior facial vein, the
external maxillary artery, and the terminal branches of the
facial nerve.

Vena Facialis Anterior (O.T. Facial). The anterior

facial vein is a less tortuous vessel than the external maxillary
artery, to which it corresponds ; and it lies posterior to the
artery, and on a slightly more superficial plane (Fig. 15). It
commences as the angular vein, which is formed at the medial
commissure of the eyelids, by the union of the frontal, and
supra-orbital veins, which descend from the forehead. It
passes downwards and backwards, in a comparatively straight
line, to the anterior inferior angle of the masseter, which it
crosses immediately behind the external maxillary artery ; then
it pierces the deep fascia of the neck, and enters the sub-
maxillary triangle. In the upper part of the face it lies on
the quadratus labii superioris ; then it is situated between the
zygomaticus and the risorius superficially and the buccinator
deeply ; and as it crosses the anterior angle of the masseter
it is covered with the skin, superficial fascia, and the platysma.

Tributaries. In addition to the frontal and supra-orbital

veins, it receives external nasal, palpebral, superior labial,
inferior labial, masseteric and superficial parotid tributaries.
As it crosses the buccinator muscle it is joined by the deep
facial vein, which connects it with the pterygoid plexus of
veins in the infra-temporal region.

Arteria Maxillaris Externa (O.T. Facial). The ex-

ternal maxillary artery is a tortuous vessel which enters the
face at the lower and anterior angle of the masseter, after
turning round the lower border of the mandible and piercing
the deep fascia of the neck. From that point it runs
forwards and upwards to the angle of the mouth, where it
assumes a more vertical direction, and becomes the angular
artery, which ascends, in the substance of the angular head
of the quadratus labii superioris, to the medial commissure of
the eyelids. Immediately after its entrance into the face it
is comparatively superficial, being covered by skin, superficial
fascia, and platysma, and it is easily compressed against the
bone. More anteriorly it lies between the zygomaticus
superficially and the buccinator deeply, then between the
quadratus labii superioris and the caninus, which springs
from the maxilla below the infra-orbital foramen. Its

FACE AND FRONTAL REGION OF HEAD 17

terminal part is usually embedded in the substance of the

quadratus labii superioris (Figs. 4, 15).

Branches. The branches of the external maxillary artery

form two groups, a posterior and an anterior. The branches

Superficial temporal

Frontal branch of
, ophthalmic artery

Supra-orbital branch of
ophthalmic artery
Middle temporal
Transverse facial

Angular
Lateral nasal

Infra-orbital
Superior labial

nferior labial

(O.T. inferior
labial.) See p. 18

Buccinator branch of internal maxillary

External maxillary
FIG. 4. Arteries of the Face.

of the posterior group pass backwards and are of small size.

They are distributed to the masseteric, buccal, and malar
regions, where they anastomose with the transverse facial, the
buccinator, and the infra-orbital arteries.

The branches of the anterior group, which run forwards,

VOL. Ill 2

1 8 HEAD AND NECK

receive special names : they are the inferior labial, the superior
labial, the lateral nasal, and the angular continuation.

The inferior labial (O.T. inferior coronary) arises below the

level of the angle of the mouth and passes towards the
median plane, under cover of the triangularis, the quadratus
labii inferioris, and the orbicularis oris. In the substance of
the lip it lies immediately adjacent to the mucous membrane,
and it anastomoses, in the median plane, with its fellow of the
opposite side.

The superior labial arises about the level of the angle

of the mouth and runs medially in the upper lip, between
the orbicularis oris and the mucous membrane. Before it
anastomoses with its fellow of the opposite side, it gives off
a branch, the septal artery of the nose, which passes upwards
and ramifies on the lower and anterior part of the nasal septum,
where it anastomoses with the septal branch of the spheno-
palatine artery.

The lateral nasal branch springs from the external

maxillary above the angle of the mouth. It ramifies on the
side of the nose and anastomoses, in the median plane, with
its fellow of the opposite side.
The angular artery is the continuation of the external
maxillary beyond the point of origin of the lateral nasal
branch. It runs upwards in the substance of the angular
head of the quadratus labii superioris, and it terminates, at
the medial commissure of the eye, by anastomosing with the
dorsal nasal branch of the ophthalmic artery.

In addition to the branches already noted, a very definite

branch is usually given off from the anterior aspect of the
external maxillary artery immediately after it crosses the
lower border of the mandible. This branch (O.T. inferior
labial) runs towards the median plane under cover of the
triangularis and the quadratus labii inferioris, and it anasto-
moses not only with the inferior labial (O.T. inferior coronary)
above, and its fellow of the opposite side in the median plane,
but also with the mental branch of the inferior alveolar artery.

The Terminal Branches of the Facial Nerve. The dis-

sector should note that there are five terminal branches, or
groups of branches, of the facial nerve : (i) temporal ; (2)
zygomatic ; (3) buccal ; (4) mandibular; (5) cervical. They
all emerge from under cover of the parotid gland, the
temporal branches at its upper end, the cervical at its lower

FACE AND FRONTAL REGION OF HEAD 19

end, and the remaining three groups of branches at its

anterior border (Fig. 5).

The temporal branches of the facial nerve cross the

zygomatic arch and pass upwards and forwards towards the
forehead ; they, supply twigs to the anterior and superior
muscles of the auricle, to the upper fibres of the orbicularis

pra-orbital

Zygomatico-temporal
upra-trochlear
Lacrimal

Infra-trochlear
External nasal
Infra-orbital

Mental

Auriculo-temporal
Posterior auric

Trunk of fa

Branch to posterior

belly of digastric

and stylo-hyoid

Buccinator

FIG. 5. Nerves of the Face. The facial nerve is depicted in green,

the sensory branches of the trigeminal in black.

i. Temporal branches.

2 and 3. Zygomatic branches.

Buccal branch.
Mandibular branch.

6. Cervical branch.

oculi and to the frontal belly of the epicranius. One of the

branches communicates with the zygomatico-temporal branch
of the trigeminal nerve, which pierces the temporal fascia
behind the zygomatic bone.

The upper filaments of the zygomatic branches run forwards

across the zygomatic bone, and terminate, in both the upper
and the lower eyelid, in the fibres of the orbicularis oculi.
If the branches are carefully traced, one of them will be
found to communicate with the zygomatico-facial branch
of the second or maxillary division of the trigeminal nerve.

in 2 a

20 HEAD AND NECK

That small nerve pierces the zygomatic bone a short distance

below the lateral border of the orbit.

The lower filaments are larger. They run forwards along

the lower border of the zygomatic arch, under cover of the
musculus zygomaticus and the infra-orbital part of the
quadratus labii superioris, and deep to the latter they com-
municate with the infra-orbital branch of the maxillary division
of the trigeminal nerve, forming with it the infra-orbital plexus.

The buccal branch or branches run towards the angle of

the mouth. At the anterior border of the masseter they com-
municate, around the anterior facial vein, with the buccinator
branch (O.T. long buccal) of the third division of the tri-
geminal, and they supply the buccinator and the orbicularis
oris.

The mandibular branch or branches run forwards along the

mandible to be distributed to the muscles of the lower lip.
They pass deep to the triangularis, and they communicate,
under cover of it, with the mental branch of the inferior
alveolar (O.T. dental) nerve.

The cervical branch after its exit from the lower end of
the parotid gland runs downwards and forwards to supply
the platysma and to communicate with the nervus cutaneus
colli, but since neither the terminal branches nor the com-
munication can be seen at present they will be displayed at
a later stage of dissection (see p. 122).

Dissection. After the branches of the facial nerve, the

external maxillary artery and the anterior facial vein have been
studied, the dissection of the deeper muscles and the deeper
vessels and nerves must be proceeded with ; but the supra-
orbital and supra-trochlear nerves, and the supra-orbital vessels,
may be left till the scalp is dissected (p. 47).

First clean the caninus muscle which lies deep to the infra-
orbital plexus and descends to the angle of the mouth, where it
blends with the orbicularis oris. Then clean the remains of the fat
from the surface of the buccinator, and as the fat is being removed
note the small molar glands which lie in it and the strong deep
bucco-pharyngeal fascia which covers the muscle. The ducts
of the molar glands pierce the bucco-pharyngeal fascia and the
buccinator and open into the vestibule of the mouth. Clean
away the bucco-pharyngeal fascia and define the attachments
of the buccinator to the maxilla and the mandible, and trace its
fibres forwards to the angle of the mouth, where they blend with
the orbicularis oris.

Musculus Caninus (O.T. Levator Anguli Oris). The

caninus is concealed by the lower part of the orbicularis

FACE AND FRONTAL REGION OF HEAD 21

oculi, the quadratus labii superioris, and the zygomaticus, and

it is crossed superficially, near the angle of the mouth, by
the external maxillary artery. When the structures superficial
to it are turned aside, the muscle will be found springing from
the canine fossa below the infra-orbital foramen. It passes
downwards to the angle of the mouth, where it blends with the
orbicularis oris, some of its fibres passing into the lower lip
(Fig. 3). It is an elevator of the angle of the mouth and
is supplied by the facial nerve.

M. Buccinator. The buccinator muscle occupies the

interval between the maxilla and the mandible and forms a
most important part of the substance of the cheek. Above,
it springs from the alveolar border of the maxilla, in the
region of the molar teeth. Below, it arises from the

FIG. 6. Arrangement of the Fibres of the Buccinator Muscles

at the Angles of the Mouth.

alveolar border of the mandible, also in the region of the

molar teeth, and, posteriorly, it is attached to the pterygo-
mandibular raphe, which forms a bond of union between
the buccinator and the superior constrictor of the pharynx.
The last-mentioned attachment will be seen to better advantage
when the wall of the pharynx is studied (p. 286). Anteriorly,
the fibres of the buccinator converge towards the angle of
the mouth, where they blend with the orbicularis oris, of
which they form a large part. The manner in which the
fibres enter the orbicularis must be carefully noted. The
upper and lower fibres pass directly to the corresponding
lips ; the middle fibres, on the other hand, decussate at the
angle of the mouth, so that the lower fibres of the series
enter the upper lip, whilst the higher fasciculi reach the
lower lip (Fig. 3).

The buccinator muscle is not classified as a muscle of

mastication, but it is used during mastication to prevent food
in 2Z>

22 HEAD AND NECK

accumulating between the cheeks and the teeth, the con-

tractions of the muscle forcing the food back, between the
teeth, into the cavity of the mouth proper. It is also used
for blowing and whistling. It is supplied by the facial nerve.
The Molar Glands. The pad of fat which covered the
buccinator posteriorly, and which was removed, as the buccal
branch of the mandibular nerve was cleaned, is known as the
corpus adiposum buccae, or suctorial pad. Its removal
exposed the bucco-pharyngeal fascia and a number of small
glands, called the molar salivary glands. The ducts of the
molar glands pierce the buccinator and open into the vestibule
of the mouth. One or two buccal lymph glands also are
sometimes found resting on the superficial surface of the
buccinator.

Dissection. After the dissection of the buccinator and the

molar glands is completed, remove the stitches from the lips ;
evert the lips and dissect the mucous membrane from the deep
surfaces, in order to expose the muscular slips which attach the
orbicularis oris to the alveolar margins of the maxilla and the
mandible, and to display the mentalis muscle. As the lips are
everted the dissector should note that a fold of mucous membrane,
the frenulum labii, passes from each lip to the adjacent gum in
the median plane ; and as the mucous membrane is removed a
number of small labial salivary glands, which lie in the sub-
mucous tissue, will be seen. They are readily felt in the living
subject when the tip of the tongue is pressed against the inner
surfaces of the lips.

Mnsculi Incisivi Labii Superioris et Inferioris. The

incisive muscles of the upper and lower lips are four small
muscular bundles, two upper and two lower, which attach
the deeper part of the orbicularis oris to the alveolar margins
of the maxillae and mandible in the regions of the upper and
lower lateral incisor teeth.

Musculus Mentalis. When the incisive muscles of the

mandible are detached from the bone and the lower lip is
further everted, a distinct muscular bundle will be found on
each side, springing from the outer surface of the socket of the
canine tooth, under cover of the quadratus labii inferioris.
The two bundles converge and blend together, between the
medial borders of the musculi quadrati labii inferioris, to
form a single bundle which is inserted into the skin of the
chin. It is an elevator of the skin of the chin. It is sup-
plied by the facial nerve.

Nervus Buccinatorius (O.T. Long Buccal). The buccinator

FACE AND FRONTAL REGION OF HEAD 23

nerve is a branch of the mandibular division of the trigeminal

nerve. It passes forwards into the cheek from under cover
of the ramus of the mandible. It is a sensory nerve, and it
supplies branches to the skin on the outer surface, and the
mucous membrane on the inner surface, of the buccinator
muscle. Its communications with the buccal branch of the
facial nerve has already been referred to (see p. 20).

Palpebrae. In the eyelids the following strata will be

exposed as the dissection is carried from the surface towards
the conjunctiva.

UPPER LID.

LOWER LID.
2.

3-

4-

Integument.
Palpebral part of the orbicularis
oculi.
The tarsus, the palpebral
fascia, and the expanded ten-
don of the levator palpebroe
superioris.
Conjunctiva.

I. Integument.
2. Palpebral part of the
oculi.
3. The tarsus and the
fascia.

4. Conjunctiva.

orbicularis
palpebral

In addition to the structures enumerated in the above

list, two ligamentous bands, named the medial palpebral
ligament (O.T. internal tarsal ligament) and the lateral
palpebral raphe (O.T. external tarsal ligament), will be
noticed. They attach the tarsi to the medial and lateral
margins of the orbit.

Integument and Orbicularis Oculi. Both the skin and

the orbicularis oculi have been examined already, and the
skin has been reflected.

Dissection. Separate the palpebral part of the orbicularis

oculi from the remainder by a circular incision ; turn the
palpebral part towards the rima palpebrarum, and take care,
whilst raising the muscle fibres, to preserve the palpebral vessels
and nerves, and at the same time to avoid injury to the palpebral
fascia. As the dissection is completed the origin of the muscle
from the medial palpebral ligament (p. 7) will be displayed.

Tarsi. The removal of the palpebral part of the orbicularis

oculi brings into view the palpebral fascia and the tarsi.
They lie in the same morphological plane, and they constitute
the ground- work of the eyelids (Fig. 7).

The tarsi are two thin plates of condensed fibrous tissue,

in 2 c
24 HEAD AND NECK

placed one in each eyelid so as to occupy an area immediately

adjoining its free margin. They differ very materially from
each other. The superior tarsus is much the larger of the
two, and presents the figure of a half oval. Its deep surface
is intimately connected with the subjacent conjunctiva, whilst
its superficial surface is clothed by the orbicularis muscle, and
is in relation to the roots of the eyelashes. Its superior
border is thin, convex, and is continuous with a tendinous
expansion of the levator palpebrae superioris, and with the
palpebral fascia which attaches it to the margin of the orbit.
The inferior border of the tarsus is thickened and straight,
and the integument adheres firmly to it.

The inferior tarsus is a narrow strip which is similarly

placed in the lower lid. It is connected with the inferior
margin of the orbit by the inferior part of the palpebral fascia.

Glandulse Tarsales (O.T. Meibomian Follicles). At this

stage the student should examine the tarsal glands, which he
will display by everting the eyelids. They are placed on the
deep surfaces of the tarsi. To the naked eye they appear
as closely placed, parallel, yellow, granular -looking streaks,
which run at right angles to the free margins of the lids.
They are more numerous and of greater length in the
upper lid, and, being lodged in furrows on the deep surface
of the tarsi, they are distinctly visible upon both aspects
of them, even while the conjunctiva is in position. Their
ducts open upon the free margin of each lid, posterior to
the eyelashes.

The Palpebral Fascia. The palpebral fascia is a sheet of

fibrous membrane which occupies the interval between the
tarsi and the margins of the orbit, forming, with the tarsi, a
septum between the orbit and the exterior. Its peripheral
border is attached to the orbital margin, except at the medial
angle of the orbit, where it occupies a more posterior plane,
and is attached to the crista lacrimalis, posterior to the medial
palpebral ligament and the lacrimal sac. Its central border
in the lower lid is connected with the lower border of the
lower tarsus. In the upper lid it blends with the expanded
tendon of the levator palpebrae superioris, and is attached
with it to the anterior surface of the upper tarsus. It is
pierced by the supra-orbital, supra-trochlear, and lacrimal
branches of the ophthalmic division of the trigeminal nerve,
and by the terminal branches of the ophthalmic artery.

FACE AND FRONTAL REGION OF HEAD 25

Raphe Palpebralis Lateralis. The lateral palpebral raphe

(O.T. external tarsal ligament) is merely a thickening of the
palpebral fascia, between the lateral commissure and the
medial border of the fronto-sphenoidal process of the zygomatic
bone (O.T. malar), to which it connects both the tarsi.
Ligamentum Palpebrale Mediate (O.T. Internal Tarsal
Ligament). The medial palpebral ligament is a strong fibrous
band which connects the medial ends of both tarsi to the
frontal process of the maxilla. It lies between the skin

Tendon of levatoi
palpebrse superiorly

Palpebral fascia

Palpebral branch of
lacrimal nerve

Superior tarsus

Raphe palpebralis
lateralis

Palpebral fascia

Supra-orbital nerve
Supra-trochlear nerve
Superciliary arch

Infra-trochlear nerve

Lacrimal sac

Ligamentum palpe-
brale mediale

Inferior tarsus

Infra-orbital nerve

p'iG. 7. Dissection of the Right Eyelid. The orbicularis oculi has been
completely removed.

anteriorly, and the lacrimal sac posteriorly. By its upper and

lower borders it gives attachment to fibres of the orbicularis
oculi, and, by the lateral part of its posterior surface, to the
pars lacrimalis of the orbicularis oculi (O.T. tensor tarsi).

Levator Palpebrse Superioris. Only the anterior expanded

tendon of the elevator muscle of the upper eyelid can be
seen at the present stage of the dissection, and that, as a
rule, in only a partially satisfactory manner. The muscle
arises within the orbital cavity, extends forwards to the upper
eyelid, and ends in an expanded tendon which splits into

26

HEAD AND NECK

three lamellae: a superior lamella, which blends with the

upper part of the palpebral fascia and is attached with it
to the anterior surface of the upper tarsus ; an intermediate
lamella, which is connected with the upper border of the
upper tarsus ; and an inferior lamella, which gains insertion
into the upper fornix of the conjunctiva. It raises the
upper eyelid by pulling on the upper tarsus, and at the same
time elevates the upper fornix of the conjunctiva. It is sup-
plied by the oculo-motor nerve.

Vessels and Nerves of the Eyelids. At the medial com-

missure two arteries, the palpebral branches of the ophthalmic,

Frontal bon

M. orbicularis oculi

Palpebral fascia \^5^

Superior conjunctival fornix

Superior tarsus

Conjunctival recess

Inferior conjunctival fornix

Palpebral fascia <
FIG. 8. Diagram of the Structure of the Eyelids.

pierce the palpebral fascia and run laterally, one in the upper
and one in the lower lid. At the lateral margin of the
orbit, one or more branches of the lacrimal division of the
ophthalmic pierce the palpebral fascia and anastomose with
the palpebral branches of the ophthalmic. An arterial arch,
arcus tarseus, is thus formed close to the margin of each
eyelid, between the orbicularis muscle and the tarsus.
The veins run medially towards the root of the nose and
open into the frontal and angular veins.

The nerves are more numerous and come from a number

of different sources. The motor filaments for the various
parts of the orbicularis oculi are derived from the temporal

FACE AND FRONTAL REGION OF HEAD 27

and zygomatic branches of the facial nerve. They enter

from the lateral margins. The sensory twigs for the upper
lid come from the lacrimal, supra-orbital, supra-trochlear, and
infra-trochlear branches of the first or ophthalmic division of
the trigeminal nerve; and the lower lid is supplied by the
infra-orbital branch of the maxillary division of the fifth
cerebral nerve. The lacrimal nerve will be found piercing
the palpebral fascia near the lateral part -of the upper border
of the orbit ; the supra-orbital lies in the supra-orbital notch
at the junction of the lateral two-thirds with the medial third
of the upper border ; and the supra- and infra-trochlear pierce
the palpebral fascia at the medial end of the upper border.
The branches of the infra-orbital nerve pass to the lower lid
in the palpebral branches of the infra-orbital plexus (p. 20).

Apparatus Lacrimalis. The following structures are in-

cluded under this head : (i) the lacrimal gland and its- ducts ;
(2) the conjunctival sac ; (3) the puncta lacrimalia ; (4) the
lacrimal ducts; (5) the- lacrimal sac; (6) the naso-lacrimal
duct ; (7) the lacrimal part of the orbicularis oculi.

Glandula Lacrimalis. The lacrimal gland lies in the

upper and lateral part of the orbital cavity, under cover of
the zygomatic process of the frontal bone. It can be exposed
by cutting through the palpebral fascia at the upper and lateral
angle of the orbit, and it will be found that the anterior part
of the gland projects slightly beyond the orbital margin and
rests upon the conjunctiva, as the latter is reflected from the
lateral part of the upper lid on to the eyeball. If the anterior
border of the gland is raised and the point of the knife
is carried carefully up and down in the fascia under it, several
exceedingly fine ducts will be found passing from the gland
into the lateral part - of the upper fornix of the conjunctiva

(Fig. 9)-

The ducts vary in number, and the secretion they

convey, which constitutes the tears, is carried, by the in-
voluntary movements of the upper eyelid, over the exposed
surface of the eyeball and is directed towards the medial
commissure ; there it passes through the puncta lacrimalia
into the lacrimal ducts, and is carried by them to the lacrimal
sac, whence it passes by the naso-lacrimal duct into the
inferior meatus of the nose. Under ordinary circumstances,
the amount of lacrimal secretion is sufficient merely for lubrica-
tion, and practically the whole of it is evaporated from the
28

HEAD AND NECK

surface of the eyeball ; consequently, when the lacrimal ducts

and the lacrimal sac are extirpated, a proceeding which is
necessary under certain circumstances, the patient suffers
little or no inconvenience from the overflow of tears, so long
as the secretion is not excessive. If the amount of secretion

Lacrimal
gland, superior part

Puncta lacrimalh
Lacrimal ducts
Lacrimal sac

Medial palpebral
ligament

Muco-periosteun
Plica lacrimalis
Inferior meatus
Inferior concha

'F IG . 9 . Dissection of Lacrimal Apparatus.

is greater than can be removed by evaporation, the excess,

under ordinary circumstances, passes through the puncta into
the ducts and thence through the lacrimal sac and naso-
lacrimal duct to the inferior meatus of the nose. If the
secretion becomes so abundant that it cannot be removed
by evaporation and drainage, part flows through the rima
as tears.

FACE AND FRONTAL REGION OF HEAD 29

The Conjunctival Sac. The cavity of the conjunctiva!

sac is the potential space between the eyelids and the eyeball.
It opens externally through the rima, and communicates with
the lacrimal sac through the puncta and the lacrimal ducts.
Puncta Lacrimalia. It has been noted already that the
punctum lacrimale of each lid lies at the lateral margin of
the lacus lacrimalis (p. 4). Small probes should now be
passed through the puncta into the lacrimal ducts and along
the ducts into the lacrimal sac (Fig. 9).

Saccus Lacrimalis. The lacrimal sac is the blind upper

end of a canal which extends from the orbit to the inferior
meatus of the nose. It is lodged in the fossa lacrimalis in
the anterior part of the medial wall of the orbit. It lies
posterior to the medial palpebral ligament, from which it
receives a fibrous expansion, and it is covered on its lateral
aspect, and on the lateral part of its posterior aspect, by
the pars lacrimalis of the orbicularis oculi. The lacrimal
ducts open into its antero- lateral aspect, under cover of
the medial palpebral ligament; and it is continuous below
with the naso-lacrimal duct. The anterior wall of the sac
should be incised and a probe should be passed down the
naso-lacrimal duct into the inferior meatus of the nose. Note
that as the probe passes along the duct it inclines down-
wards, laterally and slightly backwards.

Pars Lacrimalis M. Orbicularis Oculi (O.T. Tensor

Tarsi], The lacrimal part of the orbicularis oculi springs
from the posterior aspect of the lateral part of the medial
palpebral ligament and passes backwards and medially, round
the lateral part of the lacrimal sac, to the crista lacrimalis
of the lacrimal bone, to which it is attached. When it con-
tracts it compresses the lacrimal sac, and so tends to facilitate
the flow of the lacrimal secretion into the nose.

Ductus Naso-Lacrimalis. The naso-lacrimal duct will be

seen at a later period of the dissection. It lies in a bony
canal in the lateral wall of the nose, and extends from the
lacrimal sac to the upper and anterior part of the inferior
meatus. It is about 12.5 mm. (half an inch) long, and its
walls are composed of muco-periosteum. At the medial side
of its lower end is a fold of mucous membrane, the plica
lacrimalis, which serves as a flap valve (Fig. 9).

Dissection. The dissection of the face should be completed

by an examination of the nasal cartilages and the external nasal

HEAD AND NECK

branch of the ophthalmic division of the trigeminal nerve. The

nerve will be found emerging between the lower border of the
nasal bone and the lateral cartilage of the nose. After its
emergence it descends to the tip of the nose, supplying filaments
to the skin. After it has been displayed, strip off the nasalis
muscle and the remains of the integument and examine the
cartilaginous part of the nose.

Cartilagines Nasi. In addition to the septal cartilage,

which will be more appropriately studied in the dissection of
the nasal cavities, two cartilaginous plates will be found
upon each side. They are :

1. The lateral cartilage.

2. The cartilage of the ala.

External nasal nerve

Tl

jar Lateral cartilage

Minor alar cartilages

Major alar cartilage

FIG. 10. Cartilages of the Nose.

The lateral cartilage is triangular in form. Its posterior

margin is attached to the lower border of the nasal bone and
the upper part of the sharp margin of the nasal notch of
the maxilla. The upper part of the medial border is con-
tinuous with the corresponding cartilage of the opposite side,
and also with the subjacent anterior border of the septal
cartilage of the nose; but the lower parts of the medial
borders of the lateral cartilages are separated by a small
interval in which the margin of the nasal septal cartilage is
seen. The inferior border of the lateral cartilage is connected
with the lateral part of the alar cartilage by fibrous tissue.

The alar cartilage is a bent plate which is folded round

the anterior part of the nasal orifice. The lateral part is
oval, and reaches neither down to the margin of the nostril,

FACE AND FRONTAL REGION OF HEAD 31

nor posteriorly as far as the nasal notch of the maxilla. The

interval between it and the bone is filled in by fibrous tissue
in which one or two small islands of cartilage (cartilagines
minores vel sesamoideae) appear. Anteriorly, the bent part
of cartilage comes into contact with its neighbour and forms
the point of the nose. The medial part of the cartilage is a
narrow strip which lies against the lower part of the septal
cartilage, and projects slightly below it, so as to support the
margin of the nostril upon the medial side. Its posterior
extremity is turned slightly laterally.

SIDE OF THE NECK.

On the fourth day after the body is brought into the room
it is placed upon its back, and the dissectors of the head and
neck should examine the side of the neck and commence the
dissection of the posterior triangle.

The side of the neck is bounded below by the clavicle,

above by the lower border of the mandible, the mastoid
portion of the temporal bone, and the superior nuchal line of
the occipital bone. Anteriorly it extends to the median plane,
ycA posteriorly to the anterior border of the trapezius muscle.
It is divided into anterior and posterior parts, the anterior
and posterior triangles , by the sterno- mastoid muscle. If
the head is pulled over towards the opposite side, the sterno-
mastoid muscle will be seen descending from the mastoid
portion of the temporal bone and the superior nuchal line of
the occipital bone, to the upper border of the sternal third
of the clavicle and the anterior surface of the manubrium
sterni.

In the lower part of the posterior region, posterior to the

sterno -mastoid and above the Convex middle third of the
clavicle, there is a depression called \hzfossa supraclavicularis
major, to distinguish it from the fossa supraclavicularis minor,
which lies between the sternal and clavicular heads of the
sterno-mastoid, above the sternal end of the clavicle. The
fossa supraclavicularis major overlies the brachial plexus, the
third part of the subclavian artery, and the supra -clavicular
lymph glands ; and the fossa supraclavicularis minor indicates
the position of the lower part of the internal jugular vein.

32 HEAD AND NECK

POSTERIOR TRIANGLE.

Dissection. To expose the boundaries and contents of the

posterior triangle make the following three incisions through
the skin, (i) From the back of the auricle, along the upper
border of the mastoid part of the temporal bone and the superior
nuchal line to the external occipital protuberance. (2) From
the sternal to the acromial end of the clavicle, following the line
of that bone. (3) Join the anterior extremities of I and 2 by
an incision, passing along the back of the external acoustic
meatus, and then down the middle of the sterno-mastoid muscle.
Reflect the flap, thus marked out, from before backwards, and
note that the skin is thicker over the upper and posterior part
of the triangle than over the lower and anterior part.

When the skin is reflected the superficial fascia and the

lower part of the platysma muscle will be exposed.
The superficial fascia in the region of the posterior triangle
is comparatively thin, and embedded in its lower and anterior
part is the lower and posterior part of the platysma.

M. Platysma. The platysma is a thin sheet of muscle

which commences in the superficial fascia of the infra-clavicu-
lar region, whence it ascends, across the clavicle and through
the superficial fascia of the side of the neck, to the face, where
its upper border has been examined already (p. 7). It
covers the lower and anterior part of the posterior triangle,
and the upper and posterior part of the anterior triangle ; and
it is supplied by the cervical branch of the facial nerve,
which emerges from the lower end of the parotid gland.

Dissection. Make an incision through the lower part of the

platysma along the line of the clavicle, and turn the part above
the incision upwards and forwards. Whilst making the incision
and ^whilst reflecting the muscle, be careful not to injure the
supra-clavicular cutaneous nerves and the external jugular
vein, which lie directly subjacent to the platysma.

After the platysma is reflected, clean the external jugular

vein, which commences at the lower end of the parotid gland,
and passes downwards, inclining backwards, to the lower and
anterior angle of the posterior triangle, where it pierces the deep
fascia. (See pp. 34, 40, and Figs, n and 15.) Whilst clean-
ing the vein, avoid injury to the nervus cutaneus colli, which
sometimes crosses superficial to the vein about the middle of
its length. Secure and clean the posterior auricular vein, which
descends behind the auricle and joins the external jugular a little
below the level of the angle of the mandible. Next, find and
clean the superficial branches of the cervical plexus as they
pierce the deep fascia. They are : (i) Descending branches,
the anterior, middle, and posterior supra-clavicular nerves.
(2) A transverse branch, the nervus cutaneus colli (O.T. trans-
verse cervical). (3) Ascending branches, the great auricular
and the lesser occipital (Figs, n, 15).

POSTERIOR TRIANGLE

33

The anterior and middle supra-clavicular nerves will be found

piercing the deep fascia immediately above the clavicle, the
anterior at the posterior border of the sterno-mastoid and the
middle above the convexity of the clavicle. They descend into
the pectoral region as far as the lower border of the second rib

Greater occipital
nerve .
Posterior
auricular vein

Lesser occipital nerve

Great auricular nerve
M. splenius capitis
Accessory nerve

Middle supra-
clavicular nerve
Posterior supra-
clavicular ne

M. scalenus medius

" Nervus cuta-

neus colli,
upper branch
Exteinal jugular
vein crossing nervus
cutaneus colli

Anterior supra-
clavicular nerve.

FIG. ii. The superficial branches of the Cervical Plexus.

and their lower portions will be displayed by the dissector of the

arm. The posterior supra - clavicular nerves pierce the deep
fascia at a somewhat higher level. They descend across the
lower and anterior part of the trapezius to the acromial region,
and to the skin of the arm over the proximal part of the deltoid,
where they will be exposed by the dissector of the arm (Fig. 1 1 ) .

VOL. Ill 3

34 HEAD AND NECK

The Deep Fascia. The deep fascia forms the superficial

boundary or roof of the posterior triangle. It is attached,
below, to the upper border of the middle third of the clavicle ;
above, to the superior nuchal line of the occipital bone \
anteriorly, it is continuous with the fascia of the sterno-mastoid,
and posteriorly, with the fascia of the trapezius. It is pierced
by (i) the supra-clavicular branches of the cervical plexus, (2)
the external jugular vein, (3) small cutaneous branches of the
transverse cervical, transverse scapular (O.T. suprascapular),
and occipital arteries, and, occasionally, by the occipital artery
itself. It is not a very strong layer, and it is frequently difficult
to display it as a continuous sheet. Over the upper part of the
triangle it forms a single layer, but below it splits into two
lamellae, a superficial and a deep. The superficial layer, which
is already displayed, is attached to the upper border of the
clavicle from the sterno-mastoid anteriorly to the trapezius
posteriorly. It is pierced by the external jugular vein and
the supraclavicular nerves.

Dissection. Trace the supra-clavicular nerves upwards,

through the deep fascia, to the posterior border of the sterno-
mastoid ; then, pulling them aside, cut through the superficial
layer of the deep fascia immediately above the clavicle and along
the posterior border of the sterno-mastoid, and turn it upwards.
Introduce the handle of the scalpel behind the clavicle and note
that it can be passed downwards as far as the posterior border
of the lower surface of the bone. Its further progress is barred
by the attachment of the second layer of the deep fascia to that
border, where it blends with the posterior lamella of the costo-
coracoid membrane. Pass the handle of the knife forwards
deep to the sterno-mastoid, and note that, without using any
great force, it can be pushed medially until it crosses the median
plane ; therefore, the space between the two layers of deep fascia
in the lower part of the posterior triangle is continuous anteriorly
with the space which lies above and posterior to the manubrium
sterni, between the first and the second layers of the deep fascia
of the anterior part of the neck. Laterally, that space extends
as far as the coracoid process, and upwards to a short distance
above the posterior belly of the omo-hyoid muscle, which lies
a little above the clavicle. Take away the areolar tissue which
lies between the two layers of the deep fascia, and expose a
further part of the external jugular vein, and the terminal parts
of the transverse cervical and the transverse scapular (supra-
scapular) veins, as they join the posterior border of the external
jugular. Pull the lower part of the external jugular vein
backwards and expose the termination of the anterior jugular
vein in its anterior border. Dissect carefully behind the clavicle
and find the transverse scapular (suprascapular) artery. Trace
the second layer of the deep fascia upwards and note that it
is continuous with the fascia which surrounds the posterior

POSTERIOR TRIANGLE 35

belly of the omo-hyoid muscle ; indeed, it is the tension of the

second layer of the deep fascia which holds the posterior belly of
the muscle down in its position (Fig. 51).

Remove the remaining parts of the deep fascia, first from the
upper, and then from the lower part of the triangle, and expose
the floor and the remaining contents of the triangle.

Commence above, in the region of the junction of the upper

third and the lower two-thirds of the posterior border of the
sterno-mastoid, and secure the great auricular, the lesser occipi-
tal and the accessory nerves, and the nervus cutaneus colli.
The great auricular is most easily found. It turns round the
posterior border of the sterno-mastoid, in the region indicated,
and runs upwards and forwards, parallel with and slightly
above and posterior to the external jugular vein. The lesser
occipital will be found hooking round the lower border of the
accessory nerve a little above the great auricular ; and the nervus
cutaneus colli lies a little below the great auricular.

Follow the lesser occipital and the great auricular nerves to

their terminations ; but the nervus cutaneus colli must be traced
only to the point where it crosses either superficial or deep to
the external jugular vein. It eventually divides into upper and
lower terminal branches, which will be seen when the anterior
triangle is dissected.

N'ervus Occipitalis Minor. The lesser occipital is a sensory

branch of the second cervical nerve. It emerges from under
cover of the sterno-mastoid, and ascends for a short distance
along its posterior border; then it passes to the superficial
surface of the muscle, pierces the deep fascia, and divides
into occipital, mastoid, and auricular branches. The occi-
pital and mastoid branches supply the skin in the regions
indicated by their names. The auricular branch is distributed
to the skin of the upper third of the cranial surface of the
auricle.

Nervus Auricularis Magnus. The great auricular nerve v -

arises from the second' and third cervical nerves. After
turning round the posterior border of the sterno-mastoid,
it runs upwards and forwards, on the superficial surface of
the sterno-mastoid, towards the angle of the mandible. It
breaks up into three sets of terminal cutaneous branches
mastoid, auricular, and facial. The mastoid branches go to
the skin of the mastoid region. The auricular branches
supply the skin of the lower two-thirds of the cranial surface
and the lower third of the lateral surface of the auricle. The
facial branches, which have already been seen, ramify in the
posterior part of the face, in the parotid and masseteric regions.
Some of the filaments enter the substance of the parotid
gland.

36 HEAD AND NECK

Dissection. The accessory nerve, previously found at the

junction of the upper third with the lower two-thirds of the
posterior border of the sterno-mastoid, must now be traced
downwards and backwards, through the triangle, to the point
where it disappears under cover of the trapezius, at the junction
of the upper two-thirds with the lower third of the anterior
border of that muscle. As the nerve is cleaned, attempt to secure
twigs from the third and fourth cervical nerves which com-
municate with it in the posterior triangle.

Turn next to the posterior belly of the omo-hyoid muscle,

which crosses the lower part of the triangle. Note that it
divides the triangle into a large upper or occipital portion, and
a small lower or subclavian portion. Cut through the fascia
on the surface of the muscle, parallel with the muscle fibres,
and turn it upwards and downwards ; then turn the upper border
of the muscle laterally and find the nerve from the ansa hypo-
glossi which emerges from under cover of the sterno-mastoid
and enters the deep surface of the posterior belly of the omo-
hyoid to supply it.

Now remove any parts of the fascial roof of the upper part
of the posterior triangle which are still present, and note a
number of lymph glands which lie embedded in the subjacent
areolar tissue ; they are placed along the posterior border of
the sterno-mastoid, superficial to the stems and branches of the
cervical nerves. At the apex of the triangle look for the
occipital artery, which either emerges between the adjacent
borders of the trapezius and the sterno-mastoid, or pierces the
trapezius a little further back.

Between the accessory nerve above and the posterior belly of

the omo-hyoid below find : (i) the upper part of the brachial
plexus ; (2) its branch to the subclavius ; (3) its suprascapular
branch ; (4) its dorsalis scapulae branch ; (5) its long thoracic
branch ; (6) branches from the third and fourth cervical nerves
to the levator scapulae ; (7) branches from the third and fourth
cervical nerves to the trapezius, and others which communicate
with the accessory nerve in the posterior triangle ; and (8) the
upper and posterior part of the transverse cervical artery. Find
the transverse cervical artery as it appears from under cover of
the upper border of the omo-hyoid. It runs upwards and back-
wards. Next, secure the nerve to the subclavius, which lies
under cover of the deep fascia above the omo-hyoid immediately
behind the sterno-mastoid. Trace it upwards to its origin from
the trunk formed by the union of the fifth and sixth cervical
nerves. Clean the latter nerves and the upper part of the
seventh cervical nerve, which lies immediately below them.
Then find the suprascapular nerve, which springs from the
lateral border of the trunk formed by the fifth and sixth nerves.
It lies immediately above the anterior part of the posterior belly
of the omo-hyoid, and disappears under cover of the posterior
part. Turn the trunk formed by the fifth and sixth cervical
nerves forwards and find, posterior to it, the upper roots of the
long thoracic nerve, which spring from the fifth and sixth nerves,
and are emerging through the fibres of the scalenus medius
muscle. The nervus dorsalis scapulas (O.T. nerve to the rhom-
boids) lies at a slightly higher level than the suprascapular nerve.
It springs from the fifth cervical nerve, runs downwards and

POSTERIOR TRIANGLE 37

backwards, and disappears, through the floor of the triangle,

between the adjacent borders of the levator scapulae above and
the scalenus medius below. Above the dorsal scapular nerve
are the branches from the third and fourth cervical nerves to
the trapezius and the communications to the accessory nerve.
When the structures mentioned above have been found and
cleaned, proceed to the dissection of the subclavian portion of
the triangle. Find the transverse scapular artery which lies
behind the clavicle, and therefore, strictly speaking, outside the
limits of the triangle. Then remove the second layer of deep
cervical fascia which binds the posterior belly of the omo-hyoid
to the posterior border of the clavicle, and find behind it : (i) a
further part of the external jugular vein ; (2) a further part of
the transverse cervical artery ; (3) the lower part of the nerve
to the subclavius ; (4) the upper portion of the third part of the
subclavian artery ; (5) the lowest root and the lower parts of
the trunks of the brachial plexus ; (6) a part of the long thoracic
nerve ; (7) inferior deep cervical lymph glands.

First clean the lower end of the external jugular vein and
follow it behind the clavicle to its termination in the subclavian
vein. Note the valves near its lower end. Next clean the
transverse cervical artery and the nerve to the subclavius.
Follow the nerve to the subclavius across the front of the third
part of the subclavian artery ; and afterwards clean the lower
part of the subclavian artery and the adjacent part of the brachial
plexus, which lies behind and above the artery. Note that the
artery and the plexus are covered by a layer of deep cervical
fascia, the backward prolongation of the prevertebral layer of
fascia, which passes on to them from the lateral border of the
scalenus anterior, which lies deep to the posterior border of the
sterno-mastoid. The fascia is prolonged along the plexus and
the artery to become continuous with the sheath of the axillary
artery.

As the areolar tissue is cleared from the subclavian portion

of the triangle a number of inferior deep cervical lymph glands
may be noted. They receive lymph from the axillary glands,
and they transmit it to the large lymph vessels at the root of
the neck (Fig. 14, p. 29, Vol. I.).

After the contents of the lower part of the triangle are

thoroughly cleaned, remove the remains of the fascia covering
the muscles which form the floor of the triangle. Note that
that fascia is continuous anteriorly, round the tips of the trans-
verse processes of the cervical vertebrae, with the prevertebral
fascia. Posteriorly, it blends with the sheaths of the deeper
muscles at the back of the neck ; above, it is attached to the
superior nuchal line ; and below, as already stated, it is pro-
longed into the axilla along the axillary vessels and nerves.

Boundaries and Contents of the Posterior Triangle. The

dissection of the triangle should be completed in two days.

On the third day the dissector should revise his knowledge
of the boundaries and the relative positions of the contents.

The triangle is bounded anteriorly by the posterior border

of the sterno-mastoid ; posteriorly by the anterior border of the
in 3 b

38 HEAD AND NECK

trapezius ; below by the upper border of the middle third
of the clavicle ; and above by the superior nuchal line of the
occipital bone, or by the meeting of the upper ends of the sterno-
mastoid and the trapezius. The roof is formed by the deep

M. semispinalis capit
Posterior auricular vei

frcm posterior facial vein

Int. jugular vein
Hypoglossal nerve
Posterior facial vein
Lesser occipital N.
Hypoglossal nerve
Great auricular N.

M. digastrics

Nerve to thyreo-hyoi<
Descendens hypoglos
M. thyreohyoideus

M. splenius capitis

Nervus cutaneus colli

Accessory N.

Superior thyreoid arter

M. omohyoideus

Dorsalis scapulae nerve

External jugular vein

M. scalenus medius
Trans, cervical artery

Transverse
scapular artery
M. scalenus anteri
Subclavian artery
M. omohyoideus
Brachial plexus

FIG. 12. The Triangles of the Neck seen from the side. The clavicular head
of the sterno-mastoid muscle was small, and therefore a considerable part
of the scalenus anterior muscle is seen.

cervical fascia, which is covered by superficial fascia and skin,

and in its lower and anterior part by the platysma, which is
embedded in the superficial fascia. It is pierced by (i) the
external jugular vein, at the lower and anterior angle ; (2) the
supraclavicular nerves, a short distance above the clavicle ;
(3) small cutaneous branches of the transverse scapular, trans-

POSTERIOR TRIANGLE

39

verse cervical, and occipital arteries ; (4) lymph vessels,

passing from the superficial structures to the glands in the
triangle. It is frequently stated that the lesser occipital and
great auricular nerves and the nervus cutaneus colli also
pierce the roof. As a general rule, they turn round the
posterior border of the sterno-mastoid, under cover of the
fascia, and pierce the fascia which lies on the sterno-mastoid
muscle.

The floor is formed by the splenius capitis, the levator

scapulae, the scalenus medius, and the scalenus posterior
muscles, with the addition, occasionally, of a small part of the
semispinalis capitis (O.T. complexus), above, and the upper
serration of the serratus anterior, below ; the latter appears
in the area of the triangle only when the clavicle is very
fully depressed. The muscles of the floor are covered with
a layer of fascia which is the backward continuation of the
prevertebral fascia of the anterior cervical region.

The contents of the posterior triangle are :

1. Fatty areolar tissue.

2. The posterior belly of the omo-hyoid muscle.

3. Lymph /Lateral superior deep cervical.

Glands, \Inferior deep cervical (Supraclavicular).

f Third part of subclavian.
J Transverse cervical and its terminal branches.
[Occipital (sometimes).
f External jugular.
J Transverse cervical.

5. Veins, 2 j Transverse scapular (O.T. suprascapular).

[Termination of anterior jugular.
Accessory.
Lesser occipital.
Great auricular.
Nervus cutaneus colli.
To levator scapulae,
trapezfus.
scalenus medius.

, , posterior.
Supraclavicular.

To posterior belly of omo-hyoid, from ansa hypoglossi.

Trunks of brachial plexus.
The nervus dorsalis scapulae. "|

,, long thoracic. ^Branches of the brachial

, suprascapular. | plexus.

,, nerve to the subclavius. J

1 The transverse scapular artery (O.T. suprascapular) lies posterior to

the clavicle and is not, strictly speaking, in the triangle.

2 The subclavian vein is posterior to the clavicle and therefore is not

contained within the triangle.

Hi 3 c

4. Arteries, 1

6. Nerves,

Branches of cervical plexus.

40 HEAD AND NECK

Some of the contents of the triangle which are now

displayed require further consideration.

Vena Jugularis Externa. The external jugular vein is

superficial except in the terminal part of its extent.

It commences on the surface of the sterno-mastoid, below

the lower end of the parotid gland, by the union of the
posterior auricular vein with a branch from the posterior
facial vein. After its formation it runs downwards and back-
wards, across the sterno-mastoid, to the upper and anterior
angle of the supraclavicular portion of the posterior triangle,
in which it pierces first the superficial layer and then the
second layer of the deep fascia, and it terminates in the
subclavian vein (Figs. 12, 15).

As it crosses the sterno-mastoid it lies at first parallel with

but anterior to the trunk of the great auricular nerve, then
deep to the platysma, and whilst beneath the platysma it
crosses either superficial or deep to the nervus cutaneus colli
(Fig. 12). At the posterior border of the sterno-mastoid it
sometimes receives a vein called the posterior external jugular
vein> which descends across the upper part of the posterior
triangle from the occipital region. Between the two layers
of the deep fascia of the supraclavicular triangle it receives
the transverse cervical, the transverse scapular and the
anterior jugular veins, and it lies superficial to the lower
roots of the brachial plexus ; as it pierces the second layer
of deep fascia, it lies superficial to the third part of the sub-
clavian artery.

Immediately above its termination it is provided with a

valve, consisting of two or three semilunar cusps. The
dissector should note that, as the vein pierces the deep fascia,
its wall is closely connected with the margin of the opening
through which it passes ; consequently when the fascia is
stretched the lumen of the vein is expanded.

The Posterior Belly of the Omo-hyoid Muscle. The

posterior belly of the omo-hyoid muscle springs from the
upper border of the scapula and upper transverse scapular
ligament. It enters the posterior triangle, at its lower and
posterior angle ; runs upwards and forwards, at a variable
distance from the clavicle, to the posterior border of the
sterno-mastoid, and divides the posterior triangle into occipital
and subclavian or supraclavicular portions. Either immedi-
ately behind or under cover of the posterior border of the

POSTERIOR TRIANGLE 41

sternomastoid it joins the intermediate tendon which connects

it with the anterior belly. Its nerve has already been seen
entering its deep surface (p. 36). As it crosses the posterior
triangle it lies superficial to the suprascapular nerve, the
transverse cervical artery and the brachial plexus.

Nervus Accessorius (O.T. Spinal Accessory). The portion

of the accessory nerve which appears in the posterior triangle
consists of fibres which arise from the cervical part of the
spinal medulla, and with them are incorporated some filaments
derived from the second cervical nerve. Before appearing
in their present situation the spinal fibres entered-tbe cranium
throughjthe: foramen magnum and left it_bv passing through
the jugular foramen ; then they passed downwards and back-
wards, through the deeper fibres of sterno-mastoid, where
they received the communication from the second cervical
nerve. As already pointed out, the nerve usually enters the
posterior triangle at the level of the union of the upper third
with the lower two-thirds of the posterior border of the
sterno-mastoid or at a slightly lower level. It runs down-
wards and backwards, through the triangle, along the line of
the levator scapulae, and disappears under the trapezius at
the junction of the upper two-thirds with the lower third
of its anterior border. As it enters the triangle the lesser
occipital nerve turns round its lower border; and, as it
crosses the triangle, it is joined by twigs from the third and
fourtkervical nerves. It lies parallel with, but at a higher
level than, the dorsalis scapulae nerve (Fig. 12).

The Branches of the Cervical Plexus. The dissector

should note that whilst many of the branches of the cervical
plexus lie within the area of the posterior triangle, the plexus
itself is under cover of the upper part of the sterno-mastoid,
where it will be exposed and studied when the sterno-mastoid
is reflected. The branches which appear in the triangle are
the superficial branches (i) the lesser occipital ; (2) the great
auricular; (3) the nervus cutaneus colli, and (4) the supra-
clavicular nerves ; and the deep posterior branches, that is, the
nerves to (i) the scalenus medius and (2) the scalenus
posterior; (3) the nerve to the levator scapulae; (4) the
branches to the trapezius, and (5) the communications to the
accessory nerve.

The Third Part of the Subclavian Artery. Only a portion

of the third part of the subclavian artery is the triangle ; the

42 HEAD AND NECK

lower and lateral part is behind the clavicle. The part in

the triangle is situated deeply in the anterior inferior angle,
and below the omo-hyoid muscle. It lies deep to the skin,
superficial fascia, the platysma, deep fascia, the external
jugular vein, the ends of the transverse scapular and trans-
verse cervical veins, and the nerve to the subclavius muscle.
The lowest trunk of the brachial plexus is behind it and
separates it from the insertion of the scalenus medius. Below^
it rests upon the first rib, against which it can be compressed,
and, more medially, upon the cervical pleura.

The Brachial Plexus and its Supraclavicular Branches.

Only the upper portion of the brachial plexus lies in the
region of the posterior triangle, i.e. the roots, the trunks, and
some of the branches ; the remainder lies either posterior to
the clavicle or in the axilla. The cervical portion lies in the
lower and anterior part of the posterior triangle, partly in the
occipital and partly in the supraclavicular areas. The detailed
study of the plexus should be left till the fifth day after the
body has been placed upon its back, when the dissector of
the head and neck will assist the dissector of the upper
extremity to disarticulate the clavicle and to lay bare the
whole of the plexus (p. 36); but it should be noted now
(i) that the cervical part of the plexus lies deep to the skin,
superficial fascia, platysma and deep fascia, and that it is
crossed superficially by the posterior belly of the omo-hyoid
muscle, the external jugular vein, the transverse cervical
artery and the transverse cervical and transverse scapular
veins; (2) that part of the third portion of the subclavian
artery is superficial to the lower part of the plexus ; and
(3) that behind the plexus is the lower part of the scalenus
medius muscle.

The fourth day after the body has been placed upon its
back should be devoted to the study of the temporal region
and the scalp.

THE SCALP AND THE SUPERFICIAL STRUCTURES

OF THE TEMPORAL REGION.

Under the term " scalp " are included the soft structures
which cover the vault of the cranium above the temporal
lines and anterior to the superior nuchal line. Its con-

AURICLE

43

stituent parts are arranged in five layers : (i) skin; (2) super-
ficial fascia ; (3) the epicranius, consisting of four muscular
bellies, the two occipitales and the two frontales muscles, and
the aponeurosis called the galea aponeurotica, which connects
them together ; (4) a layer of loose areolar tissue ; (5) the
periosteum, which in the region of cranium is called the
pericranium. In the temporal region the wall of the cranium
is much more thickly covered than in the scalp area, and it
is possible to distinguish seven layers of soft tissues between
the surface and the bone: (i) skin; (2) superficial fascia;
(3) extrinsic muscles of the ear ; (4) the thin lateral extensions

Integument

L Superficial fascia

Galea aponeurotica
Loose connective tissue
Pericranium
Cranial wall

-- Dura mater

FIG. 13. Section through the Scalp and Cranial Wall.

of the galea aponeurotica; (5) the strong temporal fascia;

(6) the temporal muscle; (7) periosteum.

The Scalp. The scalp and the superficial temporal region

are richly supplied with blood vessels and nerves, which all
enter from the periphery, passing into the superficial fascia
after piercing the deep fascia of adjacent regions. As a
consequence of that arrangement large flaps of the scalp may
be torn from the centre towards the margin, but, so long as
they remain attached at the periphery, their sources of
vitality are not seriously interfered with, and, if they are cleaned
and replaced, healing occurs rapidly and satisfactorily.

Dissection. The skin has already been removed from the

anterior parts of the scalp and the temporal region. A median
longitudinal incision must now be made through the skin of the
posterior part of the scalp as far as the external occipital pro-
tuberance, and the flap on each side of the incision must be

44 HEAD AND NECK

turned downwards and backwards to the superior nuchal line.

When that has been done the dissector should examine the
auricle of the external ear, and familiarise himself with its
various parts before he commences the dissection of its extrinsic
muscles.

Auricula. The auricle consists of a thin plate of yellow

fibro-cartilage, covered with integument. It is fixed in posi-
tion by certain ligaments, and possesses two sets of feeble
muscles viz., one group termed the extrinsic muscles, passing
to the cartilage from the aponeurosis of the epicranius and
the mastoid process, and a second group in connection with
the cartilage alone, and therefore called the intrinsic muscles.

The wide and deep depression which leads into the

external acoustic meatus is the concha. The ridge behind

FIG. 14. The Auricle.

the concha is the antiJielix. It commences below, in a

prominence called the antitragus. From the antitragus it
curves upwards behind the concha, and it divides above into
two crura which enclose a small depression called the fossa
triangularis. Below the antitragus is the lobule, which forms
the soft inferior extremity of the auricle. Its posterior
border is continuous with the helix, which forms the
incurved margin of the auricle. The helix ascends from
the lobule to the summit of the auricle ; then it descends,
forming the anterior border of the upper part of the auricle,
and, finally, it turns downwards and backwards above the
external meatus, into the concha, which it partly divides into
upper and lower portions. The part of the helix attached
to the lobule is the tail of the helix (cauda helicis) and the
part which passes from the anterior border of the auricle to
the floor of the concha is the crus helicis. The depression
which lies between the helix and the antihelix is the scaphoid

AURICLE 45

fossa or fossa of the helix. At the point where the posterior

border of the auricle turns forwards towards the superior
extremity there is, sometimes,' a small triangular prominence
which is known as Darwin's Tubercle. It represents the
apex of the ear of an ordinary quadruped. In front of the
meatus, and extending backwards to overshadow it, is a
triangular prominence called the tragus. It is separated
from the antitragus by a notch known as the intertragic
notch (indsura intertragica). Numerous hairs grow from the
posterior surface of the tragus. They become very prominent
in the male after the middle period of life.

The ligaments and muscles connected with the auricle

are :

( Anterior.

Ligaments, . -j Superior.

[Posterior,
f Auricularis anterior.
Extrinsic muscles, -! Auricularis superior.
[Auricularis posterior,
f Musculus helicis major. ^
I Musculus helicis minor, i Upon the lateral face of the

Intrinsic muscles J Musculus tragicus. j cartilage.

ies ' j Musculus antitragicus. J

j Musculus transversus. \Upon the cranial face of

[Musculus obliquus. / the cartilage.

Dissection. After the dissector has noted the various parts

of the auricle he should endeavour to display its extrinsic muscles ;
they are the auriculares anterior (O.T. attrahens), superior
(O.T. attollens), and posterior (O.T. retrahens).

The auricularis anterior has already been dissected (see p. 14).

It passes from the deep fascia of the temporal region to the front
of the helix. To display the auricularis superior pull the upper
part of the auricle downwards and carefully remove the super-
ficial fascia above ft. The muscle fibres spring from the lateral
part of the galea aponeurotica and converge, as they descend,
to the medial surface of the auricle in the region of the floor of
the triangular fossa. After the auricularis superior has been
cleaned pull the auricle forwards and clean the auricularis
posterior. It is a thicker and more definite muscular bundle
which springs from the mastoid portion of the temporal bone,
above the mastoid process, and passes to the convexity on the
medial surface of the auricle which corresponds with the floor
of the concha. As the muscle is being cleaned one or more
small mastoid lymph glands may be seen, and care must be
taken to avoid injury to the branch from the posterior auricular
nerve to the occipitalis part of the epicranius. It passes back-
wards either along the lower border of the auricularis posterior
or under cover of that muscle.

The auriculares muscles are supplied by the facial nerve ;

the anterior and the anterior part of the superior by its temporal

46 HEAD AND NECK

branches, and the posterior and the posterior part of the superior
by the posterior auricular branch. After the auriculares muscles
have been denned remove the skin from the entire extent of the
auricle to display the cartilage, the ligaments, and the intrinsic
muscles. 1 Great care is required to make a successful dissection.

The auricular cartilage extends throughout the entire auricle, with the
exception of the lobule and the portion between the tragus and the helix.
Those portions are composed merely of integument, fatty tissue, and
condensed connective tissue. The shape of the cartilage corresponds with
that of the auricle itself. It shows the same elevations and depressions,
and by its elasticity it serves to maintain the form of the auricle. But it
also enters into the formation of the cartilaginous or lateral portion of the
external acoustic meatus. By its medial margin this part of the cartilage
is firmly fixed by fibrous tissue to the rough lateral edge of the auditory
process of the temporal bone, but it does not form a complete tube. It is
deficient above and anteriorly, and there the tube of the meatus is completed
by tough fibrous membrane, which stretches between the tragus and the
commencement of the helix.

In a successful dissection of the cartilage of the auricle, two other points

will attract the attention of the student. The first is a deep slit, which
passes upwards so as to separate the lower part of the cartilage of the
helix, termed the processus helids caudatus, from the cartilage of the anti-
tragus. The second is a sharp spur of cartilage which projects forwards
from the helix, at the level of the upper margin of the zygoma ; it is
termed the spina helicis.

The Ligaments of the Auricle. The ligaments are three bands of

fascia. The anterior passes from the spine of the helix to the root of the
zygoma. The superior and posterior are both attached to the cartilage in
the region of the concha ; the former blends above with the temporal fascia,
and the latter is attached to the mastoid portion of the temporal bone.
The Intrinsic Muscles of the Auricle. The two muscles of the helix,
and the tragicus and the antitragicus, are placed upon the lateral face
of the cartilage. The transversus and the obliquus lie upon the cranial
surface of the auricle.

The musculus antitragicus is the best-marked member of the lateral

group. It lies upon the lateral surface of the antitragus, and its fibres pass
obliquely upwards and backwards. Some fasciculi can be traced to the
processus helicis caudatus.

The musculus tragiciis is a minute bundle of short vertical fibres

situated upon the lateral surface of the tragus. When well developed a
slender fasciculus may sometimes be observed to pass upwards from it to
the anterior part of the helix, where it is inserted into the spine of the helix.

The musculus helicis major is a well-marked band, which springs from

the spina helicis, and extends upwards upon the anterior part of the helix,
to be inserted into the skin which covers it.

The musculus helicis minor is a minute bundle of fleshy fibres which is

placed upon the crus helicis as it crosses the bottom of the concha.

The musciihis transversus auricula is found upon the cranial aspect of

the auricle. It is generally the most strongly developed muscle of the
series, and its fibres bridge across the hollow which, on this aspect of the
auricle, corresponds to the antihelix.

1 In most cases it will be advisable to defer this part of the dissection till
the body is turned on its back for the second time, and to proceed at once to
the dissection described on p. 47.

AURICLE 47

The musculus obliquus auricula is composed of some vertical fasciculi

bridging across the depression which corresponds to the eminence of the
lower limb of the antihelix.

Dissection. After the auricle and its muscles and ligaments

have been dissected and studied, follow the superficial temporal
vessels and the auriculo-temporal nerve upwards from the point
where they emerge from the upper end of the parotid gland to
their terminal distribution in the scalp. Next, pull the auricle
forwards and trace the posterior auricular nerve to its termina-
tion in the occipitalis muscle, and in the intrinsic and extrinsic
muscles of the auricle, and the posterior auricular artery to its
anastomoses with the occipital and superficial temporal arteries.
After that part of the dissection is completed, turn to the anterior
part of the scalp and find the medial and lateral branches of the
supra-orbital nerve. The medial branch pierces the fibres of
the frontalis and the lateral branch pierces the galea aponeuro-
tica a little further back. Trace both branches backwards,
through the superficial fascia, as far as possible ; they extend to
the level of the lambdoid suture. Then secure the supra-
trochlear nerve, which pierces the frontalis above the medial
margin of the orbit, and trace it upwards to its termination.
With the branches of the supra-orbital nerve are branches of
the supra-orbital artery, and the supra-trochlear nerve is accom-
panied by the frontal branch of the ophthalmic artery.

When the nerves and vessels in the anterior region have been
cleaned, the head should be turned well over to the opposite side,
and the branches of the occipital artery and the greater occipital
nerve should be sought for in the posterior region ; they radiate
upwards and forwards from the upper extremity of the trapezius.
After they have been secured, the occipitalis muscle must be
cleaned. It springs from the lateral part of the superior nuchal
line, and after a short course upwards and forwards, it terminates
in the galea aponeurotica. The remains of the superficial fascia
should now be removed from the surface of the galea aponeuro-
tica (O.T. epicranial aponeurosis), and then the dissector should
make a survey of the vessels and nerves which are met with in
the scalp and in the superficial fascia of the temporal region.

Nerves and Vessels of the Scalp and of the Superficial

Temporal Region. Branches of ten nerves are found, on each
side, in the superficial fascia of the region which lies above
the supra-orbital margin, the zygomatic arch and the superior
nuchal line. Five of the ten lie mainly anterior to the auricle
and five posterior to it ; and of each group four are sensory
and one is motor. The four sensory nerves anterior to the
auricle are all branches of the trigeminal nerve. They are
the supra-trochlear and supra-orbital branches of the first or
ophthalmic division \ the zygomatico- temporal branch of the
maxillary or second division ; and the auriculo-temporal branch
of the mandibular or third division. The motor nerve is the
temporal branch of the facial nerve.

48 HEAD AND NECK

The four sensory nerves distributed mainly to the scalp

area behind the auricle are the great auricular and the lesser
occipital branches of the cervical plexus ; the greater occipital,
which is the medial division of the posterior ramus of the
second cervical nerve ; and the third occipital, not yet seen,
but which will be displayed when the body is turned on its
face. It lies medial to the greater occipital, and is the medial
division of the posterior ramus of the third cervical nerve.
The motor nerve distributed posterior to the auricle is the
posterior auricular branch of the facial nerve.

The arteries distributed to the scalp are five in number on

each side ; they anastomose freely, and are derived, either
indirectly or directly, from the internal and external carotid
arteries. Three are distributed mainly anterior to, and two
posterior to the region of the auricle. The three anterior to
the auricle are the frontal and supra-orbital branches of the
ophthalmic branch of the internal carotid, which accompany
the supra-trochlear and supra-orbital nerves, respectively, and
the superficial temporal branch of the external carotid. The
superficial temporary artery divides into two main divisions,
an anterior division, which accompanies the temporal branches
of the facial nerve, and is usually a very tortuous vessel, and a
posterior division, which accompanies the auriculo-temporal
nerve, as it ascends, anterior to the auricle, towards the vertex
of the cranium. The two arteries posterior to the auricle are
both branches of the external carotid. They are the posterior
auricular, which accompanies the posterior auricular branch
of the facial nerve to the mastoid region and the posterior
part of the parietal region, and the occipital, which is distri-
buted to the occipital area and posterior part of the parietal
area (Figs. 15, 17, 51).

The terminations of the veins which drain the blood from

the scalp are as follows. The frontal and supra-orbital veins
unite, at the medial border of the orbit, to form the angular
vein, which is the commencement of the anterior facial vein,
already dissected (p. 16). The blood it conveys passes
eventually to the internal jugular vein. The superficial
temporal vein accompanies the corresponding artery. It unites,
immediately above the posterior root of the zygoma, with the
middle temporal vein, which pierces the temporal fascia at
that point. The trunk formed by the union of the superficial
and middle temporal veins is the posterior facial vein, which

PLATE I

FIG. 15.

SCALP

49

PLATE I
FIG. 15. Dissection of the Head and Neck.

The sterno-mastoid muscle is left in position, the inter-

mediate third or the clavicle has been removed and the medial
part of the subclavius muscle has been turned downwards.
Parts of the anterior, posterior and common facial veins have
been removed.

1. Supra-orbital artery and nerve.

2. Frontal artery and vein.

3. Lateral nasal branch of external

maxillary artery.

4. Superior labial branch of external

maxillary artery.

5. Inferior labial branch of external

maxillary artery.

6. Anterior facial vein.

7. External maxillary artery.

8. Cervical branch of facial nerve

communicating with N. cutan-

eus colli.

9. External carotid artery.

10. Common facial vein.

11. Superior thyreoid artery.

12. Anterior jugular veins.

13. Omo-hyoid muscle (anterior

belly).

14. External jugular vein.

15. Transverse cervical vein. .

1 6. Sterno-mastoid muscle.

17. Subclavian artery.

1 8. Subclavius muscle with nerve.

19. Cephalic vein.

20. Lateral anterior thoracic nerve.

.21. Axillary vein.

22. Acromial branch of thoraco-

acromial artery.

23. Transverse scapular vessels.

24. First serration of serratus anterior

muscle.
25. Omo-hyoid muscle (posterior

belly).

26. Supra-scapular nerve.

27. Transverse cervical artery on

scalenus medius muscle.

28. Upper root of long thoracic

nerve.

29. Trapezius.

30. Ascending branch of transverse

cervical artery which arose

separately from the thyreo-
cervical trunk.

31. Accessory nerve.

32. Levator scapulae muscle.

33. Internal carotid artery.

34. Great auricular nerve.

35. Commencement of external jugu-

lar vein.

36. Lesser occipital nerve.

37. Third occipital nerve.

38. Greater occipital nerve and

occipital artery.

39. Parotid gland.

40. Transverse facial vessels.

41. Posterior auricular vein.

42. Superficial temporal vessels and

auriculo-temporal nerve.

VOL. Ill 4

5 o HEAD AND NECK

descends through the parotid gland, emerges from under
cover of its lower end and terminates, immediately below the
angle of the mandible, by joining with the anterior facial vein
to form the common facial vein. Whilst in the gland, it
gives off a branch to the external jugular vein. The posterior
auricular vein descends posterior to the external meatus
and terminates in the external jugular vein. The occipital
vein accompanies the occipital artery as far as the sub-
occipital region, and ends in the sub-occipital venous plexus.

In addition to the arteries and veins there are numerous

lymph vessels in the scalp, but they cannot be displayed by
ordinary dissecting methods. Nevertheless, it is important
that the student should remember their usual terminations.
The lymph vessels of the anterior area end in small lymph
glands which are embedded in the superficial surface of the
parotid gland. Those of the posterior area terminate either
in lymph glands which lie superficial to the mastoid part of
the temporal bone, or in occipital lymph glands, which lie in
the neighbourhood of the superior nuchal line.

Galea Aponeurotica (O.T. Epicranial Aponeurosis). The

galea aponeurotica is fully exposed as soon as the superficial
fascia of the scalp is completely removed. It is a strong
layer of aponeurosis connected anteriorly with the frontal
bellies of the epicranius, posteriorly with the occipital bellies,
and between the occipital bellies, with the external occipital
protuberance and the medial parts of the superior nuchal lines,
or with the supreme nuchal lines when they are present.
Laterally, where it becomes thinner, it descends over the upper
part of the temporal fascia, and gives origin to the anterior
and superior auriculares muscles. It is so closely connected
with the superjacent skin, by the dense superficial fascia,
that the two cannot be separated, except with the aid of
the cutting edge of the scalpel ; but above the supra-orbital
ridges, the temporal lines, and the superior nuchal lines it
is only loosely connected to the pericranium by the layer
of loose areolar tissue ; therefore the three closely connected
superficial layers, the skin, superficial fascia, and the galea
aponeurotica, can easily be torn from the pericranium, a
circumstance taken advantage of by the Indians who scalped
their defeated foes. The looseness of the areolar tissue
beneath the galea aponeurotica permits the latter to be
drawn forwards and backwards by the alternate contractions

SCALP 51

of the occipitalis and frontalis muscles, and, as it moves, it

carries with it the skin and superficial fascia with which
it is so closely blended.

Dissection. After the dissector has studied the attachments

of the galea aponeurotica, and after he has made himself
thoroughly conversant with the nerve and vascular supply of
the scalp, and has appreciated the fact that every part of its area
is supplied by more than one nerve and that the blood vessels
anastomose very freely together, he should next convince him-
self of the greater looseness of the areolar layer beneath the galea
in the medial area and its greater denseness and closer attach-
ment to the various parts of the super jacent epicranius, and the
subjacent pericranium at the margins of the scalp area. He
may do that by introducing the handle of a scalpel through a
median incision in the galea, and passing it forwards and
backwards and from side to side.

The Layer of Loose Areolar Tissue. The layer of loose

areolar tissue is the fourth layer of the scalp. It is but slightly
vascular and is of loose texture, but is not equally loose over
the whole area of the scalp ; on the contrary, in the regions
of the temporal and supra-orbital ridges it becomes much
denser, and, at the same time, much more closely connected
with the galea aponeurotica and the frontalis muscles, whilst
posteriorly it disappears where the occipitalis muscles and the
galea become attached to the superior nuchal lines. It is
on account of those peculiarities that effusions of blood of
inflammatory exudations in the areolar layer easily raise the
greater part of the scalp from the bone, but such effusions
do not readily pass from beneath the scalp into either the
facial, temporal, or occipital regions.

On the fifth day after the body has been placed upon its
back, the eighth after it was brought into the room, the
dissector of the head and neck must assist the dissector of
the upper extremity to display the whole extent of the brachial
plexus and the origins of the branches which spring from it ;
and he should take the opportunity to revise his own know-
ledge of the plexus.

Dissection. Detach the clavicular head of the sterno-

mastoid from the clavicle, and displace the sternal head towards
the median plane. When that has been done the anterior and
upper parts of the sterno-clavicular joint capsule will be fully
exposed, for the pectoralis major, which covered the lower part
of the anterior surface, has already been reflected by the dissector
of the upper extremity.

The sterno-clavicular joint is described on p. 37 of Vol. I.

After the dissectors have noted that the fibres of the capsule run

52 HEAD AND NECK

medially and downwards from the clavicle to the sternum, the

anterior, superior, and posterior portions must be divided close
to the sternum, care being taken to avoid injury to the anterior
jugular vein, which passes laterally close to the upper and
posterior part of the joint. When the division is completed,
elevate the sternal end of the clavicle by depressing the acromial
end ; introduce the knife into the cavity of the joint, close to the
sternum, and carry it laterally below the clavicle, to detach the
lower part of the articular disc from the sternum and the
cartilage of the first rib, and to divide the lower part of the cap-
sule and the costo-clavicular ligament, which lies immediately
lateral to it. If the subclavius muscle has not already been
detached, it also must be divided, and then the clavicle can be
displaced laterally, and the whole extent of the plexus will be
exposed.

Plexus Brachialis. The brachial plexus is fully described

on p. 39, Vol. I., and only a brief resume of the main facts
regarding it is given here. The plexus is formed by the last
four cervical nerves and the larger part of the first thoracic
nerve ; it also receives a communication from the fourth
cervical nerve and not uncommonly a small twig from the
second thoracic nerve. Those various nerves constitute the
roots of the plexus. The roots of the plexus emerge from
between the scalenus medius and the scalenus anterior, and
unite to form three trunks, upper, middle, and lower, which
lie superficial to the scalenus medius, the lowest of the three
being wedged in between that muscle posteriorly and the
third part of the subclavian artery anteriorly. The upper
trunk is formed by the fifth and sixth nerves and the com-
munication from the fourth. The seventh nerve alone forms
the middle trunk ; and the lowest trunk is formed by the eighth
cervical and first thoracic nerves and the communication from
the second thoracic. Almost immediately after their forma-
tion the trunks divide into anterior and posterior divisions,
and the divisions reunite to form three cords, lateral, medial,
and posterior. The lateral cord is formed by the anterior
divisions of the upper and middle trunks, the medial cord
by the anterior division of the lowest trunk, and all three
posterior divisions unite to form the posterior cord. The
cords descend behind the clavicle and subclavius muscle,
and through the cervico-axillary canal, to the level of the
coracoid process of the scapula where the plexus terminates
and each cord divides into two terminal branches. The
terminal branches of the lateral cord are the lateral head of
the median nerve and the musculo-cutaneous nerve. Those

THE BRACHIAL PLEXUS

53

of the medial cord are the medial head of the median and
the ulnar nerve, and the posterior cord divides into the axillary

FIG. 1 6. Dissection to show the General Relations of the Brachial Plexus.

1. Accessory nerve.

2. Nerve to levator scapulae.

3. Levator scapulae.

4. Dorsal scapular nerve.

5. Long thoracic nerve.

6. Scalenus medius.

7. Suprascapular nerve.

8. Serratus anterior.

9. Upper subscapular nerve.

10. Subscapularis.

11. Pectoralis minor.

12. Nerve to coraco-brachialis.

13. Axillary nerve.

14. Musculo-cutaneous nerve.

15. Radial nerve.

16. Median nerve.

17. Medial cutaneous nerve of forearm.

1 8. Medial cutaneous nerve of arm.

19. Intercpsto-brachial nerve.

20. Latissimus dorsi.

21. Thoraco-dorsal nerve.

22. Long thoracic nerve.

23. Internal jugular vein.

24. Superior thyreoid artery.

25. Submaxillary gland.

26. External jugular vein.

27. Scalenus medius.

28. Upper trunk of brachial plexus.

29. Middle trunk of brachial plexus.

30. Eighth cervical nerve.

31. Omo-hyoid.
32. Nerve to subclavius.

33. Lateral anterior thoracic nerve.

34. Medial anterior thoracic nerve.

(O.T. circumflex) nerve and the radial (O.T. musculo-spiral).

In addition to the terminal branches, collateral branches are
in 4 a

54 HEAD AND NECK

given off from the roots, the trunks and the cords ; and the
roots are connected with the middle and lower ganglia of the
cervical part of the sympathetic trunk by grey rami communi-
cantes. The branches given off from the roots are twigs of
supply to the longus colli, the scalenus anterior, the scalenus
inedius, and the scalenus posterior, the roots of origin of the
long thoracic nerve, which supplies the serratus anterior
(O.T. magnus) and the dorsal scapular nerve (O.T. nerve to
the rhomboids). The roots of the long thoracic nerve spring
from the fifth, sixth, and seventh nerves ; the upper two
pierce the scalenus medius and the lowest passes anterior to
that muscle. The three unite, behind the trunks of the
plexus, to form the stem of the nerve, which descends behind
the cords of the plexus into the axilla. The dorsalis scapulae
nerve arises from the lateral border of the fifth nerve ; it
disappears under cover of the levator scapulae and supplies
the two rhomboid muscles, and, sometimes, the levator
scapulae.

The branches from the trunks of the plexus are the supra-
scapular nerve and the nerve to the subclavius. They both
spring from the upper trunk. The collateral branches of the-
three cords of the plexus are (i) from the lateral cord: the
lateral anterior thoracic nerve; (2) from the posterior cord:
the upper and lower subscapular nerves and the thoraco-
dorsal nerve (O.T. long subscapular) ; and (3) from the
medial cord : the medial anterior thoracic, the medial
cutaneous nerve of the arm (O.T. lesser internal cutaneous)
and the medial cutaneous nerve of the forearm (O.T. internal
cutaneous).

The Position of the Brachial Plexus. The plexus lies (i) in

the lower and anterior part of the posterior triangle of the
neck, partly above and partly below the posterior belly of the
omo-hyoid ; (2) posterior to the clavicle ; and (3) in the axilla.
Above the clavicle it is covered by the skin, the superficial
fascia and the platysma, branches of the supraclavicular
nerves, the first layer of deep fascia, the external jugular vein,
and the terminal parts of the transverse cervical and trans-
verse (supra) scapular veins; the second layer of deep
cervical fascia, the transverse cervical artery, the posterior
belly of the omo-hyoid, the nerve to the subclavius, and the
third part of the subclavian artery. Behind the clavicle it is
crossed superficially by the transverse scapular artery (O.T.

THE BRACHIAL PLEXUS 55

suprascapular). Below the clavicle it is covered by the skin

and superficial fascia, the platysrna, the middle supraclavicular
nerves, the deep fascia, the pectoralis major, the pectoralis
minor, the cephalic vein, the branches of the thoraco-acromial
artery, the costo-coracoid membrane, and the axillary artery
and vein (Figs. 15, 16, 49, 51).

Its posterior relations in the neck are the scalenus medius

and the long thoracic nerve. Its posterior relations in the
axilla are the serratus anterior, the fat in the interval between
the serratus anterior and the subscapularis, and, finally, the
subscapularis itself.

After the brachial plexus has been examined, the clavicle

must be replaced in position and the skin flap, reflected from
the posterior triangle, must be replaced and fixed in position
by a few sutures.

On the ninth day after the body is brought into the room,
that is, on the sixth day after it has been placed on its back,
it will be turned upon its face, with the thorax and the pelvis
supported by blocks. The body will remain upon its face for
five days, and during that period the dissectors of the head
and neck must complete the dissection of the posterior part
of the scalp ; dissect the muscles, vessels and nerves of the
back and the sub-occipital region ; and remove and examine
the spinal medulla.

THE DISSECTION OF THE BACK.

Dissection. Make a median longitudinal incision from the

external occipital protuberance to the seventh cervical spine,
and a second incision laterally from the seventh cervical spine
to the acromion, and throw the flap laterally. When that has
been done the posterior triangle will be exposed from behind,
and the dissector should take the opportunity of noting the
positions of the contents and the constituent parts of the floor
from that aspect. Afterwards he must look for the superficial
nerves in the superficial fascia over the upper part of the trapezius.
If the greater occipital nerve was not found during the dissection
of the scalp, secure it at once, as it pierces the deep fascia covering
the upper end of the trapezius, about midway between the
external occipital protuberance and the posterior border of the
mastoid portion of the temporal bone ; trace it upwards through
the dense superficial fascia of the scalp, and clean the branches
of the occipital artery which are distributed in the same region.
The third occipital nerve will be found in the superficial fascia
between the greater occipital and the median plane. It is the
medial division of the posterior ramus of the third cervical nerve,
in 4 b
56 HEAD AND NECK

and it supplies the skin of the medial and lower part of the
posterior portion of the scalp and the adjacent part of the skin
of the back of the neck. Trace it upwards to its termination,
and downwards to the point where it pierces the deep fascia
covering the trapezius. At a still lower level look for the medial
divisions of the posterior rami of the other cervical nerves.
They are variable in number and position, but those which are
present will be found piercing the deep fascia over the trapezius,
at a short distance from the median plane, and running down-
wards and laterally towards the posterior triangle.

After the cutaneous nerves have been found remove the

remains of the superficial fascia and the deep fascia from the
surface of the trapezius.

The Terminal Part of the Greater Occipital Nerve. The

greater occipital nerve is the large medial division of the

posterior ramus of the second cervical nerve. It enters the
posterior part of the scalp, after piercing the upper part of the
trapezius and the deep fascia of the back of the neck, and it
ramifies in the superficial fascia of the scalp over the occipital
bone and the posterior part of the parietal bone. It is accom-
panied by the branches of the occipital artery, and it com-
municates with the great auricular and lesser occipital nerves.

Arteria Occipitalis. After the occipital artery emerges

from between the trapezius and the sterno-mastoid, at the apex
of the posterior triangle, or pierces the upper part of the
trapezius, its terminal part pierces the deep fascia of the
back of the neck and enters the superficial fascia of the
posterior part of the scalp. It anastomoses with its fellow of
the opposite side, and with the posterior auricular and the
superficial temporal arteries. As a rule, it breaks up into two
main branches, a lateral and a medial. The medial branch
gives off cutaneous twigs and a meningeal branch, which passes
through the parietal foramen and anastomoses with a branch
of the middle meningeal artery. Through the same foramen,
passes an emissary vein which connects the occipital veins
with the superior sagittal (longitudinal) sinus.

Musculus Trapezius. The trapezius and latissimus dorsi

constitute the first layer of the muscles of the back. Only
that part of the trapezius which lies above the level of the
seventh cervical spine belongs to the dissector of the head and
neck ; the lower part and the latissimus must be cleaned by
the dissector of the arm, but the dissector of the head should
take the opportunity to revise his knowledge of the whole
origin and insertion of the trapezius. It arises from the
medial third of the superior nuchal line of the occipital bone,

THE DISSECTION OF THE BACK

57

the external occipital protuberance, the whole length of the

ligamentum nuchae, the seventh cervical spine, the tips of
all the thoracic spines and the corresponding supraspinous
ligaments.

In the region of the seventh cervical spine the origin is

more aponeurotic than elsewhere, and the fine tendinous

M. trapezius-

Occipital belly of
M. epicranius

M. semispinalis capitis
(O.T. complexus)

M. auricularis
posterior

M. splenius
capitis
Posterior
auricular nerve

Parotid gland
sser occipital nerve
M. sternomastoideus
Great auricular nerve

M. levator scapulae

FIG. 17. Superficial dissection of the Back of the Neck.

fibres of the muscles of the two sides form an ovoid aponeurotic

area some two inches in length.

The upper fibres of the muscle descend in oblique curves

and are inserted into the lateral third of the posterior border
and the adjacent part of the superior surface of the clavicle ;
the middle fibres run horizontally, towards the shoulder, and
are inserted into the medial border of the acromion and
the upper lip of the posterior border of the spine of the

58 HEAD AND NECK

scapula. The lower fibres ascend, and terminate in a small

triangular tendon which plays over the smooth triangle at the
root of the scapular spine, and which is inserted partly into the
lower lip and partly into the upper lip of the spine. The muscle
is supplied by the accessory and the third and fourth cervical
nerves. It draws the scapula medially and braces the shoulder
backwards, raises the tip of the shoulder, or depresses the
scapula and turns the glenoid fossa upwards, according to
whether the middle, the upper, or the lower fibres are mainly
in action.

Dissection. On the second day after the subject has been

placed on its face, the dissector, in conjunction with the dissector
of the superior extremity, must reflect the trapezius muscle.
First separate the muscle from the occipital bone, and then divide
it about half an inch from the spines of the vertebrae. The
muscle can now be raised and thrown laterally towards its
insertion. On its deep surface the accessory nerve, the twigs of
supply from the third and fourth cervical nerves and the ascend-
ing branch of the transverse cervical artery will be noticed. It
is the duty of the dissector of the upper limb to dissect the
structures mentioned, but the dissector of the head and neck
should trace the artery to its origin from the transverse cervical
artery.

The attachments of the levator scapulas also must be defined.

Two twigs from the third and fourth cervical nerves, which lie
on its surface and finally enter its substance, have already been
secured. Further, passing downwards under cover of the
levator scapulae muscle, the dorsal scapular nerve (O.T. nerve
to the rhomboids) and the descending branch (O.T. posterior
scapular) of the transverse cervical artery will be found. Almost
invariably the dorsal scapular nerve gives one or two twigs to
the levator scapulas.

The levator scapulae, the rhomboids, the posterior serrati and

the splenius are classed as muscles of the second layer. The
rhomboids and the lower part of the levator belong to the dis-
sector of the arm ; the remaining muscles are the property of
the dissector of the head and neck.

Musculus Levator Scapulae. The levator scapulae arises by

four slips from the posterior parts of the transverse processes
of the upper four cervical vertebrae. The slips unite to form
an elongated muscle which extends downwards and backwards
to be inserted into that portion of the vertebral border of the
scapula which is placed above the level of the spine. Its
nerve-supply is derived from the third and fourth cervical
nerves, and also from the dorsal scapular nerve. The muscle
raises the scapula and draws it towards the vertebral column.
The origin of the posterior belly of the omo-hyoid muscle
may now be examined. It is attached to the upper transverse

THE DISSECTION OF THE BACK 59

ligament of the scapula and the adjacent part of the superior

border of the bone. The transverse scapular artery (O.T.
suprascapular) will be noticed passing over the upper trans-
verse ligament, whilst the suprascapular nerve traverses the
notch below it.

Dissection. The second day's work is now completed, and

on the same day the dissector of the upper limb must finish his
share of the dissection of the back, so as to allow the dissector
of the head and neck to begin the examination of the deeper
structures on the dorsal aspect of the trunk.

Three days are allowed for the dissection of the deeper

structures of the back. The work may be arranged in the
following manner : On the first day, all the muscles, fasciae,
nerves, and blood vessels of the back, with the exception of those
in connection with the sub-occipital triangle, should be studied ;
on the second day, the sub-occipital triangle may be examined ;
and on the third day the medulla spinalis (O.T. spinal cord) must
be displayed.

Commence work on the third day after the body has been
placed on its face by cleaning the posterior serrate muscles.
They are two in number, superior and inferior. The superior
has been exposed by the removal of the trapezius, and the
rhomboids and the inferior by the removal of the latissimus
dorsi. Both pass from the spines of the vertebras to the ribs,
the superior in a downward and lateral direction to some of the
upper ribs, and the inferior in an upward and lateral direction
to the lower four ribs.

Musculi Serrati Posteriores. The posterior serrate muscles

are two thin sheets of fleshy fibres, which are placed upon
the posterior aspect of the thoracic wall. The serratus posterior
superior is much the smaller of the two ; it arises by a thin
aponeurotic tendon from the lower part of the ligamentum
nuchae ; from the spinous process of the seventh cervical
vertebra ; and from the spinous processes of the upper two or
three thoracic vertebrae. It passes obliquely downwards and
laterally, and is inserted into the outer surfaces of the second,
third, fourth, and fifth ribs, a short distance anterior to their
angles.

The serratus posterior inferior takes origin from the spinous

processes of the last two thoracic and upper two lumbar
vertebrae, and the supraspinous ligaments between them.
The dissector will note, however, that this is not an indepen-
dent and distinct attachment, but that it is effected through
the medium of the lumbo- dorsal fascia, with which the
aponeurotic tendon of the muscle blends. The muscle
passes upwards and laterally and is inserted into the outer
6o

HEAD AND NECK

surfaces of the lower four ribs. The superior serratus elevates

the ribs to which it is attached, and is therefore a muscle of
inspiration. It is supplied by the anterior rami of the second,
third, and fourth thoracic nerves. The inferior serratus helps
to fix the lower ribs and so facilitates the action of the
diaphragm. Therefore, indirectly, it also is a muscle of
inspiration. It is supplied by the anterior rami of the lower
thoracic nerves.

Fascia Lumbo-dorsalis. After the posterior serrate muscles

have been displayed and examined on the third day after the

M. serratus
post. inf.

M. sacro-
spinalis

M. quadrati
lumborum

"' M.psoasma

FIG. 1 8. Diagram to show the Connections of the Lumbo-dorsal Fascia.

body is placed upon its face, the dissector of the head and
neck should associate himself with the dissector of the
abdomen in the examination of the lumbo-dorsal fascia. It
is an aponeurotic layer, thin in the thoracic portion of its
extent, but thick and strong in the lumbar and sacral regions.
In all three regions it binds down the deeper muscles of the
back to the sides of the spinous processes and to the trans-
verse processes of the vertebrae.

The Thoracic Part of the Lumbo-dorsal Fascia (O.T.

Vertebral Aponeurosis] is a thin transparent lamina which
extends from the tips of the spines and the supraspinous
ligaments to the angles of the ribs. At the upper end of
THE DISSECTION OF THE BACK 61

the thoracic region it dips beneath the serratus posterior

superior into the neck, and at the lower end it blends with
the aponeurosis of origin of the serratus posterior inferior,
and, through that, becomes continuous with the posterior
layer of the lumbar portion.

Dissection. To display the lumbar part of the lumbo-dorsal

fascia, take away the remains of the origin of the latissimus
dorsi, which springs from its posterior surface, and then reflect
the serratus posterior inferior by cutting through it at right
angles to its fibres and turning it medially and laterally towards
its origin and insertion. As the lateral part is turned aside
secure its nerves of supply ; they are derived from the ower
intercostal nerves, and enter its deep surface. Next, remove the
remains of the origin of the serratus posterior inferior, and then
the posterior layer of the lumbar part of the lumbo-dorsal fascia
will be completely exposed.

The Lumbar Part of the Lumbo-dorsal Fascia is separable

into three lamellae, a posterior, a middle, and an anterior.
All three fuse together laterally, where they become connected
with the internal oblique and the transversus abdominis
muscles. The posterior layer, which is the strongest of the
three, is a dense tendinous aponeurosis. It is continuous
above with the thoracic part. Below^ it is attached to the
posterior part of the outer lip of the iliac crest, and to the
dorsum of the sacrum and the coccyx. Medially^ it is attached
to the tips of the spines of the lumbar and sacral vertebrae ;
and laterally it blends with the posterior surface of the middle
lamella (Fig. 18). The aponeurosis of origin of the latissimus
dorsi and the serratus posterior inferior arise from its posterior
surface.

Dissection. Make a longitudinal incision through the

posterior layer of the lumbar part of the lumbo-dorsal fascia,
midway between its medial and its lateral borders. At each
end of the longitudinal incision make a transverse incision,
extending from the spines medially to the lateral border of the
rounded mass of spinal muscles lying under cover of the fascia.
Turn the medial part of the divided fascia towards the median
plane, and verify its attachment to the vertebral spines and the
supraspinous ligaments. Pull the lateral part aside, and at the
lateral border of the mass of posterior spinal muscles note that
it blends with a deeper middle lamella. Push the mass of
posterior spinal muscles towards the median plane, and follow
the middle lamella of the fascia to its attachment.

The middle lamella is attached, medially, to the tips of the

transverse processes of the lumbar vertebrae; below, to the
iliac crest, and, above, to the last rib. Laterally, it blends

62 HEAD AND NECK

with the posterior and anterior lamellae, and, immediately
lateral to its line of union with the posterior lamella, the
internal oblique arises from its posterior surface. To expose
it thoroughly the mass of posterior spinal muscles must be
pushed medially.

Dissection. After the middle lamella has been examined

divide it longitudinally, close to its attachment to the tips of the
transverse processes, and transversely along the line of the iliac
crest, and turn it laterally. A considerable part of the posterior
surface of the quadratus lumborum muscle will then be exposed.
Displace the lateral border of the quadratus lumborum towards
the median plane, and the anterior lamella of the lumbar part
of the lumbo-dorsal fascia will be brought into view.

The anterior lamella of the lumbar part of the lumbo-

dorsal fascia is attached, medially, to the anterior surfaces of
the roots of the transverse processes of the lumbar vertebrae ;
laterally, it blends with the fused middle and posterior lamellae
to form the common aponeurosis of origin of the transversus
abdominis muscle, and it is by means of the three lamellae
of the lumbar fascia that the latter muscle arises from the tips
of the spines, and from the tips and the roots of the transverse
processes of the lumbar vertebrae. The upper border of the
anterior lamella becomes thickened, and extends, anterior to
the quadratus lumborum, from the last rib to the trans-
verse process of the first lumbar vertebra, as the lateral
lumbo- costal arch (O.T. external arcuate ligament); the
lower border blends with the ilio-lumbar ligament. The
dissector should verify the various attachments by passing
his fingers over the posterior surface of the lamella from its
lateral to its medial border, and from its upper to its lower end.

Dissection. After satisfying himself regarding the lamellae

of the lumbar part of the lumbo-dorsal fascia and their relations
to the posterior spinal muscles, to the quadratus lumborum, and
to the internal oblique and the transversus abdominis muscles,
the dissector should make a longitudinal incision through the
anterior lamella, and the peri-nephric fascia anterior to it ; and,
introducing his finger through the opening into the extra-
peritoneal fatty tissue, he should scrape away the latter until he
exposes the kidney, below the level of the last rib, and the
adjacent part of the colon, which lies along the lower and lateral
part of the kidney. After that has been done he should reflect
the serratus posterior superior and secure its nerves of supply,
which spring from the upper intercostal nerves and enter' its
deep surface ; then he should remove the thoracic part of the
lumbo-dorsal fascia and commence the study of the posterior
spinal muscles, beginning with the splenius.

THE DISSECTION OF THE BACK 63

Musculus Splenius. The splenius has a continuous origin

from the lower half of the ligamentum nuchae, and from the
spines .of the seventh cervical and upper six thoracic vertebrae.
Its fibres pass obliquely upwards and laterally, forming a thick
flat muscle, which soon divides into a cervical and a cranial
portion, termed respectively the splenius cervicis and the
splenius capitis.

The splenius cervicis turns forwards and is inserted, by

tendinous slips, into the posterior tubercles of the transverse
processes of the upper two or three cervical vertebrae, medial
to the levator scapulae.

The splenius capitis passes under cover of the upper part

of the sterno-mastoid muscle, and gains insertion into the
lower part of the mastoid portion of the temporal bone and
into the lateral portion of the superior nuchal line of the
occipital bone. To see the insertion, the sterno-mastoid
muscle may be divided along the superior nuchal line, but
it must not be detached from the temporal bone. The
splenius capitis and cervicis bend the head and neck respec-
tively backwards and turn them to the side on which the
muscles lie. The splenius capitis and splenius cervicis are
supplied by the posterior rami of the cervical nerves.

Dissection. The deeper spinal muscles must now be dissected.

Begin by reflecting the splenius muscle. Detach it from its
origin and throw it laterally and upwards towards its insertion.
Whilst doing that preserve the cutaneous branches of the cervical
nerves which pierce the muscle.

When the splenius capitis is fully reflected, a small triangular

space will be noticed close to the superior nuchal line of the
occipital bone. Anteriorly, it is bounded by the longissimus
capitis (O.T. trachelo-mastoid) ; posteriorly, by the lateral
border of the semispinalis capitis (O.T. complexus) ; and above,
by the superior nuchal line of the occipital bone. The floor of
the little space is formed by the superior oblique muscle of the
head, and it is traversed by the occipital artery, which in that
part of its course gives off its descending branch (O.T. arteria
princeps cervicis), and its meningeal branch.

The Third Layer of Muscles. Under this head are included a series
of muscular strands which stretch, with a greater or less degree of continuity,
along the entire length of the dorsal aspect of the vertebral column. In the
lumbar region they constitute a bulky fleshy mass which may be considered
the main starting-point. The mass is the muscuhis sacro-spinalis, which
has the following origins : (i) from the spines of all the lumbar vertebrae ;

(2) from the supraspinous ligaments which bind the lumbar spines together ;

(3) from the dorsum of the sacrum and from the posterior sacro-iliac liga-
ment ; (4) from the posterior fifth of the iliac crest ; (5) from the deep
surface of the posterior layer of the lumbo-dorsal fascia. In great part the

64 HEAD AND NECK

superficial surface of this muscular mass is covered by and is adherent to

the posterior layer of the lumbo-dorsal fascia.

Superiorly, the sacro-spinalis divides into three columns. The lateral

column first separates from the general mass, and to it the name of ilio-
costalis is given ; the intermediate column is termed the longissimus, and the
medial column, which becomes quite distinct only as the upper part of the
thoracic region is approached, is called the spinalis. The semispinalis
muscle also is included in the third layer.

The Ilio-costalis is a column of muscular bundles which extends from

the lumbar to the cervical region. It is separable into three segments,
known, from below upwards, as the ilio-costalis Inmborum, the ilio-costalis
dorsi, and the ilio-costalis cervicis.

Ilio-costalis Lumborum. The lumbar part of the ilio-costalis muscle

and the longissimus dorsi become distinct at the level of the last rib, and
the interval between them is marked by the exits of the lateral divisions of
the posterior rami of lower thoracic nerves.

The ilio-costalis lumborum ends above in a series of six or seven slender

tendons, which are inserted into the angles or the corresponding parts of
the lower six or seven ribs.

The nio-costalis Dorsi (O.T. Musculus Accessorius] arises by six or seven

slender tendons from the angles of the lower ribs, on the medial sides of the
tendons of insertion of the ilio-costalis lumborum, and it is inserted by a
series of similar tendons into the angles of the upper six ribs and to the
transverse process of the seventh cervical vertebra.

The Ilio-costalis Cervicis (O.T. Cervicalis Ascendens] is the highest

segment of the ilio-costalis. It arises, on the medial side of the ilio-costalis
dorsi, by four slips which spring from the third, fourth, fifth, and sixth ribs ;
it is inserted into the transverse processes of the fourth, fifth, and sixth
cervical vertebrae.

Dissection. To display the ilio-costalis properly, the dissector

should first evert the lowest segment, and then in turn the
middle and upper segments aside, but whilst doing that he must
take care to preserve the lateral divisions of the posterior rami of
the spinal nerves.

The Longissimus is the middle and largest of the three muscle columns.
It extends upwards, through the thoracic and cervical regions, to the head,
and it also is separable into three segments : longissimus dorsi, longissimus
cervicis, and longissimus capitis.

Dissection. The interval between the longissimus and the

spinalis is frequently difficult to define, but if the fascia is care-
fully cleaned from the lateral to the medial border of the longis-
simus, in the upper thoracic region, the separation will become
apparent, and after it has been found the attachments of the
longissimus must be defined. The muscle being displaced to
the medial and lateral sides as may be necessary.

Longissimus Dorsi. The thoracic part of the longissimus possesses two

rows of slips of insertion : a medial row of tendinous slips which are
attached to the tips of the transverse processes of the thoracic and the
accessory processes of the lumbar vertebrae, and a lateral row of muscular
slips which are inserted into the lower ten ribs, on the lateral sides of their
tubercles, and to the transverse processes of the lumbar vertebrae, and to
the posterior surface of the middle lamella of the lumbar fascia.
Longissimus Cervicis (O.T. Transversalis Cervicis}. The cervical

THE DISSECTION OF THE BACK 65

portion of the longissimus springs from the transverse processes of the upper
four thoracic vertebroe, and is inserted into the posterior tubercles of the
transverse processes of the cervical vertebrae from the second to the sixth
inclusive.

Longissitmts Capitis (O.T. Trachelo-mastoid). The longissimus capitis

lies in the neck, under cover of the splenius. It arises, in common with the
longissimus cervicis, from the transverse processes of three or four of the upper
thoracic vertebrae, and, in addition, from the articular processes of a like
number of the lower cervical vertebrae. Thenarrow, fleshy band which results
is inserted into the posterior part of the mastoid portion of the temporal
bone, under cover of the splenius capitis and sterno-mastoid muscles.

Musculus Spinalis. The spinalis muscle is the most medial, shortest,

and weakest of the three columns, and the most difficult to define. Below,
it is intimately blended with the longissimus dorsi, but it may be regarded
as taking origin by four tendons from the spines of the upper two lumbar
and lower two thoracic vertebrae. The tendons end in a small muscular
belly, which is inserted by a series of slips into a very variable number of
the upper thoracic spines. It is closely connected with the subjacent semi-
spinalis dorsi.

Spinalis Cervicis. This upward prolongation of the spinalis is not

always easy to define. It springs from the spines of the lower four cervical
vertebras and is inserted into the spines of the second, third, and fourth
cervical vertebrae.

The various segments of the sacro-spinalis are supplied by the posterior

rami of the spinal nerves. When the segments on one side only act they
bencl the vertebral column to that side, but when the segments on both
sides act simultaneously they bend the vertebral column backwards.

Dissection. The occipital artery has already been seen

crossing the apex of the posterior triangle (p. 36), and its
terminal branches have been dissected as they ramify in the
scalp (p. 55). To expose the second part of the vessel, which
extends from under shelter of the mastoid process, along the
superior nuchal line of the occipital bone, to the point where it
pierces the trapezius to become superficial, divide the longissimus
capitis (O.T. trachelo-mastoid) a short distance below its inser-
tion, and throw it upwards as far as possible, along with the
splenius capitis; then clean the artery.

Arteria Occipitalis. In the region of the mastoid process

the second part of the occipital artery is very deeply placed ;
indeed, no less than five structures lie superficial to it. These
are (enumerating them in order from the vessel to the
surface) (i) the origin of the posterior belly of the digastric
muscle; (2) the mastoid process ; (3) the longissimus capitis;
(4) the splenius capitis ; and (5) the sterno-mastoid. 1 As
the artery runs backwards, it very soon emerges from under
cover of the first three of the structures mentioned, and a
little farther on it leaves the shelter of the splenius, and is
then covered by the sterno-mastoid alone. Issuing from

1 It is not uncommon to find the artery between the splenius and the
longissimus capitis, as in Fig. 20.
VOL. Ill 5

66 HEAD AND NECK

under cover of the posterior border of that muscle, the artery

crosses the apex of the posterior triangle, and disappears
under the trapezius, which it pierces afterwards, near the
external occipital protuberance, to reach the scalp. Two
muscles constitute its deep relations viz., the insertions of
the superior oblique and the semispinalis capitis (O.T.
complexus) (Fig. 20).

The following branches may be traced from the second

portion of the occipital artery: (i) ramus descendens (O.T.
arteria princeps cervicis); (2) meningeal; (3) muscular.

The descending branch (O.T. arteria princeps cervicis) is a

twig of some size, which passes medially to the lateral border
of the semispinalis capitis (O.T. complexus) ; there it divides
into a superficial and a deep branch. The former ramifies on
the surface of the semispinalis capitis, whilst the latter sinks
under that muscle, where it will be followed to its anastomosis
with the deep cervical artery at a later stage in the dissection.

The small meningeal branch enters the posterior cranial fossa

through the mastoid foramen, and supplies the dura mater
and cranial wall in the mastoid region.

The muscular twigs go to the neighbouring muscles.

The veins corresponding to the occipital artery are two,

or perhaps three, in number. They drain the blood from the
occipital portion of the scalp, and open into the sub-occipital
plexus, which is drained by the vertebral and deep cervical
veins. The most lateral of the occipital veins frequently
communicates with the transverse sinus (O.T. lateral sinus)
through the mastoid foramen.

Dissection. The semispinalis capitis, which has been exposed

by the reflection of the splenius and the turning aside of the
longissimus cervicis and longissimus capitis, must now be
cleaned, and whilst that is being done and the attachments of
the muscle are being defined, care must be taken of the medial
divisions of the posterior rami of the second, third, fourth, and
fifth cervical nerves. The first of the three or, in other words,
the greater occipital from its great size, runs little risk of injury,
but the others are liable to be overlooked. They all emerge
from the substance of the muscle close to the median plane.

Musculus Semispinalis Capitis (O.T. Complexus). The

semispinalis capitis is the uppermost part of a muscular
column consisting of three segments, which are spoken of
collectively as the semispinalis, and individually as the semi-
spinalis dorsi, the semispinalis cervicis, and the semispinalis

THE DISSECTION OF THE BACK 67

capitis. It belongs to the third layer of muscles, of which

the greater number have been dissected already. The lower
two segments will be dissected subsequently, but it is convenient
to examine the semispinalis capitis at once. It is a thick
fleshy mass which springs by tendinous slips from the
transverse processes of the upper six thoracic vertebrae and
the articular processes of the fourth, fifth, and sixth cervical
vertebrae. Its massive upper extremity is inserted into a
somewhat oval area on the occipital bone, between the
superior and inferior nuchal lines close to the external occipital
crest. It is separated from its fellow muscle of the opposite
side by the ligamentum nuchae; and its most medial part,
which is to a certain extent distinct from the general mass,
is divided into two bellies by an intermediate tendon, and
is spoken of as the biventer cerviris. Occasionally the remainder
of the muscle is also intersected by a tendinous septum.

The semispinalis capitis bends the head backwards. It

is supplied by the posterior rami of the upper cervical nerves.

Dissection. The semispinalis capitis must now be reflected

by detaching it from the occiput and throwing it laterally. Care
must be exercised, not only on account of the nerves which have
been seen to perforate the muscle to reach the surface, but also
on account of the structures which it covers. In its upper part
it lies over the sub-occipital triangle and the muscles bounding
it, whilst, below, it covers the semispinalis cervicis. A thick,
dense fascia is placed over the subjacent parts, and in the fascia
lie certain of the cervical nerves and the anastomosis between
the descending branch of the occipital artery and the arteria
profunda cervicis. The dissector must specially look for a small
twig from the posterior ramus of the sub-occipital nerve which
enters the deep surface of the upper part of the semispinalis
capitis, and for a larger branch to the same muscle from the
greater occipital nerve.

As soon as the twig to the semispinalis capitis is secured the

dissector should cut out a small piece of the muscle to which the
nerve goes, and leave it attached to the nerve to serve as a guide
to the other branches of the sub-occipital nerve when the bound-
aries and contents of the sub-occipital triangle are being dissected
(see p. 75).

Ligamentum Nuchse. When the semispinalis capitis has

been turned aside the corresponding surface of the ligamentum
nuchae will be exposed (Fig 19). The ligament is a strong and
fibrous partition, placed in the median plane, between the
muscles on each side of the back of the neck. It represents a
powerful elastic structure in quadrupeds, which helps to sustain
the weight of the dependent head. In man, however, there is
in 5 a
68

HEAD AND NECK

not much elastic tissue developed in connection with it, and

it appears to be a continuation upwards of the supraspinous
ligament from the spine of the seventh cervical vertebra to the
external occipital protuberance. In shape it is somewhat
triangular. By its base it is attached to the external occipital
crest ; by its anterior border it is fixed by a series of slips to
the posterior tubercle of the atlas, and to the bifid spines of the
cervical vertebrae, in the intervals between their tubercles. Its

Posterior atlanto-

occipital membrane

Posterior ramus of

sub-occipital nerve

Greater occipital ne

Vertebral artery.

Anterior rami
of spinal nerves'

Posterior arch of atlas

Ligamentum nuchae

Posterior rami of spinal

nerves

Seventh cervical vertebra

FIG. 19. Dissection of the Ligamentum Nuchae and of the

Vertebral Artery in the Neck.

apex is attached to the spine of the seventh cervical vertebra,

whilst its posterior border is, in a measure, free, and gives
origin to the trapezius, rhomboid, serratus posterior superior,
and splenius muscles

Arteria Profunda Cervicis. The deep cervical artery springs

from the costo-cervical branch of the subclavian, and reaches
the back of the neck by passing between the transverse
process of the last cervical vertebra and the neck of the first
rib. At the present stage of the dissection it is seen ascend-
ing upon the semispinalis cervicis muscle and anastomosing

THE DISSECTION OF THE BACK 69

with the descending branch of the occipital. Both vessels

anastomose with twigs from the vertebral artery.

The arteria profunda cervicis is accompanied by a large

vein the vena profunda cervicis. That vessel begins in the
sub-occipital plexus, and it ends in the vertebral vein close to
its termination. It reaches its termination by turning forwards
under the transverse process of the last cervical vertebra.

Posterior Rami of the Spinal Nerves. The nerves of the

back must now be examined. They are the posterior rami
of the spinal nerves. With -four exceptions (viz., the first
cervical, fourth and fifth sacral, and the coccygeal nerves),
each posterior ramus will be found to divide into a lateral
and a medial division.

Examine the nerves successively in the cervical, thoracic, and lumbar

regions. It is well, however, to defer the dissection of the sacral and
coccygeal nerves until the multifidus muscle has been studied.

Cervical Region. In the neck the posterior rami

of the spinal nerves are eight in number. The posterior
ramus of the sub-occipital or first spinal nerve fails to divide into
a medial and a lateral division. It lies deeply in the sub-
occipital triangle, and will be examined when that space is
dissected.

The posterior ramus of the second cervical nerve is very

large. It appears between the vertebral arches of the first
and the second cervical vertebrae. The posterior rami of the
succeeding six cerincal nerves arise from the corresponding
spinal nerve-trunks in the intervertebral foramina, but they
turn dorsally, on the medial sides of the posterior inter-
transverse muscles, and appear in the intervals between the
transverse processes.

The lateral divisions are of small size, and are entirely

devoted to the supply of adjacent muscles.

The medial divisions are not all distributed alike, nor

indeed do they present the same relations. Those from the
second^ third, fourth, and fifth nerves run medially towards the
spinous processes, superficial to the semispinalis cervicis
muscle, and under cover of the semispinalis capitis. When
close to the median plane they turn backwards, pierce the
semispinalis capitis, splenius, and trapezius muscles, and
become superficial. In their course to the surface they give
numerous twigs to the neighbouring muscles.

The medial division of the second nerve is remarkable for

yo HEAD AND NECK

its large size. It receives the special name of greater occipital,

It will be noticed turning round the lower border of the
inferior oblique muscle, to which it supplies some twigs. In
passing to the surface it pierces the semispinalis capitis (O.T.
complexus) and trapezius. To the former it gives several
twigs. The distribution of this nerve on the occiput has
been noticed already (p. 56).

The medial division of the third nerve also sends an offset

to the occipital portion of the scalp (p. 55).

The medial divisions of the lower three posterior rami

of the cervical nerves resemble the preceding, in so far that
they take a course medially towards the spinous processes.
They differ from them, however, in running deep to the semi-
spinalis cervicis, and in being, as a rule, entirely expended
in the supply of muscles.

Thoracic Region. The posriteor rami of the thoracic

nerves make their appearance in the intervals between the
transverse processes. The lateral divisions proceed laterally,
under cover of the longissimus muscle, and appear in the
interval between the longissimus dorsi on the one hand and
the ilio-costalis on the other. The upper six or seven of the
nerves are exhausted in the supply of the intermediate and
lateral columns of the sacrospinalis ; the lower Jive or six,
however, are considerably larger, and contain both motor and
sensory fibres. After giving up their motor fibres to the muscles,
they become superficial, by piercing the serratus posterior in-
ferior and the latissimus dorsi, in line with the angles of the
ribs. Their cutaneous distribution has already been examined
by the dissector of the upper limb.

The medial divisions also are distributed differently in the

upper and lower portions of the thoracic region. The lower
five or six are very small, and end in the multifidus
muscle. The upper six or seven pass medially between the
multifidus and semispinalis, and, after supplying the muscles
between which they are situated, they become superficial. In
passing towards the surface they pierce the splenius, rhom-
boids, and trapezius muscles, and thus gain the superficial
fascia, where they have been dissected already.

Lumbar Region. The medial divisions of the posterior

rami of the five lumbar nerves are small, and, like the
corresponding twigs in the lower thoracic region, they have
a purely muscular distribution. They end in the multifidus.
THE DISSECTION OF THE BACK 71

The lateral divisions sink into the substance of the sacro-

spinalis, and are concerned in the supply of that muscle,
and also of the lumbar intertransverse muscles. The lateral
divisions of the upper three lumbar nerves are of large size,
they become cutaneous by piercing the superficial lamella of
the lumbo- dorsal fascia. They have already been traced by
the dissector of the lower limb to the skin of the gluteal
region. The lateral division of the fifth communicates with
the corresponding branch of the first sacral nerve.

Blood Vessels of the Back. In the cervical region the

dissector has already noticed the arteria profunda cervicis,
and the descending branch of the second part of the occipital
artery. Deep in the sub-occipital region he will subsequently
meet with a small portion of the vertebral artery. In addition,
however, minute twigs from the vertebral artery may be
discovered, in a well-injected subject, passing backwards in
the intervals between the transverse processes, and also in
the sub -occipital space. They supply the muscles, and
anastomose with the other arteries in that region.

In the thoracic region the posterior branches of the aortic

intercostal arteries and superior intercostal artery make
their appearance between the transverse processes. Each of
them passes dorsally in the interval between the body of a
vertebra and the costo-transverse ligament. It is associated
with the corresponding posterior ramus of a spinal nerve, and
is discributed, with the nerve, to the muscles and integument
of the back.

In the lumbar region similar branches are derived from the

lumbar arteries. They are distributed in the same manner.

In both thoracic and lumbar regions, before reaching

the back, the vessels under discussion furnish small spinal
branches which enter the vertebral canal through the inter-
vertebral foramina. These will be traced at a later period.

The veins accompanying the dorsal branches of the lumbar

and intercostal arteries pour their blood into the lumbar
and intercostal veins. They are of large size, being joined
by tributaries from the posterior vertebral venous plexus, and
also by others from within the vertebral canal.

Dissection. The remainder of the third layer of spinal

muscles must now be dissected. They are the semispinalis dorsi
and semispinalis cervicis. The semispinalis cervicis is already
exposed ; but to display the semispinalis dorsi it is necessary to
remove the spinalis dorsi muscle,
in 5 6

72 HEAD AND NECK

Musculus Semispinalis. The semispinalis dorsi is composed of a

series of muscular slips, with long tendons at each end, which arise from
the transverse processes of the sixth to the tenth thoracic vertebrae. It is
inserted into the spines of the upper four thoracic and lower two cervical
vertebrae. The semispinalis cervicis lies under cover of the semispinalis
capitis. It springs from the transverse processes of the upper five thoracic
vertebrae, and is inserted into the spines of the second to the fifth cervical
vertebras. The slips composing the semispinalis muscles stretch over five
or more vertebrae. The fibres of the semispinalis run upwards and medi-
ally. Therefore they turn the trunk and neck to the opposite side. They
are supplied by the posterior rami of the spinal nerves.

Dissection. The fourth layer of muscles must now be

examined. It includes the multifidus, the rotatores, the inter-
spinales, the intertransversales, and the recti and oblique muscles
of the sub-occipital region. The latter have already been exposed
by the reflection of the splenius and semispinalis capitis (corn-
plexus). To display the other members of the group the semi-
spinalis dorsi and cervicis must be detached from the spines and
drawn aside, and the sacrospinalis must be separated from the
lumbar and sacral spines and turned laterally, if that has not
already been done in tracing the nerves.

Musculus Multifidus. In the lumbar and sacral regions the multi-

fidus will be seen to constitute a thick fleshy mass which clings closely
to the vertebral spines. In that situation it has a very extensive origin
viz., (i) from the deep surface of the aponeurotic origin of the sacrospinalis ;

(2) from the posterior surface of the sacrum, as low as the fourth aperture ;

(3) from the posterior sacro-iliac ligament ; (4) from the posterior superior
spine of the ilium ; and (5) from the mamillary processes of the lumbar
vertebrae. In the thoracic region it takes origin from the transverse processes
of the vertebrae, and in the cervical region from the articular processes of at
least four of the lower cervical vertebrae. Each of the bundles of which the
multifidus is composed passes upwards and is inserted into the whole length
of the lower border of the spine of the second, third, or fourth vertebra
above. The insertions extend from the fifth lumbar vertebra to the second
cervical vertebra.

Musculi Rotatores. The rotator muscles are a series of small muscles

which are exposed when the multifidus is pulled aside. In the thoracic
region each muscle springs from the root of a transverse process, and is
inserted into the lamina of the vertebra immediately above, close to the
root of the spinous process. Somewhat similar muscles have been
described in the cervical and lumbar regions, and also a series of longer
and more superficial slips which connect alternate vertebrae with each
other. The multifidus and the rotatores are supplied by the posterior rami
of the spinal nerves. They turn the trunk and neck towards the opposite
side.

Musculi Interspinales et Intertransversarii. The inter spinous muscles

can hardly be said to exist in the thoracic region, except in its upper
and lower parts, where they are present in a rudimentary condition. In
the neck they are arranged in pairs, occupying each interspinous interval,
with the exception of that between the first and second cervical vertebrae.
In the lumbar region also they are well marked and in pairs*: there, they are
attached to the whole length of the spinous processes. The intertransverse
muscles are strongly developed in the lumbar region, and occupy the entire
THE DISSECTION OF THE BACK 73

length of the intertransverse intervals. Additional rounded fasciculi may

be observed passing between the accessory processes ; they are termed
the interaccessorii. In the thoracic region intertransverse muscles poorly
developed are found only in the lower three or four spaces. In the cervical
region they are present in pairs and will be examined subsequently.

The interspinous muscles help to bend the vertebral column backwards.

The intertransverse muscles bend it towards their own side. Both groups
are supplied by the posterior rami of the spinal nerves.

Levatores Costarum. The elevators of the ribs constitute

a series of twelve fan-shaped muscles, which are classified as
muscles of the thorax, but .they are exposed when the
longissimus and ilio-costalis are removed, and therefore
should be examined now.. They pass from the transverse
processes to the ribs. The first muscle of the series springs
from the tip of the transverse process of the last cervical
vertebra, and, expanding as it proceeds downwards and
laterally, it is inserted into the outer border of the first rib,
immediately beyond the tubercle. Each of the succeeding
muscles takes origin from the tip of a thoracic transverse
process, and is inserted into the outer surface of the rib
immediately below, along a line extending from the tubercle
to the angle. The levatores costarum are muscles of in-
spiration. They are supplied by the anterior rami of the
thoracic nerves.

Posterior Rami of the Sacral Nerves. The posterior

rami of the sacral nerves are very small. The upper four
will be found emerging from the posterior sacral foramina j
the fifth appears at the lower end of the sacral canal.

To expose the upper three^ the multifidus, covering the

upper three sacral apertures, must be carefully removed.
Each of the three nerves will be found dividing in the
usual manner into a medial and lateral division.

The medial divisions are very fine, and end in the

multifidus.

The lateral divisions are somewhat larger, and join

together to form a looped plexus upon the dorsum of the
sacrum. The plexus communicates, above, with the lateral
division of the posterior ramus of the last lumbar nerve and,
below, with the posterior ramus of the fourth sacral nerve.
Branches proceed from the loops to the surface of the sacro-
tuberous ligament (O.T. great sacro-sciatic). Finally, they
become superficial by piercing the glutaeus maximus muscle,
and they supply a limited area of skin over the gluteal

74 HEAD AND NECK

region. They have already been examined by the dissector

of the lower limb.

The posterior rami of the loivest two sacral nerves do

not separate into medial and lateral divisions. They are
very small, and, after communicating with each other, and
also with the coccygeal nerve^ they distribute filaments to the
parts on the posterior aspect of the lower portion of the
sacrum and on the dorsal aspect of the coccyx.

Twigs from the lateral sacral arteries accompany the sacral

nerves and anastomose with twigs from the gluteal arteries.

Posterior Ramus of the Coccygeal Nerve. This is a slender

twig which emerges from the inferior opening of the sacral
canal, and, after being joined by a filament from the last
sacral nerve, is distributed on the dorsum of the coccyx.

Posterior Vertebral Venous Plexus. A plexus of veins is

situated upon the superficial aspect of the vertebral arches
subjacent to the multifidus muscle. Blood passes to it from
the integument and muscles of the back, and is conveyed by
it, in the thoracic and lumbar regions, into the posterior
tributaries of the intercostal and lumbar veins. In the neck
it is especially well marked, and there blood is emptied from
it into the vertebral veins. In an ordinary dissection, the
plexus is not very noticeable, but it is a source of serious
trouble during operations upon the vertebrae (comp. p. 79).

Dissection. The fourth day after the body is placed upon

its face must be devoted to the dissection of the sub-occipital
triangle, and the fifth day to the display of the medulla spinalis
(O.T. spinal cord), its membranes, nerve-roots, and blood vessels.

If the dissector is pushed for time, it is better that he should

proceed at once to expose the spinal medulla (p. 78), and defer
the dissection of the sub-occipital region until the head and neck
have been removed from the trunk.

Sub-Occipital Space. The sub-occipital space is a small

triangular area, exposed by the reflection of the semi-
spinalis capitis (O.T. complexus) and the splenius muscle.
It is bounded by three muscles (i) the rectus capitis
posterior major forms its upper and medial boundary ;
(2) the obliquus inferior limits it below ; and (3) the obliquus
superior bounds it above and to the lateral side. Its
floor consists of two structures viz., the posterior arch of
the atlas and the thin posterior atlanto-occipital membrane.
It contains a portion of the vertebral artery and the posterior
ramus of the sub-occipital or first cervical nerve (Fig. 20).

THE DISSECTION OF THE BACK

75
Dissection. The dissection of the sub-occipital space is
difficult, because the connective tissue in which its contents lie
is dense. The first structures to secure are the posterior ramus
of the sub-occipital nerve and its branches. The branch to the
semispinalis capitis was retained, with a small piece of the

Occipitalis "

Sterno-mastoid ?

Meningeal branch ]|
of occipital artery "7

Occipital artery r

Splenius capitis

Vertebral artery
iigastricus, post, belly -4

sterno mastoideus (cut) --

Descending branch of
occipital artery

M. levator scapulae

M. splenius cervicis
M. longiss;mus capitis

~ Occipital artery

Greater occipital nerve

M. trapezius

M. semispinalis capitis

(O.T. complexus)

M. obliquus superior
Greater occipital nerve

M. rectus cap. post, mino:

M. rectus cap. post, major

Edge of occ.-atlantal mem
Post. br. of sub-occipital ne
Post, arch of atlas

Spine of epistropheus
M. obliquus inferior

M. semispinalis cervicis

M. trapezius
\ M. semispinalis capitis
(O.T. complexus)

M. splenius capitis

FIG. 20. Dissection of the Sub-Occipital Region. Note that in this specimen
the occipital artery was superficial to the longissimus capitis muscle.

muscle attached to it, when the semispinalis was reflected

(P- 67) ; trace it into the space until it joins the posterior ramus,
then follow the other branches from the posterior ramus to their
terminations. One branch passes upwards to the superior
oblique ; one passes upwards and medially to supply the rectus
capitis posterior major and the rectus capitis posterior minor ;
each of the two twigs into which it divides enters the superficial
surface of the muscle it supplies, and the twig to the rectus

76 HEAD AND NECK

capitis posterior minor crosses the superficial surface of the

rectus capitis posterior major ; the last branch passes down-
wards to the inferior oblique muscle ; it supplies that muscle
and sends a twig of communication to the greater occipital nerve,
which in its turn sends a communicating twig to the medial
branch of the posterior ramus of the third cervical nerve. The
union of the posterior rami of the first three cervical nerves thus
formed is called the posterior cervical plexus. After the nerves
mentioned have been secured and cleaned, clean the muscles
which form the boundaries of the space, and afterwards remove
the remains of the fascia from the space, and display the posterior
arch of the atlas, the third portion of the vertebral artery, which
lies on the upper surface of the posterior arch of the atlas above
the trunk of the sub-occipital nerve, and the posterior atlanto-
occipital ligament.

Musculus Rectus Capitis Posterior Major. The major

posterior rectus muscle of the head springs by a pointed origin
from the spine of the epistropheus (O.T. axis), and expanding
as it passes upwards and laterally, it is inserted into the occipital
bone along the lateral portion of the inferior nuchal line and
into the surface immediately below. It draws the head
backwards and rotates it to the same side. It is supplied by
the posterior ramus of the sub-occipital nerve.
Musculus Rectus Capitis Posterior Minor. The minor
rectus capitis posterior muscle is a small fan-shaped muscle,
placed to the medial side of, and overlapped by, the rectus
major. It takes origin from the tubercle on the posterior
arch of the atlas, and is inserted into the medial part of the
inferior nuchal line of the occipital bone and into the surface
between that line and the foramen magnum. It draws the
head backwards and is supplied by the posterior ramus of
the sub-occipital nerve (Fig. 20).

Musculus Obliquus Capitis Inferior. The inferior oblique

muscle extends from the extremity of the spine of the
epistropheus to the posterior border of the transverse process
of the atlas. The greater occipital nerve will be seen hooking
round its lower border. It is supplied by the posterior ramus
of the sub-occipital nerve and it rotates the atlas and the
head to the same side.

Musculus Obliquus Capitis Superior. The superior oblique

muscle springs from the transverse process of the atlas, and is
inserted into the occipital bone, in the interval between the
nuchal lines, below and to the lateral side of the semispinalis
capitis. Acting with its fellow of the opposite side it draws
the head backwards. Acting alone it turns the head slightly

THE DISSECTION OF THE BACK 77

to the opposite side. It is supplied by the posterior ramus

of the sub-occipital nerve (Fig. 20).

The Actions of the Deep Muscles of the Back. The

dissector will have noted that many of the deep muscles of the
back, such as the various prolongations of the sacro-lumbalis,
run vertically upwards ; others run upwards and medially,
viz., the semispinalis dorsi and cervicis and the multifidus
spinae. A third group, exemplified by the splenius capitis and
cervicis, the serratus posterior inferior and the inferior oblique
muscle, run upwards and laterally. When the muscles which
run vertically upwards contract, on one side only, they bend
the vertebral column to that side, but if the muscles of both
sides act simultaneously they bend the vertebral column
backwards. When the muscles which run upwards and
laterally contract they turn the head or trunk to the same
sides, whilst those which run upwards and medially turn the
head or trunk to the opposite side. The muscles which lie
at the sides of the sub-occipital space need further considera-
tion. They act either upon the occipito-atlantal joints, the
joints between the first and second cervical vertebrae, or
upon both sets of joints. At the occipito-atlantal joints back-
ward and forward movement and a slight oblique movement
whereby the head is turned a little to one or the other side
take place. The main movement between the atlas and the
second cervical vertebrae is a movement of rotation, the atlas
carrying the head rotating around the dens of the second
vertebrae.
The rectus capitis posterior minor and the superior
oblique act on the joints between the atlas and occipital
bone only : the rectus capitus posterior minor producing
backward movement only and the superior oblique backward
movement and a very slight oblique movement which turns
the head slightly towards the opposite side, The inferior
oblique acts only on the joints between the atlas and the
second vertebra, turning the head to the same side. The
rectus capitis posterior major alone acts on both sets of
joints, drawing the head backwards and turning it to the
same side.

Posterior Ramus of the Sub -Occipital Nerve. The

posterior ramus of the sub -occipital nerve does not divide
into medial and lateral divisions. It enters the sub-occipital
triangle by passing dorsally, between the posterior arch of

78 HEAD AND NECK

the atlas and the vertebral artery, and at once breaks up

into branches which go to supply five muscles viz., the two
posterior recti, the two oblique muscles, and the semispinalis
capitis. In addition to the muscular twigs it gives a com-
municating, and sometimes a cutaneous filament.

The communicating branch generally proceeds from the

nerve to the obliquus capitis inferior, and joins the greater
occipital nerve. The cutaneous branch, when present, accom-
panies the occipital artery to the integument over the occiput.

Arteria Vertebralis. Only the third portion of the

vertebral artery lies in the sub-occipital triangle. It emerges
from the foramen in the transverse process of the atlas, and
runs backwards and medially in the groove upon the posterior
arch of that bone. As it passes medially it lies immediately
posterior to the lateral mass of the atlas and above the sub-
occipital nerve. It leaves the space by passing anterior to
the thickened lateral extension of the posterior atlanto-
occipital membrane, which runs from the posterior arch of
the atlas to the posterior lip of its articular process and is
called the oblique ligament of the atlas ; then the artery
pierces the dura mater and enters the spinal canal (Fig. 37).

Small branches proceed from the vertebral artery, as it lies

in the sub-occipital space, to supply the parts in its immediate
neighbourhood, and to anastomose with the descending
branch of the occipital artery and the arteria profunda
cervicis.

Dissection to open the Vertebral Canal. The first step

consists in thoroughly cleaning the laminae and spinous pro-
cesses upon both sides. The multifidus must be completely
removed from the dorsum of the sacrum. At the same time
the posterior rami of the nerves must be retained, so that their
continuity with the various spinal nerve-trunks may be after-
wards established. The dissector should then remove the
posterior wall of the vertebral canal in one piece by sawing
through the laminae on each side, and dividing the ligamenta
flava, from the third cervical vertebra down to the lower opening
of the sacral canal.

In making this dissection the student must attend to the

following points : (i) the cut should be directed through the
laminae close to the medial sides of the articular processes ;
(2) the saw must be used in an oblique plane, so that the cut
through the laminae slants slightly medialwards ; (3) as the
cervical laminae are cut through, the head and neck should hang
over the end of the table, and be flexed as much as possible, whilst
the saw is worked from below upwards ; (4) in the case of the
lumbar region, where, indeed, most difficulty will be met, a high

THE DISSECTION OF THE BACK 79

block must be placed under the abdomen of the subject, whilst

the blocks supporting the chest and pelvis are removed. It will
probably be necessary at this point to have recourse to the hammer
and chisel.

The laminae and spinous processes which are thus removed

are connected with each other by the ligamenta flava and the
supraspinous and interspinous ligaments. They should be laid
aside for the present. A description of the ligaments will be
found on p. 269. Whilst the specimen is fresh, however, the
dissector should test the high elasticity of the ligamenta flava by
stretching them.

Between the dura mater and the walls of the canal, the
dissector will notice a quantity of loose areolar tissue and soft fat.
The latter is especially plentiful in the sacral region, where it
somewhat resembles the marrow in the medullary cavity of a
long bone. Great numbers of large veins and minute arteries
ramify in this areolo-fatty material.

Arterise Spiuales. In a well injected subject a minute spinal artery

will be seen entering the vertebral canal through each intervertebral
foramen. These arteries are derived from different sources in the different
regions of the vertebral column. In the cervical region they come from
the vertebral artery ; in the thoracic region, from the posterior branches
of the intercostal arteries ; in the lumbar region, from the dorsal branches
of the lumbar arteries. They supply the spinal medulla and its meninges,
the bones, the periosteum, and the ligaments ; and their arrangement is
very much the same in each of the three regions.

Each spinal artery may be looked upon as giving off three main twigs ;
one of them, termed the pre-laminar branch, is a very small twig which
ramifies upon the deep surface of the vertebral arches and ligamenta
flava. Another, the neural branch, can be followed to the dura mater,
which it pierces immediately above the point of exit of the corresponding
spinal nerve. It divides into two twigs, one of which passes along the
posterior and the other along the anterior root of the nerve to join the
plexus in the spinal pia mater. The third, the post-central branch, is
carried medially, anterior to the dura mater, towards the posterior surface
of the vertebral bodies ; it divides into an ascending and a descending twig
which anastomose with the corresponding twigs above and below, and in
that manner a continuous series of minute arterial arcades is formed,
from which branches pass medially to form a series of cross anastomoses
with the corresponding vessels of the opposite side.

In the cervical region small branches from the ascending cervical artery
also find their way into the vertebral canal ; whilst in the sacral portion
of the canal the dissector will find branches from the lateral sacral arteries.

Internal Vertebral Venous Plexus. The internal vertebral venous

plexus extends along the whole length of the vertebral canal, and consists
essentially of four subsidiary longitudinal plexuses, two anterior and two
posterior, which anastomose freely with each other.

The posterior plexuses are united by many cross branches, which run
along the deep aspect of the vertebral arches and ligamenta flava.
Above, they communicate with the occipital sinus, whilst, all the way
down, they are connected with the posterior vertebral venoiis plexus by
wide channels which pierce the ligamenta flava. Laterally, they send
branches through the intervertebral foramina to join the posterior branches
of the intercostal and lumbar veins.

The anterior plexuses cannot be dissected whilst the medulla spinalis

8o HEAD AND NECK

(O. T. spinal cord) and its membranes are in sittt, but it is convenient to
describe them at this stage. Indeed, the dissection is one of considerable
difficulty, even under the most advantageous circumstances. They form
two main longitudinal venous channels, placed one upon each side of the
posterior longitudinal ligament of the vertebral bodies, and they are joined
by transverse branches which cross the median plane, anterior to that
ligament, opposite each vertebral body. Each transverse vein receives
large tributaries from the interior of the vertebra. Superiorly, each of the
main longitudinal channels communicates with the occipital sinus or the
basilar plexus, within the cranium ; and each of the posterior channels
gives off a branch which emerges above the posterior arch of the atlas
to join the commencement of the vertebral vein. Opposite the various
intervertebral fibro-cartilages the anterior plexus sends oft" branches which
run towards the intervertebral foramina, where they join with correspond-
ing branches of the posterior plexus, to form the intervertebral veins which
accompany the corresponding spinal nerves.

Meninges of the Medulla Spinalis (Fig. 21). The medulla

spinalis, like the brain, with which it is continuous, is enveloped
by three membranes, termed menmges. The most external
investment is a strong fibrous membrane called the dura
mater \ the second, in order from without inwards, is a non-
vascular tunic termed the arachnoid ; whilst the third and
most internal is the pia mater. The three membranes are
directly continuous with the corresponding investments of
the brain.

Dissection. The outer surface of the dura mater must now

be cleaned. This is effected by the removal of the loose areolar
tissue, soft fat, and posterior internal vertebral from the vertebral
canal. It is necessary, also, to define carefully the numerous
lateral prolongations which the membrane gives to the spinal
nerves.

Dura Mater Spinalis (Fig. 21). In the vertebral canal the

dura mater constitutes an exceedingly dense and tough fibrous
tube, which extends from the foramen magnum above, to the
level of the second or third piece of the sacrum below. It is
separated from the walls of the vertebral canal and its lining
periosteum by an interval which is filled with loose fat and
areolar tissue and the internal vertebral venous plexus. Even
before the membranous tube is laid open, the dissector can
readily satisfy himself that it forms a very loose sheath around
the spinal medulla and the nerve-roots which form the cauda
equina below the spinal medulla ; in other words, it is very
capacious in comparison with the volume of its contents.
Its calibre, moreover, is by no means uniform ; in the cervical
and lumbar regions it is considerably wider than in the
thoracic region, whilst in the sacral canal it rapidly contracts

THE DISSECTION OF THE BACK

81

and finally ends, at the level of the second sacral vertebra,

by blending with the filum terminate, a fibrous thread which
is prolonged downwards through the sacral canal from the
extremity of the medulla spinalis (O.T. spinal cord).

The cylindrical tube of spinal dura mater does not

lie free within the vertebral canal, but its attachments
do not in any way interfere with the free movement of

Dura mater
^-Arachnoid
Ligamentum denticulatum

Arachnoid

Posterior nerve-root
Spinal ganglion

Anterior ramus
of nerve

Posterior ramus
of nerve

Dura mater
Anterior nerve-root
(cut)

Posterior nerve-root

Anterior nerve-root
(cut)

Ligamentum
denticulatum

Pia mater

Anterior nerve-root

FIG. 2i. Membranes of the. Medulla Spinalis (O.T. Spinal Cord), and the
mode of origin of the Spinal Nerves.

the vertebral column. Above, the dura mater is firmly

attached around the margin of the foramen magnum, and
to the bodies of the' second and third cervical vertebrae ;
below, the filum terminale, on which the dura mater termin-
ates, can be traced as far as the dorsum of the coccyx, where
it is lost by blending with the periosteum. On each side, the
spinal nerve-roots, as they pierce the dura mater, carry with
them, into the intervertebral foramina, tubular sheaths of the
membrane, which are attached to the margins of the foramina ;
whilst, anteriorly, loose fibrous prolongations more numerous
VOL. in 6

82 HEAD AND NECK

above and below than in the thoracic region connect the tube
of dura mater to the posterior longitudinal ligament of the
vertebral column. No connection of any kind exists between
the dura mater and the vertebral arches or ligamenta flava.

Dissection. The tube of dura mater may now be opened with

the scissors. The incision should be carried through the mem-
brane in the median plane. Care, however, must be taken not
to injure the delicate arachnoid, which is subjacent.

Cavum Subdurale. The subdural cavity is the capil-

lary interval between the dura mater and the arachnoid
(Fig. 20). The deep surface of the dura, which is turned
towards the space, is smooth, moist and polished. The
dissector will notice, upon each side, the series of apertures
of exit for the roots of the spinal nerves. They are ranged
in pairs opposite each intervertebral foramen. The subdural
space is prolonged laterally, for a short distance, upon each
of the nerve-roots, and has a free communication with the
lymph paths present in the nerves.

Viewed from the inside of the tube of dura mater, each of the two
nerve-roots belonging to a spinal nerve is seen to carry with it a special
and distinct sheath. When examined, however, on the outside of the tube
of dura mater, they appear to be enveloped in one sheath, because the two
sheaths are closely held together, on the outside, by intervening connective
tissue which can be removed with a little careful dissection. When that is
done, the two tubular sheaths will be seen to remain distinct as far as the
ganglion on the posterior root of the nerve. At that point they blend
with each other.

Arachnoidea Spinalis (Fig. 20). The arachnoid, like the

dura mater, forms a loose, wide investment for the spinal
medulla. Unlike the dura, however, it is remarkable for its
great delicacy and transparency. The sac is most capacious,
and can be demonstrated most easily towards its lower part,
where it envelops the extremity of the spinal medulla and
the collection of long nerve-roots which constitute the cauda
equina. Make an incision into it, and insert the handle of
the scalpel, or, better still, inflate the sac with air by means
of a blowpipe. Above, the spinal arachnoid becomes con-
tinuous, through the foramen magnum, with the arachnoid
membrane of the brain. On each side, it is prolonged upon
the various nerve-roots, contributing a tubular sheath to each.
It ends, below, at the level of the second sacral vertebra, by
fusing with the filum terminale.

Cavum Subarachnoideale (Fig. 20). The sub-arachnoid

THE DISSECTION OF THE BACK 83

cavity is the wide space between the arachnoid and pia mater.
It is occupied by a variable amount of cerebro-spinal fluid, and
is directly continuous with the cranial sub-arachnoid space
through the foramen magnum. Three incomplete septa
partially subdivide the spinal sub-arachnoid space into com-
partments. One of the septa is a median partition, called
the septum subarachnoideale, which connects the arachnoid with
the pia mater covering the posterior aspect of the spinal
medulla. In the upper part of the cervical region the sub-
arachnoid septum is represented merely by a number of
strands passing between the two membranes ; in the lower part
of the cervical region and in the thoracic region it is almost
complete. The other two septa are the ligamenta denticu-
lata. They spread laterally, one from each side of the medulla
spinalis, and will be studied with the pia mater.

Dissection. Take away the arachnoid from a portion of the

spina medulla, and proceed to the study of the pia mater.

Pia Mater Spinalis. The pia mater of the spinal medulla

is a firm vascular membrane, which adheres closely to the
surface of the medulla spinalis (O.T. spinal cord). It is
thicker and denser than the pia mater of the brain, largely
owing to the addition of an outer layer of fibres, which run
chiefly in a longitudinal direction. It is folded into the
antero - median fissure of the medulla spinalis; and the
posterior median septum of the medulla spinalis is firmly
attached to its deep surface. Anteriorly, in the median
plane, it is thickened to form a longitudinal glistening band,
which receives the name of the linea splendens. Of course,
that can be seen only after the medulla spinalis has been
removed from the vertebral canal. The blood vessels of the
medulla spinalis lie between the two layers of the pia mater
before they enter the substance of the spinal medulla ; and
the various spinal nerves receive from it closely fitting sheaths
which blend with their connective-tissue coverings.

Ligamentum Denticulatum (Figs. 20 and 22). There are

two dentate ligaments, one on each side. Each stretches
laterally from the corresponding side of the medulla spinalis
and connects it with the dura mater. Its medial attachment
extends in a continuous line, between the anterior and
posterior nerve-roots, from the level of foramen magnum,
above, to the level of the body of the first lumbar vertebra,

in 6 a

8 4

HEAD AND NECK

below. Its lateral margin is widely serrated or denticulated.

From twenty to twenty-two denticulations may be recognised ;
the highest is attached to the margin of the foramen
magnum. They occur in the intervals between the spinal
nerves, and, pushing the arachnoid before them, they are
attached by their pointed extremities to the inner surface of
the dura mater.

The ligamenta denticulata maintain the medulla spinalis

(O.T. spinal cord) in the middle of the tube of dura mater, and
partially subdivide the sub-arachnoid space into an anterior

and a posterior com-

partment. In the

Posterior. JHBS^I^Kl.. Anterior anterior compart-

ment the anterior

Ligamentum
denticulatum
nerve-root

FIG. 22. Lateral view of the Medulla Spinalis,

Dura Mater, and Ligamentum Denticulatum.
(Hirschfeld and Leveille".)

nerve-roots pass
laterally ; the pos-
terior compartment
contains the pos-
terior nerve - roots,
and is imperfectly
subdivided into two
lateral subdivisions
by the septum sub-
arachnoideale.

Medulla Spinalis
(O.T. Spinal Cord).
The spinal
medulla itself may now be studied in situ. It is almost cylin-
drical in form but is slightly flattened anteriorly and pos-
teriorly. It extends from the foramen magnum, where it is
continuous with the medulla oblongata of the brain, to the
lower border of the body of the first or the upper border of
the body of the second lumbar vertebra. Its lower end
rapidly tapers to a point, and is termed the conus medullaris.
From the extremity of the conus a slender filament, termed
the filum terminate, is prolonged downwards to the dorsal
surface of the coccyx.

In the female the average length of the medulla spinalis is

43 cm. j in the male it is 45 cm. (18 inches).

Throughout the greater part of the thoracic region,

the medulla spinalis presents a uniform girth, but in the
cervical and lower thoracic regions it shows marked swellings,

THE DISSECTION OF THE BACK

L.V.

Conus
medullaris
termed respectively the intumescentia cervicalis and intumescentia
lumbalis. The cervical enlargement, which is connected with
the nerves of the superior extremities, is the more evident of
the two. It begins at the upper end of the medulla spinalis
(O.T. spinal cord), attains its greatest breadth (13 or
14 mm.) opposite
the fifth or sixth
cervical vertebra,
and subsides op-
posite the second
thoracic vertebra.
The lumbar en-
largement is con-
nected with the
nerves of the in-
ferior extremities.
It begins at the
level of the tenth
thoracic vertebra,
attains its maxi-
mum transverse
diameter (n to
13 mm.) opposite
the last thoracic
vertebra, then it
rapidly tapers
into the conus
medullaris.

Filum Termin-
ate. The deli-
cate thread - like
terminal filament
lies amidst the
numerous long
nerve-roots which
occupy the lower part of the vertebral canal, but it can
readily be distinguished from them (i) by its silvery glisten-
ing appearance, and (2) by its continuity with the extremity
of the conus medullaris (Fig. 23).

It is composed chiefly of pia mater, although the central

canal of the medulla spinalis is prolonged down in its interior
for nearly half its length, and nervous elements can be traced

s.v.

Coccyx

FIG. 23. Sagittal section through the lower part

of the Vertebral Canal.

86 HEAD AND NECK

in its substance for a like distance. The lima splendens and

the lower ends of the ligamenta denticulata may also be
considered to be continued into it. At the level of the
second or third sacral vertebra it pierces the tapered end of
the tube of dura mater, and receives an investment from
it ; finally it reaches the lower end of the sacral canal, where
it terminates by blending with the periosteum on the dorsal
surface of the coccyx or the last piece of the sacrum.

In length it measures about 15 cm. (6 inches). The part

within the tube of dura is termed the filum terminate internum^
the portion outside is \hefilum terminate externum.

Nervi Spinales. Thirty-one spinal nerves take origin from

each side of the medulla spinalis (O.T. spinal cord). They
are classified into five groups, according to the vertebrae with
which they are associated. The thoracic, lumbar, and sacral
nerves correspond in number with the vertebrae in each of
those regions thus, there are twelve thoracic, five lumbar,
and five sacral nerves, each of which issues from the vertebral
canal below the vertebra with which it numerically corresponds.
In the cervical region, however, there are eight nerves. The
first of them comes out between the occiput and the atlas,
and is therefore distinguished by the special name of the sub-
occipital nerve. There is only one coccygeal nerve on each
side.

Spinal Nerve-Roots (Figs. 21 and 24). Each spinal nerve

springs from the side of the spinal medulla by two roots an
anterior and a posterior. Except in the case of the sub-occipital
nerve (where the posterior root is sometimes absent), the
posterior nerve-root is the larger of the two. In addition,
the posterior root is distinguished by possessing an oval
ganglion, termed the spinal ganglion. There is, also, a
wide physiological difference between the two roots the
posterior root is composed of afferent fibres ; the anterior root
consists of efferent fibres. Immediately beyond the ganglion
the two roots unite to form the spinal nerve-trunk^ which
contains a mixture of both efferent and afferent nerve-fibres.

The mode of attachment of the two nerve-roots to the side of

the medulla spinalis is somewhat different in the two cases.
In each instance they are attached by several separate fila
radicularia, which spread out from each other as they approach
their attachments. In the case of the posterior root the
fila enter the spinal medulla consecutively, along a continuous

THE DISSECTION OF THE BACK 87

straight line and at the bottom of a slight furrow. The fila

of the anterior root, on the other hand, are not so regularly
placed. They emerge from the medulla spinalis over an area
of some breadth. The portion of the medulla spinalis which
stands in connection with a pair of nerves receives the
name of a "neural segment."

It will be noted that the size of the nerve-roots differs greatly.

The lower lumbar and upper sacral nerve-roots are much
the largest, whilst the lower sacral and the coccygeal roots
are the smallest. In the cervical region the roots increase in
size from above downwards, but more rapidly in the lower
members of the group ; in the thoracic region the roots of the

6'

7'

FIG. 24. A segment of the Medulla Spinalis ; anterior aspect.

(Schwalbe, after Allen Thomson. )

1. Anterior median fissure. 6. Posterior nerve-root.

2. Posterior median sulcus. 6'. Spinal ganglion.

3 and 5. Fila of anterior nerve-root. 7. Anterior ramus.

4. Posterior lateral groove. 7'. Posterior ramus.

first nerve are large, but those which succeed it are small and
of uniform size.

In relative length, and in the direction which they follow in

the vertebral canal, the n-erve-roots also show great differences.
The differences are due to the medulla spinalis being so much
shorter than the canal in which it lies. In the upper part of
the cervical region the nerve-roots are short, and proceed
laterally and almost horizontally. Below the upper cervical
region the nerve-roots become more oblique, and the lower
the origin of the nerve the longer is its course in the canal.
The arrangement of the lower thoracic, the lumbar, sacral,
and coccygeal nerve-roots is particularly characteristic. They
are exceedingly long, and descend vertically from the lower
portion of the medulla spinalis, forming the bundle which
is called the cauda equina.

88 HEAD AND NECK

The origins of the eight cervical nerves lie between the

level of the atlas and the level of the spine of the sixth
cervical vertebra ; the origins of the first six thoracic nerves
extend from the sixth cervical to the third thoracic spine ;
the origins of the lower six thoracic nerves lie between the
third and the ninth thoracic spines ; and the origins of the
lumbar and sacral nerves are between the ninth thoracic and
the first lumbar spine.

Mode of Exit of Spinal Nerves from Vertebral Canal.

The lower six cervical nerves, the thoracic nerves, and the
lumbar nerves make their exit through the intervertebral
foramina; whilst each of the two rami of the upper four
sacral nerves finds its way out by a sacral foramen. The
upper two cervical nerves, the fifth sacral nerve, and the
coccygeal nerve, however, follow a different course. The
sub-occipital emerges by passing over the posterior arch of
the atlas, and the second cervical nerve by passing over the
vertebral arch of the epistropheus (O.T. axis). The fifth
sacral and the coccygeal nerve leave the sacral canal through
its lower aperture (Fig. 25).

Dissection. The nerve-roots of one or two spinal nerves in

each region should be followed into the corresponding inter-
vertebral foramina. That can be easily done by snipping away
the articular processes with the bone-forceps. The position of
the ganglion on the posterior root, the connections of the sheath
of dura mater, the union of the two roots to form the spinal nerve-
trunk, and the division of the trunk into the anterior and posterior
rami can then be studied. An attempt should also be made, at
the same time, to discover the minute ramus meningeus. It
is a fine twig which is formed by the union of a small filament
from the spinal nerve-trunk with a minute branch from the
sympathetic trunk. It takes a recurrent course through the
intervertebral foramen to end in the bones and periosteum and
meninges of the vertebral canal.

Ganglia Spinalia. The spinal ganglia are oval swellings

developed upon the posterior nerve-roots, just before they
unite with the anterior roots to form the spinal nerve-trunks.
They are found upon the posterior roots of all the nerves,
except, occasionally, those of the sub-occipital and the coccy-
geal nerves.

The ganglia are formed upon the posterior nerve -roots

as they lie in the intervertebral foramina, except in the
cases of the first two cervical and the sacral and coccygeal
nerves. The ganglia of the first two cervical nerves lie upon

THE DISSECTION OF THE BACK

89

the posterior arch of the first and the vertebral arch of the
second cervical vertebrae, respectively ; the ganglia of the
sacral nerves are placed within the sacral canal, but out-
side the tube of dura mater. The ganglion on the posterior
root of the coccygeal nerve is inside the tube of dura mater.
Filum terminals

Filum

.nale
Fifth sacral nerve

Coccygeal nerve

FIG. 25. The Sacral Nerve-roots (lower part of Cauda Equina) and the
Membranes in relation to them. (After Testut. ) The posterior wall of
Sacral Canal has been removed.

Spinal Nerve -Trunks.- The trunks of the spinal nerves

are formed by the union of the anterior and posterior nerve-
roots immediately beyond the spinal ganglia. The union
takes place in the case of the coccygeal and sacral nerves
in the sacral canal ; in the lumbar, thoracic, and lower six
cervical nerves, in the intervertebral foramina ; and in the
case of the first two cervical nerves, on the arches of the
atlas and epistropheus respectively.

90 HEAD AND NECK

The nerve-trunk is exceedingly short in most cases;

indeed, it divides almost immediately into its anterior and
posterior rami. In the cases of the sacral and coccygeal nerves,
the subdivision takes place in the sacral canal, and the
spinal nerve-trunks of those nerves are distinctly longer than
the trunks of the nerves which occupy a higher level.

The distribution of the posterior rami has already been

examined (p. 69).

Dissection. At this stage the dissector may adopt one of two

methods in the further treatment of the medulla spinalis and
the nerves which spring from it. If the medulla spinalis is fresh
and in such a condition that it may be successfully hardened, it
is best to transfer it at once to the preservative fluid. If, on the
other hand, it is soft and not fit for proper preservation, it should
be removed with all its membranes and nerve-roots, and placed
in a cork-lined tray filled with water. There is no method by
which the arachnoid, the pia mater, the ligamenta denticulata,
and the nerve-roots can be so well studied as this.

To remove the medulla spinalis, the dissector should divide

the spinal nerves as they lie in the intervertebral foramina, and
in such a manner that as long a piece as possible of each nerve
remains attached to the dura mater and the spinal medulla.
Wherever it is possible the ganglia should be taken with the
nerves. The same rule applies to the sacral nerves also. The
medulla spinalis and its membranes should then be cut across
at the highest limit of the vertebral dissection. Pull upon the
dura mater in order to lift the whole specimen from the vertebral
canal, and then transfer it to the water-bath. Slit up the dura
mater along the median plane anteriorly, and turn aside the edges
of the incision. By fixing the dura mater with pins to the cork
at the bottom of the tray, the dissector can conduct the further
dissection with great advantage, and can display in turn the
arachnoid, and the pia mater with the ligamenta denticulata.

Arteries of the Medulla Spinalis (O.T. Spinal Cord). It

is only when the arterial injection is particularly good that
the spinal arteries can be made out satisfactorily.

Numerous small arteries are supplied to the medulla

spinalis. They are the anterior and posterior spinal arteries,
which spring from the vertebral artery in the cranium, and a
series of lateral spinal arteries, which reach the side of the
medulla spinalis and are derived from different sources in each
region. In the neck they come from the vertebral, ascending
cervical, and deep cervical arteries ; and in the thoracic and
lumbar regions, from the posterior branches of the intercostal
and lumbar arteries. By the anastomoses of the various
arterial twigs, five longitudinal trunks are formed upon the
surface of the medulla spinalis. One lies in the median

THE DISSECTION OF THE BACK 91

plane anteriorly, and may be termed the antero-median artery.

The other four are placed in relation to the sulci along
which the posterior nerve-roots enter the medulla spinalis.
One runs downwards anterior to the line of entrance of those
roots, and the other posterior to it, on each side of the
medulla spinalis. The posterior vessels may, therefore, be
termed the postero-lateral longitudinal vessels.

The antero-median vessel is formed above by the union of the two

anterior spinal branches of the vertebral arteries. One of them is larger
than the other, and takes a much -greater share in the formation of the
median trunk. Below the level of the fifth pair of cervical nerves the
continuity of the median vessel depends upon the reinforcements which
it obtains from the lateral spinal vessels. The number of lateral spinal
arteries which join the median vessel is very variable. The majority
of them end on the nerve - roots ; only five to ten reach the median
vessel. The antero-median artery runs downwards, under cover of the
linea splendens of the pia mater. Its calibre is uniform throughout,
and where the medulla spinalis ends it proceeds onwards for some distance
upon the filum terminale.

The postero-lateral arteries on each side of the medulla spinalis are formed
in the upper part of the cervical region by the bifurcation of the corre-
sponding posterior spinal branch of the vertebral artery. Lower down
their continuity is maintained by twigs which reach them, on the posterior
roots of the spinal nerves, from the lateral spinal arteries. It may be
regarded as a rule, that where a lateral spinal artery gives a branch to
one of the postero-lateral arterial trunks, it does not furnish another
to the antero-median arterial trunk. Nevertheless, the different lateral
spinal arteries are in connection, directly or indirectly, with the longitudinal
trunks on the anterior and posterior aspects of the medulla spinalis. The
postero-lateral vessels end at the lower extremity of the medulla spinalis.

F r om the five main arterial channels which thus extend along the spinal
medulla spring numerous anastomosing twigs which ramify in the pia
mater.

Veins of the Medulla Spinalis. The veins of the spinal

medulla are small and numerous, and their disposition cannot
be said to correspond with that of the arteries. They are
very tortuous, and form a plexus with elongated meshes.
Six more or less perfect longitudinal venous trunks may be
noticed on the surface of the medulla spinalis in connection
with the venous plexus; two of them are median, and are
placed respectively on the anterior and posterior aspects.
The anterior trunk runs upwards under cover of the antero-
median spinal artery. The other four are lateral, and are
situated two on each side, in relation, respectively, to the
anterior and posterior nerve-roots.

Upon each side, the veins of the medulla spinalis effect

92 HEAD AND NECK

communications with the veins in the vertebral canal by means

of small twigs which run laterally on the nerve-roots.

How to distinguish the anterior from the posterior surface of

the medulla spinalis.

ANTERIOR SURFACE. POSTERIOR SURFACE.

I. Linea splendens. i. The postero - lateral arteries, in

relation to the posterior nerve-

roots.

Fila of origin of posterior

nerve-roots entering the medulla
spinalis along a straight and
continuous line, and at the
bottom of a distinct sulcus.

Posterior nerve-roots, larger than

the anterior, and provided with

2. Single anterior spinal artery, in

median plane.

3. Anterior nerve - roots, smaller

than posterior, and springing

by fila which emerge from
the medulla spinalis, not in a
continuous straight line, but
irregularly over an area of some
width. ganglia.

Preservation of the Medulla Spinalis. If the medulla spinalis is in a

fit state for preservation, it should be immersed for a few weeks in
methylated spirit, to which a small amount (4 per cent. ) of formalin has been
added. When sufficiently firm, the dissector should endeavour to learn
something of its internal structure by making transverse sections across
it at different levels, and inspecting the cut surface closely with the naked
eye, or with the aid of a magnifying glass.

Internal Structure of the Medulla Spinalis. The medulla

spinalis is composed of an inside core of grey matter which is
surrounded on all sides by an external coating of white matter,
and a good deal can be learned by a naked-eye inspection of
cross sections through it made in different regions and at
different levels.

In such sections the antero-median fissure and the postero-

median septum and sulcus, which partially divide it along the
whole of its length into right and left halves, become obvious.

The antero-median fissure is much shorter than the postero-

median septum. It dips dorsally to a commissure of white
matter, the anterior white commissure, which connects the white
matter of the two halves of the medulla spinalis ; and it con-
tains a fold of pia mater and branches of the anterior spinal
vessels. The postero-median sulcus is a shallow furrow which
runs along the posterior surface of the medulla spinalis in
the median plane, and the postero-median septum extends
from the bottom of the sulcus to a transverse grey com-
missure called the posterior commissure, which connects the
two halves of grey matter.

THE DISSECTION OF THE BACK

93

The two halves of the medulla spinalis, thus marked off

from each other, are to all intents and purposes symmetrical,
and they are joined by a more or less broad band or com-
missure which intervenes between the anterior fissure and the
posterior septum.

An inspection of the surface of each half of the medulla

spinalis brings into view a groove or furrow at some
little distance from the postero-median sulcus ; it is called
the postero-lateral sulcus. Along the bottom of that groove
the fila of the posterior nerve-roots enter the medulla spinalis
(O.T. spinal cord) in accurate linear order. There is no

Fasciculus gracilis
Posterior funiculus. /Fasciculus cuneatus

Entering fila of

posterior nerve-root

Formatio reticularis
Lateral funiculus

Central canal

Root of accessory

nerve

Anterior column of
grey matter

Posterior column of
grey matter

Root of accessory
nerve

Fila of anterior
nerve-root

Anterior funiculus

FIG. 26. Transverse section through the upper part of the

Cervical Region of the Medulla Spinalis.

corresponding furrow on the anterior part of each half of

the medulla spinalis in connection with the emergence of
the fila of the anterior nerve -roots ; and it should be noted
that the anterior root fila emerge over a relatively broad
area, which corresponds in its width to the thickness of the
subjacent anterior column of grey matter (Fig. 26).
Grey Matter of the Medulla Spinalis. The grey matter in
the interior of the medulla spinalis has the form of a fluted
column. When seen in transverse section, it presents the
shape of the letter H. In each half of the medulla spinalis
there is a mass of grey matter, comma-shaped in section
with the concavity directed laterally. The grey columns of
opposite sides are connected across the median plane by a
transverse band, which is called the grey commissure. The

94 HEAD AND NECK

postero-median septum passes from the surface of the medulla

spinalis to the grey commissure. The bottom of the antero-
median fissure is separated from the grey commissure by an
intervening strip of white matter which is termed the anterior
white commissure. In the grey commissure may be seen the
central canal of the spinal medulla. It is just visible to the
naked eye as a minute speck. The canal tunnels the entire
length of the spinal medulla, and opens above (after having
traversed the lower half of the medulla oblongata) into the
fourth ventricle of the brain. The portion of the grey com-
missure which lies posterior to the central canal is called the
posterior commissure ; the portion anterior to it receives the
name of anterior grey commissure.

In each lateral mass of grey matter certain well-defined

parts may be recognised. The projecting portions which
extend posterior and anterior to the connecting transverse
grey commissure are termed the posterior and the anterior grey
columns. They can be distinguished from each other at a
glance.

The anterior grey column is short, thick, and its anterior

margin is very blunt. Further, its anterior margin is separated
from the surface by a moderately thick coating of white matter,
through which the fila of the anterior nerve-roots pass on their
way to the surface. The thickened anterior margin of the
anterior column is termed its head, and the constricted part
close to the grey commissure is called the neck. The posterior
grey column^ in most localities, is narrow. Further, it is drawn
out to a fine edge, which almost reaches the bottom of the
postero-lateral sulcus. This sharp edge receives the name of
the apex of the posterior column ; the slightly swollen part
which succeeds it is the head of the posterior column ; whilst
the slightly constricted part adjoining the grey commissure
goes under the name of the neck of the posterior column.

Covering the edge of the posterior column there is a sub-

stance which differs in its composition from the general mass
of grey matter, and presents a translucent appearance. It
is termed the substantia gelatinosa (Rolandi}.

The grey matter is not present in equal quantity through-

out the entire length of the medulla spinalis. Therefore it is
necessary that it should be considered in different regions; and
it must be understood, when the terms cervical, lumbar, sacral,
etc. are applied to different portions of the spinal medulla,
THE DISSECTION OF THE BACK 95

that those terms apply to the regions to which the nerves of

the same name are attached.

Wherever there is an increase in the size of the nerves

attached to a particular part of the medulla spinalis, there a
corresponding increase of the grey matter may be noticed. It
follows that the districts in which the grey matter bulks
most largely are the lumbar and cervical enlargements.
The great nerves which go to form the limb plexuses enter
and pass out from those portions of the medulla spinalis. In
the intervening thoracic region there is a reduction in the .
quantity of grey matter, in correspondence with the smaller
size of the thoracic nerves.

The shape of the columns of grey matter, in section, is not

the same in all regions. In the thoracic region both columns
are narrow, although the distinction between the anterior grey
column and the more attenuated posterior grey column is still
sufficiently manifest. In the cervical region the contrast
between the grey columns is most marked ; the anterior grey
column is very thick in comparison with the posterior grey
column. In the lumbar region, on the other hand, the
difference in the thickness of the two grey columns is not
nearly so apparent, owing to a broadening out of the
posterior grey column. A section taken from the centre of
each region can very readily be recognised by the features
mentioned (Fig. 27).

In the thoracic region of the spinal medulla, more especi-

ally in the upper part, there is another character which is
very distinctive. A pointed and prominent triangular pro-
jection juts out from the lateral aspect of the crescentic mass
of grey matter, nearly opposite the grey commissure. It is
called the lateral grey column (Fig. 27, B and C). It dis-
appears in the cervical and lumbar enlargements generally,
but again becomes evident both in the upper cervical and in
the lower sacral regions.

Below the thoracic region the postero- median septum

diminishes and the antero-median fissure increases in depth,
until, in the sacral region, they are almost equal in depth and
the central canal occupies the centre of the medulla spinalis.
White Matter of the Medulla Spinalis. The white matter
forms a thick coating on the outside of the fluted column of
grey matter. It is marked off into three funiculi. The
posterior funiculus is wedge-shaped in transverse section,

9 6

HEAD AND NECK

Postero-median septum

termed, post, septum

Fasciculus gracilis

Fasciculus cuneatus
Substantia gela-
tinosa Rolandi
Lateral funiculus

Central canal

Anterior column
Grey commissure
Antero-median fissure
Fila of anterior
nerve-root
Anterior funiculus
Postero-median
septum

Substantia Rolandi

Thoracic nucleus
(O.T. posterior
vesicular column)
Lateral column

Anterior column
Antero-median fissure

Postero-median septum
Entering fila of
posterior nerve-root

Thoracic nucleus
(O.T. posterior
vesicular column)
Lateral column

ntero-median
fissure

Postero-median
septum

_ Antero-median
~ fissure
FIG. 27. Transverse sections through the Medulla
Spinalis in different regions. A. Cervical Region ;
B. Mid -thoracic Region; C. Lower Thoracic
Region ; D. Lumbar Region.

region a faint longitudinal groove runs

and lies between

the postero-
median septum
and the posterior
grey column.
The lateral funi-
culus occupies the
concavity of the
grey crescent.
Posteriorly, it is
bounded by the
posterior grey
column and the
postero-lateral sul-
cus, whilst, an-
teriorly, it extends
as far as the most
lateral fila of the
anterior nerve-
roots. The an-
terior funiculus in-
cludes the white
matter between
the antero-median
fissure and the
anterior column
of grey matter,
and also the white
matter which
separates the thick
margin of the
anterior grey
column from the
surface of the
spinal medulla
and is traversed
by the emerging
fila of the an-
terior nerve-roots
(Figs. 26, 27).

In the cervical
downwards on the

THE DISSECTION OF THE BACK

97

surface of the posterior funiculus of the medulla spinalis.

It indicates the position of a septum which passes into the
funiculus from the deep surface of the pia mater and divides
it incompletely into two unequal strands. The groove is
termed the intermediate posterior sulcus. The strand on its
medial side is the fasciculus gracilis (Coil's), whilst the lateral
and larger strand receives the name of the fasciculus cuneatus
(Burdach's).

The white matter of the medulla spinalis increases steadily

in quantity from below upwards.

Fasciculus gracilis

Postero-median septum *iflil Fasciculus cuneatus

Postero-lateral sulcus 7~C ? n|ifHuPf v'* ^

Substantia gelatinosa
Rolandi

Fasciculus cerebro-
spinalis lateralis

Fasciculus spino-
cerebellaris posterior

Fila of origin of
the accessory nerve

Fasciculus cerebro-
spinalis anterior

Antero-median fissure

FIG. 28. Transverse section through the upper cervical part of the Medulla
Spinalis of a full-time Foetus, treated by the Pal-Weigert process.

The fasciculi, gracilis and cuneatus, which form the posterior funiculus
of the medulla spinalis, are composed of fibres which enter the spinal medulla
as the fila of the posterior nerve-roots. In the lower portion of the medulla
spinalis the two fasciculi are not marked off from each other.

In the lateral and anterior funiculi of the adult spinal medulla it is not
possible with the naked eye to distinguish the different strands of fibres of
which they consist, but the student should remember that such strands or
tracts are present. The three best-defined tracts in the antero-lateral part
of the spinal medulla are, (i)the fasciculus spino-cerebellaris (O.T. direct
cerebellar tract) ; (2) the fasciculus cerebro-spinalis lateralis (O.T. crossed
pyramidal tract) ; (3) the fasciculus cerebro-spinalis anterior (O.T. direct
pyramidal tract).

The fasciculus spino-cerebellaris ascends to the cerebellum in thepostero-

lateral part of the lateral funiculus. Traced in the opposite direction, it
is found to disappear in the lower thoracic region of the medulla spinalis.
The fasciculus cerebro-spinalis lateralis occupies a larger district of the
medulla spinalis. It is placed in the lateral funiculus, anterior to the pos-
terior column of grey matter and immediately medial to the fasciculus spino-
cerebellaris. As the fasciculus spino-cerebellaris disappears in the lower
part of the medulla spinalis the fasciculus cerebro-spinalis lateralis comes
to the surface, and it can be traced as low as the fourth sacral nerve. The
fasciculus cercbro-spinalis anterior forms the narrow strip of the anterior
VOL. Ill 7

98 HEAD AND NECK

funiculus which lies immediately adjacent to the antero-median fissure.

It reaches down to about the middle of the thoracic region of the medulla
spinalis and then disappears.

After the body has been five days on its face it will be
replaced upon its back, with the thorax and pelvis supported
by blocks ; and the dissectors of the head and neck should at
once proceed to clean the temporal fascia, and afterwards to
remove the brain and study the interior of the cranium.

Dissection. Take away the anterior and superior auricular

muscles and remove the thin layer of fascia subjacent to them
which descends from the lower border of the galea aponeurotica
to the zygomatic arch. When that has been done the strong
temporal fascia will be exposed. Note that it is attached above
to the temporal ridge and below to the upper border of the
zygomatic arch. The details of its connections will be studied at
a later period.

REMOVAL OF THE BRAIN.

After the superficial attachments of the temporal fascia

have been noted the dissectors of the head and neck should
proceed to remove the brain.

Dissection. The head being supported upon a block, extend

the median incision, already made in the galea aponeurotica, to
the nasion anteriorly and to the external occipital protuberance
posteriorly, and cut through the loose areolar tissue and the
pericranium in the same line down to the bone. With the
handle of the scalpel, or with a chisel, detach the pericranium
from the bone on each side and turn it downwards to the temporal
lines, leaving the bone perfectly bare. Note that although the
pericranium is not firmly attached over the surface of the various
bones of the vault, it is firmly attached along the lines of the
cranial sutures by processes that dip in between the bones and
separate their edges. Detach the galea aponeurotica and the
temporal fascia from the temporal ridge, on each side, with the
edge of the knife ; then, carrying the edge of the knife forwards
and backwards between the temporal muscle and the bone, detach
the upper part of the muscle from the skull. When that has
been done, each half of the scalp can be turned down over the ear.

The dissectors should next obtain a saw, a chisel, and a mallet,

and proceed to remove the skull cap or calvaria. The line along
which the saw is to be used may be marked out on the skull by
encircling it with a piece of string, and then marking the cranium
with a pencil along the line of the string. Anteriorly, the cut
should be made fully three-quarters of an inch above the margins
of the orbits ; posteriorly, it should be carried round at the level of
a point midway between the lambda l and the external occipital

1 The term " lambda " signifies the apex of the occipital bone, or the point
at which the sagittal and lambdoidal surures meet.

REMOVAL OF THE BRAIN

99

protuberance. The saw should be used to divide the outer table

of the skull only. When the diploe is reached, the sawdust will
become red and moist, and the saw should then be abandoned.
The hammer and chisel are now brought into requisition, and by
short sharp strokes with these the inner table can readily be
split along the line in which the outer table of the cranium is
divided. When that has been done, insinuate the hook at the
end of the cross-bar of the chisel into the fissure in front, and
wrench off the skull-cap.

Dura Mater Encephali. The brain is clothed by three

distinct membranes, which are termed the mentnges. From
without inwards they are (r) the dura mater; (2) the
arachnoid ; and (3) the pia mater.

Vein Sub-arachnoid space and trabeculae

" ~ Dura mater

~~ -Subdural space
C "Arachnoid
Pia mater
Artery* ''

FIG. 29. Diagrammatic section through the Meninges of

the Brain. (Schwalbe. )

co. Grey matter of cerebral gyri.

When the skull-cap is detached, the outer surface of the

dura mater, as it covers the upper surface of the cerebral
hemispheres, is exposed. It is rough, and dotted over with
bleeding points. If a portion is placed in water, its roughness
becomes still more manifest, and is seen to be due to a multi-
tude of fine fibrous and vascular processes by which it was
connected with the deep surface of the bones. The processes
were necessarily torn asunder t in 5 the removal of the skull-
cap. The bleeding points are mosi numerous aloiig th^
median line, or, in other worcls, along the line of die superior
sagittal sinus (O.T. longitudinal) :. and j.f ;he liar. die, cf, the
knife is run from before JbacXwartis, so as to mafce. pressure?
along that line, a considerable^!! J|i0 6fj f bipod will ooze out,

iu-ia . t :;\ T;LUlu/l/

-AlJ\J

showing that a number of small veins from the cranial bones

have been ruptured. The degree of adhesion between the
dura mater and the inner surface of the cranial bones varies
in different subjects and in different localities. In all cases
it is strongly adherent along the lines of the sutures, like
the pericranium externally; and, further, it is much more firmly
attached to the base than to the vault of the cranium. In the
child indeed, as long as the bones of the cranium are grow-
ing it is more adherent than in the adult ; and it is more
firmly bound to the bone again in old age.

The dissectors should now clean the- outer surface of the

dura mater with a sponge. They will then recognise the middle

Arachnoideal granulation Opening of cerebral vein

f^-

FIG. 30. Median section through the Frontal Bone and corresponding part of
the Superior Sagittal Blood Sinus. The arachnoideal granulations are
seen protruding into the sinus. (Enlarged. )

meningeal artery upon each side, ascending in the substance

of the outer part of the membrane, and sending off its
branches in a widely arborescent manner. It stands out in
bold relief from the membrane. If the skull-cap is examined,
its inner surface will be observed to be deeply grooved by
the artery and its branches, and by the veins which accom-
pany and lie external to them (Wood Jones). The meningeal
arteries are not intended for the supply of the membrane
alone, as the name might lead one to imagine. They are
also- the .nutrient .vessels of -th^Jrtner table and diploe of the
c rarvia 1 bone-s (Fig, ^ 3 2 )." ^

Grranulatipnes Arachnoideales (O.T. Pacchionian Bodies).

Tbe afaohhoideal . granulations are almost invariably present,
and; as a -rule, arc- best markred in old subjects. They are
small granular bodies, ranged in clusters on each side of

REMOVAL OF THE BRAIN

101

the superior sagittal sinus, into which many of them protrude

(Fig. 31). As a general rule, they are most evident towards
the posterior part of the parietal region. At first sight they
appear to be protrusions from the dura mater, but that is not
the case. They spring from the arachnoid and the subarach-
noid tissue, and are normal erlargements of processes of
the arachnoid (Figs. 30, 31).

Two Layers of the Dura Mater. Having noted the

preliminary details from an examination of the outer surface
of the dura mater, the student is in a position to understand

Lateral lacuna

Arachnoideal
granulation

Superior sagittal sir

Blood vessels

Grey cortex

of a gyrus

Arachnoideal granulation
Lateral lacuna

Dura mater

Pia mater
Subarachnoid space

Arachnoid

Falx cerebri

FIG. 31. Diagram of a frontal section through the middle portion of the
cranial vault and subjacent brain to show the membranes of the brain
and the arachnoideal granulations.

that the membrane does not belong entirely to the brain.

It performs a double function : (i) it acts as an internal
periosteum to the bones forming the cranial cavity; and (2)
it gives support to the different parts of the brain. Conse-
quently, it consists of two strata, which, in most localities, are
firmly adherent, but they can usually be easily demonstrated in
the dissecting-room. The two strata may very appropriately
be termed the endocranial and the supporting layers. Along
certain lines the two layers separate from each other. In
some places they separate to form blood channels, termed sinuses
of the dura mater, for the passage of venous blood ; in other
places they separate not only to form blood channels but also
in 76

102

HEAD AND NECK

that the inner supporting layer may form strong partitions,

which pass in between certain parts of the brain ; and by
those partitions the cranial cavity is divided into compart-
ments communicating freely with one another, and each hold-
ing a definite subdivision of the brain (Figs. 33, 34).

Frontal air sinus

!ut edge of superior
sagittal sin

Cerebral vein

Arachnoid
>vermg cerebral
vein

Cerebral ve

Dura mater

Anterior branch of
mid. meningeal arte
and accompanying
in

rachnoideal
granulation

Posterior bran
f mid. mening
rtery, with ve:

ningof asuperi
cerebral vein

FIG. 32. Superior Sagittal Sinus; Dura Mater; Middle Meningeal Artery
and Vein ; Arachnoidea and Superior Cerebral Veins.

Dissection. -The points mentioned must now be verified.

Begin by tilting the head forwards. Support it in that position,
and make two incisions through the dura mater in an antero-
posterior direction one on each side of the superior sagittal
sinus, and along its whole length. From the mid-point of each
of the two incisions another cut must be made through the
corresponding lateral portion of the dura mater downwards to
the cut margin of the skull immediately above the ear (Fig. 32).
The dura mater covering the upper aspect of the brain will then
be divided into a central strip containing the superior sagittal

REMOVAL OF THE BRAIN 103

sinus, and four triangular flaps. The flaps must be turned down-
wards over the cut margin of the skull, as on the left side in Fig.
32. In that position they cover the sharp edge of the bone
and prevent laceration of the brain during its removal.

Cavum Subdurale. The term subdural space is applied

to the interval between the dura mater and the arachnoid
Figs. 29 and 31. It contains a very small quantity of serous
fluid, which moistens the opposed surfaces of the membranes.
A striking contrast between the two surfaces of the dura
mater will be noted. The external surface is rough and
flocculent ; the internal surface is smooth and glistening.

Venae Cerebri. After the dura mater is reflected, the

cerebral veins which return the blood from the surface of
the cerebral hemispheres can be seen shining through the
arachnoid. They are lodged, for the most part, in the sulci
between the gyri of the brain, and those at present visible
run upwards to the median plane. When they reach the
superior sagittal sinus they turn forwards, and lie against the
wall of the sinus, for some distance, before they open into it.

Dissection. Open into the superior sagittal sinus by running

a knife through its upper wall, from behind forwards, Figs. 31
and 32.

Sinus Sagittalis Superior (O.T. Superior Longitudinal).

The superior sagittal sinus begins, anteriorly, at the crista

galli of the ethmoid bone, where it not infrequently com-
municates with the veins in the nasal cavity through the
foramen caecum. It extends backwards, grooving the cranial
vault in the median plane, to the internal" occipital protuber-
ance, on the right aspect of which it becomes continuous
with the right transverse sinus (O.T. lateral). Its lumen,
which is triangular in cross-section, is very small anteriorly,
but expands greatly posteriorly. On each side of the sinus,
and opening into it, are a number of clefts between the two
layers of the dura mater ; they are the lateral lacuna. The
inferior angle of the sinus is crossed by a number of minute
bands, named chordcz Willisii\ and arachnoideal granulations
bulge into it. The mouths of the superior cerebral veins
open into the sinus, or into the lateral lacunae, pouring their
blood into the sinus in a direction contrary to that in which
the blood flows within the channel that is, the terminal
portions of the veins are directed forwards, whilst the blood
in the sinus flows backwards,
in 7 c

104
HEAD AND NECK

The Relation of the Arachnoideal Granulations to the Superior

Sagittal Sinus and the Lateral Lacunae. When the granulations project
themselves into the sinus or into the lateral lacunae, they push before them
a thin, continuous covering of the floor of the space, and when they project
still further and encroach upon the bones of the skull they are covered also
by a thin expansion of the roof of the space.

Dissection. In order to expose the falx cercbri divide the

superior cerebral veins, on each side, and displace the upper
parts of the hemispheres of the brain laterally.

Falx cerebri

Inferior sagittal sinus

Superior sagittal

Cavernous si

Vena cerebri magna

.Tentorium

.Transverse sinus

Falx cerebelli
Transverse sinus
Inferior petrosal sinus Superior petrosal sinus

FIG. 33. Sagittal section through the Skull, a little to the left of the
median plane, to show the processes of Dura Mater.

V. Trigeminal nerve.
VII. Facial nerve.
VIII. Acoustic nerve.

IX. Glossopharyngeal nerve.

X. Vagus nerve.
XI. Accessory nerve.
XII. Hypoglossal nerve.

Falx Cerebri (Figs. 33, 34). The falx cerebri is a sickle-

shaped reduplication of the inner layer of the dura mater
which descends, in the median plane, between the two
cerebral hemispheres. Anteriorly, it is small, and it is
attached to the crista galli of the ethmoid bone. As it
passes backwards it increases in vertical extent, and the
lower border of its posterior portion is attached, in the
median plane, to the upper surface of the tentorium cerebelli.
The anterior part of the falx is frequently cribriform, and
is sometimes perforated by apertures to such an extent that

REMOVAL OF THE BRAIN

I0 5

it almost resembles lace-work. Between its anterior attach-

ment to the crista galli of the ethmoid and its posterior
attachment to the tentorium cerebelli its lower margin is free
and concave, and it overhangs the corpus callosum, which
connects the two hemispheres together, but it is not in contact
with the corpus callosum except to a very slight extent
posteriorly. Along each border its two layers separate to
enclose a blood sinus. Along its upper convex margin runs
the superior sagittal sinus ; along its concave free . border

Superior sagittal sinus

Cerebellar fossa

ssjg^c:

Foramen magnum\ Transverse sinus

'erebellar fossa

FIG. 34. Frontal section through the Cranial Cavity in a plane which passes
through the posterior part of the foramen magnum. The posterior
part of the cranial cavity, from which the brain has been removed, is
depicted.

courses the much smaller inferior sagittal sinus ; whilst along

its attachment to the tentorium lies the straight sinus.
Dissection. Removal of the Brain. 1 The dissectors should
now proceed to remove the brain. Divide the attachment of the
falx cerebri to the crista galli and pull the falx backwards. Next,
remove the block upon which the head rests, support the occiput
and posterior lobes of the brain with the left hand, and let the
head drop well downwards. In all probability, the frontal lobes of
the brain will fall away, by their own weight, from the anterior
fossa of the base of the cranium, and perhaps carry with them the
olfactory bulbs. Should they remain in position, however,
gently raise them with the fingers, and at the same time separate
the olfactory bulbs from the cribriform plate of the ethmoid with

1 For alternative method see p. 115.

106 HEAD AND NECK

the handle of the knife. As the olfactory bulbs are raised the
minute olfactory nerves, which perforate the cribriform plate of
the ethmoid bone and pass to the bulbs, will be torn across. The
large, round and white optic nerves (second pair of cerebral nerves)
then come into view, as they pass towards the optic foramina.
Divide the optic nerves and the internal carotid arteries will be
exposed. More posteriorly, in the median plane, the infundi-
bulum will be seen ; it is a hollow conical process which extends
from the tuber cinereum, at the base of the brain, to the hypo-
physis (O.T. pituitary body), which lies in the fossa hypophyseos
(O.T. pituitary fossa). Divide the carotid arteries and the
infundibulum. Posterior to the infundibulum is the upper
border of the dorsum sellae, terminating on each side in the
rounded posterior clinoid process. Passing forwards, on each
side of the dorsum sellae, is the corresponding oculomotor nerve,
which must not be touched at present. A little more laterally,
and on a slightly lower plane, is the free border of the tentorium
cerebelli. The tentorium cerebelli is a fold of the inner layer of the
dura mater which lies above the cerebellum and forms the roof
of the posterior fossa of the cranium (Figs. 34, 35).

Carefully displace the temporal pole of the brain from under

cover of the posterior border of the small wing of the sphenoid,
which lies to the lateral side of the optic nerve and the cut end
of the internal carotid artery ; then raise the temporal lobe
from the floor of the middle fossa, and from the upper surface
of the tentorium cerebelli, and note a thick stalk the midbrain
ascending from the posterior fossa. Push the knife back-
wards, along the side of the midbrain, immediately above the
level of the oculomotor nerve, and cut through the midbrain,
from its lateral surface inwards to the median plane, slanting the
knife so that it is in the same plane as the surface of the tentorium
cerebelli. Repeat the operation in the same way on the opposite
side ; then turn the hemispheres backwards, divide the great
cerebral vein, immediately behind the cut midbrain, and remove
the cerebrum and upper part of the midbrain from the cranium.

Place the removed cerebrum in the vault of the cranium and

lay it aside. Then note the relative positions of the parts exposed.
Anteriorly lies the floor of the anterior fossa of the cranium ;
behind it, on a more depressed plane, the middle fossa, and still
more posteriorly the sloping tentorium cerebelli.

In the median plane anteriorly is the projecting crista galli,

partially dividing the anterior fossa into halves. On each side
of the crista galli is the depression from which the olfactory
bulb was dislodged, and still more laterally are the portions of
the floor of the anterior fossa which form the roofs of the orbits ;
they bulge upwards as well-marked convexities. Each lateral
part of the floor of the anterior fossa terminates posteriorly in
a sharp margin formed by the posterior border of the small wing
of the sphenoid. That margin overhangs the anterior part of the
middle fossa. It is covered with a thickening of dura mater
in which runs the spheno -parietal blood sinus, and it terminates
medially in a projecting process, the anterior clinoid process.
On the medial side of each anterior clinoid process lie the corre-
sponding optic nerve and internal carotid artery, and springing
from the upper surface of the artery is its ophthalmic branch,
which runs forward under cover of the" optic nerve. Posterior

REMOVAL OF THE BRAIN

107

to the divided ends of the internal carotid arteries, and in the

median plane, is the infundibulum descending into the hypo-
physeal fossa, and more posteriorly, one on each side, are the
projecting posterior clinoid processes. The area between the
four clinoid processes is partially covered by a fold of the inner
layer of the dura mater, termed the diaphragma sellce. It binds

Superior sagittal sinus

Falx cerebri

Optic nerve

Ophthalmic artery

Maxillary nerve
icmilunar ganglio

tliddle meningeal
artery

osterior cerebral
artery

reat superficial
petrosal nerve

Pedunculus
cerebri

Substantia
nigra

Lamin
quadrigemina

Cerebellum .

Straight si

Internal carotid art<

Infundibulum

Cavernous sinu
.Oculo-motor ne

--Basilar artery

ochlear nerve
Basal vein

Transverse sinus
Great cerebral vein
FIG. 35. Interior of the Cranium after the removal of the cerebrum. The
transverse, straight, and superior petrosal sinuses have been opened, and
the dura mater has been removed from the floor of the left middle fossa.

down the hypophysis and in its centre is an aperture through

which the infundibulum passes to join the hypophysis (O.T.
pituitary body), which lies in the hypophyseal fossa in the base
of the skull. In the anterior and posterior margins of the
diaphragma sellae are lodged respectively the sinus inter-
cavernosus anterior and the sinus intercavernosus posterior,
which should not be opened at present.

io8 HEAD AND NECK

In the dura mater, on each side of the hypophyseal (pituitary)

fossa, lies the corresponding cavernous sinus, which will be
dissected later, and still more laterally are the depressed lateral
portions of the middle cranial fossa, lined with dura mater, in
which the trunk and some of the branches of the middle
meningeal artery are visible. Posterior to the middle fossa lies
the tentorium cerebelli covering the cerebellum. The peripheral
margin of the tentorium is attached, on each side, to the posterior
clinoid process, the upper margin of the petrous part of the
temporal bone, the mastoid angle of the parietal bone, and to the
transverse ridge on the inner surface of the occipital bone. The
central or free margin crosses the attached margin, behind the
posterior clinoid process, on each side, and is attached anteriorly
to the apex of the anterior clinoid process. It bounds an oval
opening, the door of the tent, through which pass the midbrain,
surrounded by the arachnoid and the pia mater, and the posterior
cerebral arteries. Traversing the midbrain, nearer its posterior
than its anterior border, is a canal called the aquaeductus cerebri
(O.T. aqueduct of Sylvius). Posterior to the aqueduct is the
lamina quadrigemina or tectum of the midbrain, and anterior
to it are the right and left pedunculi (O.T. crura) cerebri. Each
peduncle consists of an anterior part, the basis pedunculi (O.T.
crusla), and a posterior part, the tegmentum, the two being
separated by a lamina of dark coloured tissue, the substantia
nigra. The bases pedunculi are entirely free from each other,
but the tegmental portions are united together, anterior to the
aqueduct.

Running forwards and laterally from the medial side of each

peduncle to the angle between the anterior ends of the free and
the attached borders of the tentorium, is the oculomotor nerve.
Close to the midbrain the nerve passes between the posterior
cerebral artery above and the superior cerebellar artery below ;
and, between the free and attached borders of the tentorium, it
pierces the dura mater, in the middle fossa, and enters the wall
of the cavernous sinus. Between the posterior ends of the
oculomotor nerves lies the upper end of the basilar artery, divid-
ing into the two posterior cerebral branches ; and the dissectors
should note that the arteries lie in an enlargement of the sub-
arachnoid space which is known as the cislerna interpeduncularis.
In the median plane, posterior to the midbrain, is the divided vena
cerebri magna (O.T. great vein of Galen}. It passes backwards
and upwards, and pierces the apex of the tentorium to enter
the straight sinus, which lies in the angle of union between the
falx cerebri and the tentorium cerebelli.

Curving backwards around the midbrain and ending

posteriorly in the great cerebral vein, on each side, is the vena
basalis, and immediately above it, running forwards, is the
slender trochlear nerve. If the free border of the tentorium is
turned laterally, at the point where it is crossing the attached
border, the trochlear nerve will be seen perforating the inner
layer of the dura mater to enter the wall of the cavernous sinus.

When the dissectors have verified the facts noted above,

they should examine the lower, free border of the falx cerebri,
in which they will find the small inferior sagittal sinus, which
terminates posteriorly, at the apex of the tentorium, in the straight
sinus. The straight sinus must now be opened by carrying the

REMOVAL OF THE BRAIN 109

knife backwards through the falx cerebri along its line of union
with the tentorium. Then the falx cerebri must be cut away
from the occipital bone, and as that is done the posterior
part of the superior sagittal sinus will be opened up. After
the falx has been removed the right and left transverse and the
right and left superior petrosal sinuses must be opened by incisions
carried along the attached border of the tentorium (Fig. 36).
The dissectors will probably find that the superior sagittal sinus
turns to the right and becomes continuous with the right trans-
verse sinus, whilst the posterior end of the straight sinus turns
to the left and joins the left transverse sinus. In a certain
number of cases that arrangement is reversed, and not uncom-
monly, as in the specimen shown in Fig. 36, there is a communi-
cation between the right and left transverse sinuses across the front
of the internal occipital protuberance. Occasionally the superior
sagittal, the two transverse sinuses, the straight sinus, and the
occipital sinus unite, anterior to the internal occipital protuber-
ance, in a common dilatation, the confluens sinuum (O.T.
torcular Herophili). The transverse sinus, on each side, runs
from the internal occipital protuberance to the lateral end of
the superior border of the petrous part of the temporal bone,
where it dips downwards into the posterior fossa, and at the
same point it is joined by the superior petrosal sinus, which
runs postero -laterally, along the superior border of the petrous
part of the temporal bone, from the cavernous sinus to the
transverse sinus, connecting the two together.

With the point of the scalpel open the spheno-parietal sinus,

which runs along the posterior border of the small wing of the
sphenoid, and trace it medially to the cavernous sinus. Care-
fully dissect the lateral wall of the cavernous sinus and find in
it : the oculomotor nerve, dividing into two branches ; the
slender trochlear nerve, crossing the lateral side of the oculomotor ;
the ophthalmic division of the fifth and its three terminal branches
naso-ciliary, lacrimal, and frontal. Remove the remains of
the lateral wall and expose the internal carotid artery and the
abducens nerve (p. 234). Then remove the dura mater from
the lateral part of the middle fossa on one side to expose the
semilunar (O.T. Gasserian) ganglion of the trigeminal nerve ;
the middle meningeal artery and its two terminal branches ; the
accessory meningeal artery, if it is present; and the greater
superficial petrosal nerve. Commence immediately to the
lateral side of the anterior part of the free border of the ten-
torium, where a cut through the inner layer of the dura will
open into a space between the two layers of the dura in which
lies the semilunar ganglion. From the postero-medial border
of the ganglion the sensory root passes backwards into the
posterior fossa to enter the pons ; and from its anterior-lateral
border the ophthalmic branch passes upwards and forwards in
the lateral wall of the cavernous sinus, the maxillary branch
runs forwards to the foramen rotundum, and the mandibular
branch passes downwards into the foramen ovale. By the
side of the mandibular nerve the accessory meningeal artery
may be found entering the cranium ; and a little further
posteriorly the middle- meningeal artery will be seen passing
into the middle fossa through the foramen spinosum. After
entering the cranium the middle meningeal artery runs forwards

no HEAD AND NECK

and laterally, across the floor of the middle fossa, towards the
lateral wall, and divides into an anterior and a posterior branch ;
the former ascends on the anterior part of the lateral wall to the
anterior inferior angle of the parietal bone, and the latter runs
backwards and laterally, and then ascends on the inner surface
of the squamous part of the temporal bone. The greater super-
ficial petrosal nerve appears on the anterior surface of the
petrous part of the temporal bone, through the hiatus nervi
facialis, which lies to the medial side of an eminence called the
eminenlia arcuata. It runs forwards and medially and disappears
beneath the semilunar ganglion (Fig. 36).

When the structures mentioned above have been found and

cleaned, the dissectors must remove the tentorium cerebelli.
Cut through the free border immediately posterior to the point
where it crosses the attached border ; the trochlear nerve will
be divided by the incision. Repeat the incision on the opposite
side, and then cut through the membrane close to its attached
border, but to the medial sides of the superior petrosal and
transverse sinuses ; next divide the venae basales at their points
of junction with the vena cerebri magna ; then raise the anterior
part of the tentorium and. passing the knife beneath it, separate
it from the falx cerebelli, which is attached to its lower surface
in the median plane. The tentorium may now be lifted out,
and the arachnoid covering the upper surface of the cerebellum
will be exposed.

After the upper surface of the cerebellum has been cleaned,

cut through the oculomotor nerves, and then press backwards
the pedunculi cerebri and the pons (Varolii), which lie immedi-
ately below them, to expose the trigeminal and the abducens
nerves. Cut the trigeminal nerves as they cross the upper
borders of the petrous parts of the temporal bones, and then
divide the small abducens nerves, which lie more medially and
at a slightly deeper level. Press the pons and cerebellum still
further back and divide the facial and acoustic nerves as they
enter the internal acoustic meatus. Below the acoustic nerves
lie the glossopharyngeal, vagus, and accessory nerves. They
also must be cut ; and the roots of the hypoglossal nerves, which
lie deeper and more medially, must be identified and divided.
The pons can then be displaced still further backwards and the
front of the medulla oblongata will be brought into view. Pass
the knife downwards, anterior to the medulla oblongata, into
the vertebral canal, and, cutting firmly backwards and laterally,
on each side, divide the medulla spinalis and the vertebral
arteries. Withdraw the knife, pass two fingers downwards,
anterior to the medulla oblongata, and lift it and the pons and
the cerebellum out of the posterior fossa. Place the lower parts
of the brain, which collectively constitute th hind brain, with
the hemispheres previously removed, and then examine the cut
ends of the cerebral nerves and the blood sinuses which lie in
the region of the posterior fossa (Fig. 36).

In the upper end of the vertebral canal lies the upper extremity
of the severed medulla spinalis, attached, on each side, to the
margin of the foramen magnum by the uppermost dentation
of the ligamentum denticulatum. Anterior to the ligamentum
denticulatum, on each side, is the vertebral artery, and still
more anteriorly, on a slightly deeper plane, the fila of the anterior

REMOVAL OF THE BRAIN

in

root of the first cervical nerve may be distinguished. At a

higher level, on each side, the two rootlets of the hypoglossal
nerve pierce the dura, as they pass into the hypoglossal canal
(O.T. anterior condyloid foramen). The spinal root of the

Anterior and posterior intercavernous sinuses

Ophthalmic artery !

Internal carotid t 1

Tent, cerebelli, ant. end of

attached border

Tent, cerebelli, ant. end J '

of free borde

Spheno-parietal sinu
Inferior petrosal sinus

Superior
petrosal sinus

Middle

meningeal

artery

Infundibulum
: Diaphragma sellae
, Optic nerve

ilo-motor nerve
Abducent nerve

Trochlear nerve

Trigeminal nerve
Facial nerve

^Acoustic nerve

Sigmoid part
transverse sinus

Basilar plexus

agus nerve

Vertebral artery

Ligamentum denticulatun

Occipital sinus

Transverse sinus

FIG. 36. Dissection of the Interior of the Cranium after the removal of the
brain and the tentorium cerebelli.

Accessory nerve
ypoglossal nerve
> First cervical nerve

Spinal medulla

accessory nerve passes through the foramen magnum into the

cranium posterior to the ligamentum denticulatum, and,
turning laterally over the margin of the foramen magnum it
joins the cerebral fibres of the accessory and the vagus nerves,
with which it passes through an aperture in the dura opposite
the jugular foramen. Immediately above the accessory and

112

HEAD AND NECK

vagus nerves the smaller trunk of the glossopharyngeal nerve

pierces the dura. Above the glossopharyngeal nerve the acoustic
nerve and the motor and sensory roots of the facial nerve pass
into the internal acoustic meatus, accompanied by the small
auditory branch of the basilar artery and the auditory vein.
The two roots of the facial nerve lie in a groove on the upper
and anterior aspect of the acoustic nerve, the small sensory root
(O.T. pars intermedia) being situated between the motor root
and the acoustic nerve. The small motor and the large sensory
root of the trigeminal nerve pass through an opening in the
dura which lies above and medial to the internal acoustic meatus ;

Trochlear nerve

Oculo-motor nerve /- Sensory root of the trigeminal nerve

Motor root of the trigeminal

Abducens nerve

Motor root of facial

nerve

Cut edge of the

:entorium

Sensory root of
facial nerve
Acoustic nerve
Right transverse
sinus

Glosso-pharyngeal
nerve
Vagus nerve

Accessory nerve

Vertebral artery
Hypoglossal nerve
First spinal nerve
Accessory nerve

FIG. 37. Section through the Head a little to the right of the median
plane. It shows the posterior cranial fossa and the upper part of the
vertebral canal after the removal of the brain and the medulla spinalis.

and the abducens nerve pierces the dura mater below and to the
medial side of the opening for the trigeminal nerve, opposite
the side of the base of the dorsum sellae. The small trochlear
nerve pierces the inferior surface of the free border of the ten-
torium at the point where it is crossing the attached border.

After the dissectors have familiarised themselves with the

positions of the cerebral nerves as they pierce the dura mater,
they should examine the falx cerebelli and complete the
display of the cranial blood sinuses.

Falx Cerebelli. The falx cerebelli is a small sagittal fold

REMOVAL OF THE BRAIN 113

of the inner layer of the dura mater which projects forwards,

between the lateral lobes of the cerebellum, from the internal
occipital crest (Figs. 33, 34).

Sinus Transversus (O.T. Lateral). The horizontal part of

the transverse sinus has already been traced from the internal
occipital protuberance to the superior border of the petrous
part of the temporal bone, where it turns downwards to
the jugular foramen. At first the descending portion runs
downwards, on the inner surface of the mastoid part of the
temporal bone, and then forwards and again downwards
across the upper and anterior surfaces of the jugular process
of the occipital bone. On account of the sinuosity of its
course this part is called the sigmoid portion of the transverse
sinus (Fig. 36).

Dissection. Open the sigmoid part of the sinus and find

the mouth of the mastoid emissary vein in its posterior border,
about half-way down.

The dissectors should now obtain the basal part of a

macerated skull and should note the relation of the transverse
sinus to the outer surface. They will find that the position
of the sinus can be indicated on the external surface, by a line
which commences at the external occipital protuberance, passes
forwards, with a slight upward convexity, along the superior
nuchal line to the upper part of the mastoid part of the
temporal bone and then descends to the level of the lower
margin of the external meatus (Figs. 38, 204).

Sinus Occipitalis. The occipital sinus is not uncommonly

absent. When it is present it commences in the right or left
transverse sinus or the confluens sinuum, and descends for a
short distance in the posterior border of the falx cerebelli.
It terminates below in two branches, which leave the falx
cerebelli and run along the borders of the foramen magnum,
between the layers of the dura mater, to terminate anteriorly
in the lower ends of the transverse sinuses.

Sinus Petrosus Inferior. The inferior petrosal sinus lies

along the posterior border of the petrous part of the temporal
bone, extending from a point lateral to the opening for the
abducens nerve to the medial side of the opening in the dura
for the glossopharyngeal nerve of the same side. Lay the
sinus open. It opens anteriorly into the cavernous sinus,
from which it receives blood, and posteriorly it passes through

VOL. Ill 8

u 4 HEAD AND NECK

the jugular foramen to join the upper end of the internal

jugular vein.

Plexus Basilaris. The two inferior petrosal sinuses are

connected together, across the upper surface of the basilar
part of the occipital bone, by a plexus of small venous channels,
to which the term basilar plexus is applied. Unless the
channels happen to be distended with blood the dissectors will
probably be unable to display the plexus (Fig. 36).

The dissectors should note that the dura mater is much

more firmly attached to the bones of the base than it was to
the bones of the vertex, a fact which should have attracted
their attention as they removed the membrane from the floor
of the middle fossa. They should note also that it gives
sheaths to the nerves which pierce it, and that at the margins
of the various foramina its outer layer becomes continuous
with the periosteum on the outer surface of the cranium,
whilst at the margin of the foramen magnum the inner layer
becomes continuous with the single layer of dura mater which
surrounds the medulla spinalis ; and that, at the same level, the
arachnoid and pia mater of the brain become continuous with
the arachnoid and pia mater of the spinal medulla (O.T. spinal
cord). Before terminating the survey of the interior of the
cranium, the dissectors should revise their knowledge of the
blood vessels, and their relations to the dura mater ; and they
should remove the hypophysis (O.T. pituitary body) and in-
vestigate its naked-eye structure.
Sinus Durse Matris. Four blood sinuses lie in the median
plane-, (i) the superior sagittal sinus, in the upper or attached
border of the falx cerebri ; (2) the inferior sagittal sinus, in the
free part of the lower border of the falx cerebri ; (3) the
straight sinus, along the line of attachment of the falx cerebri
with the tentorium cerebelli ; (4) the occipital sinus, in the
upper part of the attached border of the falx cerebelli.

Two sinuses lie in a higher horizontal plane : they are the

spheno-parietal sinuses, which run along the posterior borders
of the small wings of the sphenoid bone.

Six sinuses lie in a lower horizontal plane: (i) the two

cavernous sinuses, at the sides of the body of the sphenoid ;
(2) the two superior petrosal sinuses, along the upper borders
of the petrous parts of the temporal bones, in the anterior
parts of the attached border of the tentorium cerebelli ; (3)
the horizontal parts of the transverse sinuses, in the posterior

REMOVAL OF THE BRAIN 115

parts of the attached border of the tentorium. The terminal

parts of the transverse sinuses descend along the anterior parts
of the lateral walls of the posterior fossa.

Tivo sinuses run obliquely downwards, backwards, and later-

ally : they are the two inferior petrosal sinuses.

Three sinuses run transversely, connecting paired sinuses of

opposite sides: (i) the anterior intercavernous sinus, in the
anterior border of the diaphragma sellae; (2) the posterior
intercavernous sinus, in the posterior border of the diaphragma
sellae ; and (3) the basilar plexus, which connects together the
inferior petrosal sinuses, across the upper surface of the basilar
part of the occipital bone.

Alternative Method of removing the Brain. If it is thought

desirable to remove the brain entire, by the more rapid but less
instructive method usually adopted in the post-mortem room,
then the following steps should be taken after the falx cerebri
has been detached from the crista galli and the dura mater lining
the vault of the cranium has been thrown aside (see p. 105).

Remove the block upon which the head has been resting,
supporting the occiput and the posterior part of the brain with
the left hand, and let the head drop well downwards, and, in all
probability, the weight of the frontal lobes will draw them away
from the floor of the anterior fossa of the skull, and possibly
the olfactory bulbs may be carried with them. If the olfactory
bulbs remain in position on the cribriform plates of the ethmoid
at the sides of the crista galli, gently raise them with the handle
of the scalpel and press them backwards on to the lower surfaces
of the frontal lobes. As the olfactory bulbs are raised the
oljactory nerve filaments, which enter their lower surfaces after
passing through the cribriform plates, are torn. As the frontal
lobes are pressed backwards, the large, round and white optic
nerves come into view, as they are approaching the optic fora-
mina. When they are divided the internal carotid arteries will
be exposed. More posteriorly, in the median plane, lies the
infundibulum, a hollow conical process which connects the
hypophysis cerebri (O.-T. pituitary body] with the tuber cinereum
at the base of the brain ; and more laterally are the oculo-
motor nerves. Sever each of the structures mentioned in turn.
On the lateral side of each oculo-motor nerve lies the medial or
free border of the tentorium cerebelli, passing forwards to be
attached to the anterior clinoid process. Turn that margin
aside with the point of the knife, and the small trochlear nerve
(fourth cerebral nerve) will be brought into view. It lies under
shelter of the free border of the tentorium, and should be divided
at this stage. The head must in the next place be turned forcibly
round, so that the face is directed over the left shoulder. Raise
the posterior part of the right cerebral hemisphere with the
fingers, and note that it rests upon the tentorium cerebelli a
broad sloping process of dura mater which intervenes between
it and the cerebellum. Divide the tentorium along its attached
border, and take care whilst doing that not to injure the sub-
in 8 a

n6 HEAD AND NECK

jacent cerebellum. Next turn the head so as to bring its left

side uppermost, and treat the tentorium on that side in the same
manner. Now let the brain fall well backwards ; then the pons
and medulla will be drawn away from the anterior wall of the
posterior fossa of the skull, and the nerves in the posterior fossa
will come into view. They are the two parts of the trigeminal
nerve (fifth cerebral nerve), perforating the dura mater near
the apex of the petrous portion of the temporal bone ; the
abducent nerve (sixth cerebral nerve), piercing the dura mater
behind the dorsum sellae of the sphenoid bone ; the facial nerve
and the acoustic nerve, disappearing into the internal acoustic
meatus ; the glossopharyngeal, the vagus, and the accessory
nerves, leaving the skuli through the jugular foramen; and
the two slips of the hypoglossal nerve, piercing the dura mater
over the hypoglossal canal (O.T. anterior condyloid foramen).
Each in turn will be displayed upon each side. They must be
divided in the order mentioned, except that, in the case of the
nerves passing out of the cranium through the jugular foramina,
the dissector should endeavour to leave the accessory of the
right side intact within the cranium, by dividing its roots of
origin from the medulla oblongata, whilst on the other side he
should remove it with the brain. The accessory nerve is readily
recognised because its spinal part ascends from the vertebral
canal into the cranial cavity through the foramen magnum.
Now, thrust the knife into the vertebral canal, and divide the
medulla spinalis and the vertebral arteries, as they turn forwards
upon the upper part of the medulla spinalis (O.T. spinal cord) ;
then sever the accessory nerve of the left side, and the roots of
the first pair of spinal nerves. When that has been done let
the head fall well downwards, gently dislodge the medulla
oblongata and cerebellum, and the whole brain can be removed.
The vena cerebri magna (Galen), as it passes from the interior
of the brain to enter the straight sinus, is ruptured as the brain
is removed. The dissector should now return to p. 112, and
should study the positions and relations of the cranial blood
sinuses.

Meningeal Veins. In addition to the named blood sinuses, venous

channels accompany the meningeal arteries, and more particularly the
trunks and branches of the middle meningeal artery. The meningeal veins
are of wider calibre than the corresponding arteries, and lie external to them,
in the grooves on the inner surfaces of the cranial bones. When the
arteries are distended they compress the middle parts of the veins and
drive the blood into their anterior and posterior margins. When that
occurs each artery appears to be accompanied by two veins, a circumstance
which is probably responsible for the statement that some of the meningeal
arteries have venae comites.

Emissaria. Emissary veins are blood channels which

connect the sinuses of the dura mater with the veins which
lie outside the cranium. They are: (i) Emissary veins con-
nected with the superior sagittal sinus (a) from the anterior
extremity of the sinus an emissary vein passes through
the foramen caecum ; this vein divides below, and either

PLATE II

FIG. 38. Radiograph of Half a Head in which the various fissures, etc.,
shown have been made visible by metal filaments, by cords impregnated
with metallic powders, or by means of metallic powder.

1. Coronal suture.

2. Interventricular foramen.

3. Ascending limb of lateral fissure.

4. Inferior frontal sulcus.

5. Anterior horizontal limb of lateral

fissure.

6. Second temporal sulcus.

7. Basilar artery.

S. Internal carotid artery at side.

hypophyseal fossa.
9. Line of superior border of external

acoustic meatus and lower margin

of orbit.
10. External acoustic meatus.

11. Pharyngeal orifice of auditory tube.

12. Body of occipital bone.

13. Anterior arch of atlas.

14. Position of tonsil.

15. Vertebral artery.

16. Fourth ventricle.

17. Transverse sinus.

1 8. Calcarine fissure.

19. Lambdoid suture.

20. Chorioid plexus.

21. Parieto-occipital fissure*

22. First temporal sulcus.

23. Posterior limb of lateral fissure.

24. Upper surface of corpus callosum.

25. Central sulcus.

26. First frontal sulcus.

27. Temporal ridge.

PLATE III

Floor of hypo-
physeal fossa

Anterior clinoid
process

Internal carotid
artery

Dorsuni sellae
Occipito-sphenou
synchondrosis

FIG. 39. Radiograph of Skull of a Child lateral view showing the

relation of the internal carotid artery to the base of the skull. The
portion of the artery shown was injected. (Dr. H. M. Traquair. )

REMOVAL OF THE BRAIN 117

becomes continuous with the veins of the nasal fossae, or its

branches pass through foramina in the nasal bones and join
the angular veins ; (b) two parietal emissary veins, which
pass through the parietal foramina and connect the superior
sagittal sinus with the occipital veins. (2) Emissary veins
connected with the transverse sinuses (a) two mastoid
emissary veins, one on each side, pass through the mastoid
foramina and connect the sigmoid parts of the transverse
sinuses with the posterior auricular veins ; (b) two posterior
condyloid veins, one on each side, pass through the condyloid
canals and connect the lower ends of the transverse sinuses
with the plexuses of veins in the sub-occipital triangles. One
or both of the posterior condyloid veins may be absent. (3)
Emissary veins connected with the cavernous sinuses (a) a
vein which traverses the foramen ovale, or the foramen Vesalii,
and connects the cavernous sinus with the plexus of veins
around the external pterygoid muscle ; (b) a plexus of veins
which passes through the temporal bone with the internal
carotid artery, and connects the cavernous sinus with the
pharyngeal venous plexus ; (c) in a sense, the ophthalmic
vein may be considered an emissary vein, for, although under
ordinary circumstances it is a tributary of the sinus, blood can
flow through it, in the opposite direction, from the sinus into
the orbit, and then along the tributaries which connect the
ophthalmic vein with the angular vein, and along the channels
which connect the ophthalmic vein, through the inferior
orbital fissure, with the veins in the infratemporal region.

The Arteries of the Cranial Cavity. (i) The vertebral

arteries; (2) the internal carotid arteries; (3) the meningeal
arteries.

Arterise Vertebrates. The vertebral arteries, right and

left, pierce the spinal dura mater below the foramen magnum,
through which they enter the cranium. As each artery passes
through the foramen it lies anterior to the highest dentation
of the ligamentum denticulatum, and it passes between the
hypoglossal and first cervical nerves. It was divided when
the hind brain was removed, and its cut extremity lies near
its point of entrance into the cranial cavity (Figs. 36, 37).

Arterise Carotides Internse. Each internal carotid artery

enters the cranium at the foramen lacerum, between the apex
of the petrous part of the temporal bone and the body of the
sphenoid, where it pierces the outer layer of the dura mater.

n8 HEAD AND NECK

Then it runs forwards, in the cavernous sinus, to the medial

side of the anterior clinoid process, where it turns upwards,
pierces the inner layer of the dura mater and the arachnoid,
and gives off its ophthalmic branch, which runs forwards
below the optic nerve into the orbit. The artery was cut
immediately behind its ophthalmic branch during the early
stages of the removal of the brain (Pigs. 36, 39).

Meningeal Arteries. The meningeal arteries are the

nutrient arteries of the dura mater, and of the inner table
and diploe of the cranial bones. They are derived from a
great number of different sources, but the only one of any
size is the middle meningeal branch of the internal maxillary
artery. The others are small twigs, and, except in a well-
injected subject, will not be easily made out. They are :
(i) anterior meningeal^ from the anterior ethmoidal artery; (2)
a meningeal branch of the lacrimal artery ; (3) the accessory
meningeal) from the internal maxillary artery; (4) some small
branches from the ascending pharyngeal, occipital, and ver-
tebral arteries.

Each middle meningeal artery is a branch of the corre-

sponding internal maxillary artery. It enters the cranium
through the foramen spinosum of the sphenoid bone, and
divides, upon the inner surface of the great wing of that bone,
into two large terminal branches. The anterior of the two
branches ascends upon the great wing of the sphenoid, and
upon the anterior inferior angle of the parietal bone, grooving
both deeply, whilst the posterior branch turns backwards and
upwards upon the squamous portion of the temporal bone.
The branches which proceed from the two main divisions
spread out widely and, with the accompanying venous
channels, occupy the arborescent grooves on the inner
surface of the cranial vault (Fig. 204).

The vein which accompanies the middle meningeal artery

passes through the foramen spinosum and ends in the plexus
around the external pterygoid muscle.

Each anterior meningeal artery proceeds from the anterior

ethmoidal artery as it accompanies the anterior ethmoidal
nerve across the cribriform plate of the ethmoid bone.
It supplies a limited area of dura mater and bone in the
anterior fossa of the cranium.

The meningeal branch of the lacrimal artery enters the

middle cranial fossa through the superior orbital fissure, and

REMOVAL OF THE BRAIN

119

it anastomoses with the rami of the anterior division of the

middle meningeal artery.

The accessory meningeal artery (O.T. small meningeal} is

somewhat inconstant ; it arises either directly from the
internal maxillary or from the middle meningeal, and
enters the cranium through the corresponding foramen ovale,
but it should not be looked for at the present stage, as it
is best examined along with the semilunar (O.T. Gasserian)
ganglion and the three divisions of the trigeminal nerve.

The meningeal branches from the ascending pharyngeal arteries

are the terminal twigs of those vessels. They enter the
cranium through the lacerate and jugular foramina, and

FIG. 40. i, Hypophysis ; 2, in median section ;

3, in horizontal section. (Schwalbe. )

a. Anterior lobe.

b. Posterior lobe.
cm. Corpus mamillare.

i. Tuber cinereum.

ch. Optic chiasma in section.

ro. Optic recess of the third ventricle.

o. Optic nerve.

a'. Infundibulum, with projection from

anterior lobe upwards anterior
to it.

through the hypoglossal canal (O.T. anterior condyloid

foramen). The branch which passes through the jugular
foramen is the largest.

The meningeal branches of the occipital and vertebral arteries

are small, and are distributed in the posterior cranial fossa.
The former enter through the jugular, mastoid, and parietal
foramina, the latter through the foramen magnum.

The meningeal veins may be regarded as being arranged in

two sets : one set consists of small channels which pour their
blood into the blood sinuses ; the other set is composed of
veins which accompany the meningeal arteries and carry
their blood to venous trunks on the exterior of the cranium.

Dissection. Cut away the overhanging margins of the dia-

phragma sellae and carefully dislodge the hypophysis from the
fossa hypophyseos (pituitary fossa) of the sphenoid bone ; then,

120 HEAD AND NECK

with a chisel chip away the floor of the hypophyseal fossa and
open up the sphenoidal air sinuses right and left which lie in
the body of the sphenoid bone below the fossa. They are gener-
ally of unequal size and may be replaced in some cases by a
single cavity. Attempt to pass a probe through the aperture in
the anterior wall of each sinus into the corresponding section of
the nasal cavity (Fig. no).

Hypophysis Cerebri (O.T. Pituitary Body) (Fig. 40).

The hypophysis is an oval structure, slightly flattened from
above downwards, and with its long axis placed transversely,
It consists of a large anterior lobe, and a smaller posterior
lobe. The anterior lobe is hollowed out posteriorly so as
to form a concavity for the lodgment of the posterior lobe.
If a sagittal section is made through the hypophysis, the
line of separation between the two lobes is seen very distinctly.
The infundibulum, which connects the hypophysis with the
tuber cinereum of the brain, is attached to the posterior lobe
only (Fig. 40, i). Thus, even in the adult, there is a clue to
the different modes of development of the two lobes. The
posterior lobe is derived from the brain, whilst the anterior
lobe is an off-shoot from the primitive buccal cavity.

When the inspection of the interior of the cranium is completed the

dissectors must fill the cranial cavity with tow steeped in preservative solu-
tion ; replace the skull-cap in position and retain it by bringing the scalp flaps
over it, and stitching them accurately together. The brain must be put in
a jar in a 5 per cent solution of formalin and placed aside till the dissection
of the remaining parts of the head and neck is finished.

THE ANTERIOR PART OF THE NECK.

After the skull-cap has been replaced and the scalp has
been stitched over it, let the head hang down over the end of
the table, pull the chin as far from the sternum as possible
and fix it in position with hooks. Then examine the region of
the front of the neck. It is a large triangular area, bounded
laterally by the anterior borders of the sterno-mastoid muscles,
above by the lower border of the mandible, and below by the
middle part of the upper border of the manubrium sterni ; and
it is divided by the median plane into two smaller subsidiary
triangles, the anterior triangles of the neck, each of which is
bounded above by the mandible, behind by the sterno-
mastoid, and in front by the middle line of the neck. Pass
the index finger from the chin to the sternum along the

THE ANTERIOR PART OF THE NECK 121

median line and locate in sequence the body of the hyoid

bone, the angular anterior border of the thyreoid cartilage,
the rounded arch of the cricoid cartilage and the rings of the
trachea. The latter are partly masked by the isthmus of the
thyreoid gland. Place the thumb and the forefinger on the
body of the hyoid bone and carry them backwards, one on
each side, along its greater cornua. Note that the posterior
ends of the cornua lie immediately in front of the anterior
borders of the sterno-mastoid muscles. Above the body of
the hyoid bone lies the submental triangle bounded superiorly
by the mylo-hyoid muscles, which form the diaphragm of the
mouth ; and above each greater cornu is the corresponding
sub maxillary region. Between the body of the hyoid bone
and the upper margin of the thyreoid cartilage is the thyreo-
hyoid space, bounded posteriorly by the middle part of the
thyreo-hyoid membrane, which lies anterior to the upper part
of the pharynx and the middle of the epiglottis (Fig. no).
Trace the upper border of the thyreoid cartilage backwards
and note that it terminates, on each side, in a pointed projec-
tion, the superior cornu, which lies immediately in front of
the anterior border of the sterno-mastoid. Between the lower
margin of the thyreoid cartilage and the upper border of the
cricoid cartilage lies the cricothyreoid ligament, forming part
of the anterior wall of the lower portion of the larynx.

The dissectors should make themselves thoroughly familiar

with the landmarks mentioned above, both on their own necks
and on the necks of their friends, and they should note that,
whilst in the dead subject there may be some difficulty in
palpating the isthmus of the thyreoid gland, as it crosses
anterior to the second, third and fourth rings of the trachea,
they will have no difficulty in locating the small soft cushion-
like mass in the living subject.

Dissection. The skin was cut along the lower border of the
mandible at the commencement of the dissection of the face ;
now, make a median incision through it, from the chin to the
sternum, and turn the triangular flap, thus marked out, back-
wards and laterally, to a short distance beyond the anterior
margin of the sterno-mastoid. When that is done the super-
ficial fascia covering the anterior triangle on each side will be
exposed ; it is thickest and most laden with fat in the submental
region. In the upper and posterior part of it lie the fibres of the
platysma, running upwards and forwards towards the mandible.
Some of the anterior fibres of the muscle gain attachment to the
anterior part of the lower border of the mandible, and some

122 HEAD AND NECK

decussate with their fellows of the opposite side beneath the chin.
The posterior fibres ascend into the face, where they have already
been followed to their connection with the risorius and the
orbicularis oris (p. 7). Cut through the platysma along the
anterior border of the sterno-mastoid and turn it upwards,
dividing the twigs of the cervical branch of the facial nerve
which supply it. Secure the two terminal branches of the
nervus cutaneus colli (O.T. transverse cervical nerve), crossing
the middle of the sterno-mastoid ; trace its two branches for-
wards, and note the union between the upper branch and the
cervical branch of the facial nerve, which was found passing
downwards and forwards behind the angle of the mandible in
a previous dissection (see p. 15^. In the superficial fascia of
the submental region and the anterior part of the submaxillary
region secure the tributaries of the anterior jugular vein ; trace
them downwards to the trunk of the vein, and follow the trunk
to the point where it pierces the deep fascia ; then remove the
superficial fascia and expose the deep fascia of the anterior
region. Note that the deep fascia extends in a continuous layer
from the mandible to the sternum and from the sterno-mastoid
of one side to that of the other side. Note, further, that it is
attached to the body and the greater cornua of the hyoid bone.
The latter attachment separates the infra-hyoid muscles, which
lie in the lower part of the neck, from the supra-hyoid muscles,
which are situated in the region of the floor of the mouth.

The dissectors will remember that in the course of the dis-

section of the posterior triangle they met with several layers of
the deep fascia. A similar division into layers exists in the
anterior region, and the opportunity should be taken, whilst the
fascia is still uninjured, to demonstrate certain of the layers and
the presence of the spaces between them.

The Suprasternal Space. Make a transverse incision

through the deep fascia, immediately above the sternum, and
two vertical incisions, one along the anterior border of each
sterno-mastoid muscle. Carry the latter incisions upwards for
about 38 mm. (one and a half inches), and turn the flap of
fascia marked out upwards. The space opened into by the
reflection of the first layer of deep fascia of the lower part of the
neck is the suprasternal space (Burns). Remove the areolar
tissue which fills it, find the lower parts of the anterior jugular
veins and the transverse anastomosis between them, and expose
the second layer of deep fascia, which forms the posterior
boundary of the space and covers and binds together the infra-
hyoid muscles of opposite sides. Pass the handle of the scalpel
downwards along the posterior wall of the space, and note that
it terminates, a short distance below the upper border of the
sternum, where the second layer of fascia is attached to the
posterior surface of the manubrium, immediately above the
origins of the infra-hyoid muscles. If the handle of the knife is
passed laterally, along the posterior wall of the space, it will
pass deep to the sterno-mastoid into the posterior triangle
(see p. 34), and if it is pushed upwards it will be stopped by the
union of the first and second layers of the deep fascia, about
half-way between the sternum and the thyreoid cartilage. The
attachments of the second layer of deep fascia of the lower
part of the neck may be summarised as follows. It is attached,
THE ANTERIOR PART OF THE NECK 123

below, to the posterior surface of the manubrium sterni and to

the posterior border of the clavicle, to which it binds the posterior
belly of the omo-hyoid (p. 34). Above, it fuses with the more
superficial layer, along an oblique line which ascends from the
level of the coracoid process to the level of the upper end of the
trachea.* Above that level it forms, with the superficial layer,
a common lamella, which ascends on the infra-hyoid muscles
to gain attachment to the body and greater cornu of the hyoid
bone. The space between the two layers contains, in the region
of the anterior triangle, the lower parts of the anterior jugular
veins, the anastomosis between them, and the areolar tissue in
which they are embedded. In the posterior triangle its contents
are the lower end of the external jugular vein, the terminations
of the transverse cervical and transverse scapular veins, the
transverse scapular artery, and areolar tissue. Note that the
anterior jugular vein, on each side, arises in the superficial fascia
of the submental region and descends superficial to the deep
fascia in the upper part of the neck ; then it pierces the first
layer of deep fascia and lies between the two layers, where it
anastomoses with its fellow of the opposite side ; finally, it turns
laterally, deep to the sterno-mastoid, and terminates in the
external jugular vein at the anterior boundary of the subclavian
part of the posterior triangle.

Make two incisions through the deep fascia of the upper part of
the anterior triangle, one along the lower border of the mandible,
from the angle to a point 12.5 mm. (half an inch) from the
chin, and a second at right angles to the first, from its middle to
the greater cornu of the hyoid bone. Whilst making the hori-
zontal incision avoid injuring the external maxillary artery
(O.T. facial) and the anterior facial vein, which pierce the deep
fascia at the level of the anterior border of the masseter. Reflect
the two triangular flaps of fascia marked out by the incisions,
and expose the lower surface of the submaxillary salivary gland,
the submaxillary lymph glands, the anterior and posterior bellies
of the digastric muscle, the lower part of the stylo-hyoid muscle,
and a further part of the anterior facial vein.

The majority of the submaxillary lymph glands lie along

the lower border of the mandible, on the superficial surface of
the submaxillary gland. The anterior facial vein crosses the
posterior part of the submaxillary gland superficially. The
external maxillary artery dips deeply between the lower border
of the mandible and the submaxillary gland. The posterior and
lower part of the submaxillary gland usually overlaps the stylo-
hyoid and the posterior belly of the digastric muscles, and not
infrequently it overlaps the greater cornu of the hyoid bone also.
Its anterior border may overlap the anterior belly of the digastric.
Raise the lower border of the gland and expose another layer
of deep fascia covering the muscles which lie deep to the gland.
Place the handle of the knife on that fascia and push it gently
upwards. Note that it passes upwards to the level of the mylo-
hyoid line on the medial surface of the mandible, to which the
mylo-hyoid muscle is attached. The fascial sheath in which
the submaxillary gland is enclosed consists, therefore, of a
superficial layer of deep fascia which extends from the greater
cornu of the hyoid bone to the lower border of the mandible,
and a deeper layer which passes from the greater cornu of the

i2 4 HEAD AND NECK

hyoid to the mylo-hyoid line of the mandible. In front of the

anterior belly of the digastric, the two layers blend with the
single layer of deep fascia which covers the lower surfaces of
the mylo-hyoid muscles. Behind the posterior belly of the
digastric they unite with the connective tissue in which the
carotid vessels are embedded.

When the details of the deep fascia have been examined, the
sterno-mastoid should be studied.

M. Sternocleidomastoideus. The sterno-mastoid muscle

lies between the anterior and posterior triangles of the neck
(Fig. 43). It is attached, below, by two heads a sternal
and a clavicular. The sternal head is rounded, and chiefly
tendinous ; it springs from the upper part of the anterior
surface of the manubrium sterni. The clavicular head is
broad and fleshy, with only a few tendinous fibres intermixed ;
it arises from the medial third of the upper surface of the
clavicle. A narrow interval filled with fascia separates the
heads below, but at a higher level the sternal portion over-
laps the clavicular, and half-way up the neck the two heads
unite into a fleshy mass which ascends to the mastoid portion
of the temporal bone and occiput. There the muscle
expands somewhat. At its insertion it is thick and tendinous
where it is attached to the fore-part and lateral surface of the
mastoid process ; posteriorly it is thin and aponeurotic, and
is inserted into rather more than half of the corresponding
superior nuchal line of the occipital bone. In the dissection
of the back, the latter part of the muscle was detached from
the occiput.

The dissectors should note that the insertion of the

sterno-mastoid into the skull is mainly posterior to the trans-
verse axis of rotation of the atlanto-occipital joint. There-
fore if one sterno-mastoid acts the head is drawn downwards
to that side and the face is turned to the opposite side and
tilted upwards. If both sterno-mastoids act simultaneously
the head is drawn backwards. The muscle is supplied by
the spinal part of the accessory nerve and by the second
cervical nerve.

Dissection. Turn the anterior border of the sterno-mastoid

backwards and search for the arteries which supply it. At the
level of the angle of the mandible the sterno-mastoid branch of
the occipital artery will be found entering the deep surface of
the muscle.

At the level of the cricoid cartilage the sterno-mastoid branch

of the superior thyrcoid artery enters the muscle, and a short

THE ANTERIOR PART OF THE NECK 127

of the thyreoid body, secure the tributaries of the inferior
thyreoid veins at its lower border, and follow them downwards
to the upper aperture of the thorax ; then clearing away the
remains of the pretracheal fascia they should display the front
of the lower part of the cervical portion of the trachea upon
which the inferior thyreoid veins descend. At this stage a
small artery, the thyreoidea ima, may occasionally be found
ascending on the front of the trachea to the isthmus of the
thyreoid body.

When the dissection of the lower part of the infra-hyoid area

is completed return to the upper part. Clean the anterior ends
of the crico-thyreoid muscles which spring from the cricoid
cartilage ; they run upwards and laterally, one on each side.
Between the crico-thyreoid muscles, on a deeper plane, secure
the crico-thyreoid arteries, which anastomose across the front
of the median crico-thyreoid ligament. Note that the median
crico-th)^reoid ligament is attached below to the upper border
of the cricoid cartilage, and above to the lower border of the
thyreoid cartilage ; then push the handle of the scalpel or a broad
probe backwards along the surface of the conus elasticus, which is
continuous with the median ligament, and note that it ascends
medial to the thyreoid cartilage. It becomes continuous above
(see Fig. 126), with the vocal ligament, but that fact cannot be
demonstrated at the present stage of the dissection. Next clean
the prominent anterior part of the thyreoid cartilage, which forms
the laryngeal prominence in the front of the neck. Lastly,
clean away the fascial tissue between the upper part of the
thyreoid cartilage and the body of the hyoid bone and display
the middle thyreo-hyoid ligament which extends from the
upper border of the thyreoid cartilage behind the body of the
hyoid bone to its upper border. As the fascia is removed from
the upper part of the median thyreo-hyoid ligament behind the
body of the hyoid bone a small bursal sac will be opened. It
facilitates the movement of the hyoid bone over the upper part
of the thyreoid cartilage during deglutition. When the dissec-
tion is completed revise the structures which have been exposed.

The Middle Line of the Neck. In the supra-hyoid part

of the median portion of the neck lie the structures which
are concerned in the construction of the floor of the mouth.
The dissector will have noticed already that the fatty superficial
fascia was more fully developed there than elsewhere in the
neck, and that the anterior margins of the two platysma
muscles met and decussated in the median plane, for 10 or
1 2 mm. (about half an inch), below the chin. The anterior
attachments of the bellies of the two digastric muscles to the
mandible, one on each side of the symphysis, was noted.
Thence they descend towards the hyoid bone, and diverge
slightly from each other so as to leave between them a narrow
triangular space, called the submental triangle (Fig. 44). The
floor of the space is formed by the anterior portions of the

128
HEAD AND NECK

two mylo-hyoid muscles, whilst bisecting the floor of the

triangle, in the median plane, is the fibrous raphe into which
those muscles are inserted. Not infrequently the medial
margins of the digastric muscles send decussating fibres across
the interval. Within the submental triangle are the submental

Anterior facial vein

M. mylohyoideus

Common facial
vein

Lingual vein
Lesser occipital N.
Great auricular N.
Nervus
cutaneus colli
I nternal j ugular vei
Descending
cervical--
nerves/
Brachiall
plexus \
External^,
jugular vein
Descendens
hypoglossi
Anterior
jugular vein

Inferior
thyreoid veins

Platysma

External maxillj
artery
Parotid gland

- Submental lymp

land
ubmaxillary gl;

Sterno-mastoid a
Ext. carotid artt

Sup. thyreoid ai
Common carotid
artery

Lymph gland

Thyreo-glossal c
M. omohyoideu

M. cricothyreoi<
M. sternohyoid(

Isthmus of thyn
gland

M. sternothyreo

FIG. 44. Dissection of the Front of the Neck. The Right Sterno-mastoid
has been removed.

glands, which receive lymph from the median part of the

lower lip and chin and the anterior part of the tongue.

In the median area of the infra-hyoid part there is a

narrow intermuscular interval, bounded on each side, above,
by the medial margins of the sterno-hyoid muscles, and to a
smaller extent, below, by the medial margins of the sterno-
thyreoid muscles (Fig. 44); more laterally lie the anterior bellies

THE ANTERIOR PART OF THE NECK 129

of the omo-hyoid muscles. In the median intermuscular

interval the following structures will be found : (i) the median
part of the thyreo-hyoid membrane ; (2) the anterior border
of the thyreoid cartilage, with the projecting prominentia
laryngea (O.T. pomum Adami) at its upper end; (3) the
arch of the cricoid cartilage ; (4) the crico-thyreoid ligament,
with the anastomosis between the crico-thyreoid arteries, and
the anterior ends of the crico-thyreoid muscles ; (5) the first
ring of the trachea, with the anastomosis between the medial
terminal branches of the superior thyreoid arteries ; (6) the
isthmus of the thyreoid gland ; (7) the inferior thyreoid veins,
and (8) the lower cervical rings of the trachea. Occasionally
the third or middle lobe of the thyreoid gland and the
levator glandulae thyreoideae, or one or other of them, is found
extending upwards from the isthmus of the thyreoid gland.
When it is present the middle lobe either terminates above
ma pointed extremity or becomes continuous with a fibrous
cord, the remains of the thy reo- glossal duct, which disappears
in the region of the hyoid bone. The levator extends from
the isthmus or from the third lobe, and is attached, above, to
the lower border of the hyoid bone.

Dissection. The superficial layers of the deep fascia must

now be removed from the whole area of each anterior triangle,
and for that purpose, and for the satisfactory dissection of the
contents of the triangles, it is necessary that the head be turned
well over to the opposite side ; therefore the dissectors must
arrange to work alternately.

Commence with the digastric triangle. Its boundaries are

the lower border of the mandible and the two bellies of the
digastric muscle.

Its contents are: (i) the lower part of the submaxillary

gland; (2) the submaxillary lymph glands; (3) part of the
external maxillary artery ; (4) part of the anterior facial vein ;
(5) the mylo-hyoid nerve; (6) the mylo-hyoid artery; (7) a
small part of the hypoglossal nerve ; (8) a small part of the
lingual vein.

Dissection. Remove the deep fascia which was previously

turned aside (p. 123) and clean the submaxillary lymph glands.
Most of those glands lie immediately below the mandible, in
the angle between it and the submaxillary gland, but some may
be found on the superficial surface of the gland. Turn the gland
upwards and fix it with hooks ; then secure the mylo-hyoid
nerve and artery, as they enter the posterior border of the
anterior belly of the digastric about the middle of its length,
VOL. Ill 9

1 30 HEAD AND NECK

and the twig which the nerve gives to the mylo-hyoid muscle.
Define the band of fascia which surrounds the intermediate
tendon of the digastric and binds it to the greater cornu of the
hyoid bone. Note that the tendon is embraced by the cleft
lower end of the stylo-hyoid muscle. Clean the posterior belly
of the digastric and the stylo-hyoid muscle, which descends along
its anterior border. Note that the posterior belly of the digastric
and the stylo-hyoid disappear, postero-superiorly, under cover
of the angle of the mandible. Clean the anterior belly of the
digastric, and then examine the floor or medial boundary of the
triangle. Immediately behind the anterior belly of the digastric
it is formed by the posterior fibres of the mylo-hyoid muscle ;
and more posteriorly and on a deeper plane it is formed by the
hyoglossus muscle (Figs. 51, 68).

Clean the portion of the mylo-hyoid which is exposed and,

at its posterior border, immediately above the greater cornu of
the hyoid bone, secure the hypoglossal nerve and the lingual
vein ; the vein lies below the nerve. Displace the lingual vein
and the hypoglossal nerve upwards ; cut through the fibres
of the hyoglossus, immediately above and parallel with the
greater cornu, and display the lingual artery, which in that
position lies immediately above the greater cornu, parallel with
the lingual vein but separated from it by the hyoglossus
muscle.

All the structures which have been mentioned above will be

met with in the dissection of other regions, when a full account
of them will be given.

Turn next to the carotid triangle, so called because it

contains parts of the common, internal, and external carotid
arteries. It is bounded posteriorly by the anterior border of
the sterno-mastoid ; above and anteriorly by the posterior
belly of the digastric ; and below and anteriorly by the anterior
belly of the omo-hyoid.

Dissection. Trace the anterior facial vein from the digastric

triangle, across the superficial surface of the posterior belly of
the digastric, to the posterior border of the muscle, where it
unites with the posterior facial vein, which is descending from
under cover of the lower end of the parotid gland. The trunk
formed by the union of the anterior and posterior facial veins
is the common facial vein. Trace the common facial vein
downwards and backwards to its union with the internal jugular
vein, at or under cover of the anterior border of the sterno-
mastoid. Remove the deep fascia and the areolar tissue, and
the lymph glands which lie in the angle between the posterior
belly of the digastric and the anterior border of the sterno-
mastoid, below the lower end of the parotid gland ; secure the
lingual vein, which passes backwards from the tip of the
greater cornu of the hyoid bone to join the internal jugular
vein ; and the hypoglossal nerve, as it crosses, at a higher
level, superficial to the internal and external carotid arteries.
As the nerve turns forwards across the large arteries it is
itself crossed, superficially, by the sterno-mastoid branch of

THE ANTERIOR PART OF THE NECK 131

the occipital artery, and it gives off its descending branch.

Trace the descending branch downwards, in the fascia which
lies superficial to the lower part of the internal and the upper
part of the common carotid arteries, to the point where it dis-
appears under cover of the anterior belly of the omo-hyoid,
avoiding injury to the lingual, common facial, and superior
thyreoid veins ; : and secure the communicating branches,
from the second and third cervical nerves, which join its
posterior aspect. The latter nerves may cross either superficial
or deep to the internal jugular vein. Return to the hypoglossal
nerve at the point where it gives off its descending branch, and
trace it forwards to the upper aspect of the posterior end of
the greater cornu of the hyoid bone, where it gives off the branch
of supply to the thyreo-hyoid muscle. Trace the branch into
that muscle, below the level of the greater cornu ; then follow
the trunk of the hypoglossal anteriorly to the digastric triangle.
Note that as it runs forwards it passes deep to the posterior belly
of the digastric and the stylo-hyoid muscle, and superficial to
the hyoglossus, which ascends to the tongue from the upper
border of the greater cornu. Remove the fascial sheath from
the superficial surfaces of the lower parts of the internal and
external carotid arteries, and from the upper part of the common
carotid artery. Note that the latter divides into the two former
at the level of the upper border of the thyreoid cartilage, and
that the external carotid is at first medial and anterior to the
internal carotid.

Five branches may spring from the external carotid artery

in the carotid triangle three from its anterior surface : the
superior thyreoid, the lingual and the external maxillary ; one
from its medial surface, the ascending pharyngeal ; and one
from its posterior surface, the occipital ; but not uncommonly
the occipital and the external maxillary arise, beyond the limits
of the carotid triangle, under cover of the posterior belly of the
digastric. The superior thyreoid springs from the front of the
lower part of the external carotid, below the level of the greater
cornu of the hyoid, and runs downwards towards the lower angle
of the carotid" triangle, where it disappears under cover of the
anterior belly of the omo-hyoid. The lingual arises about the
level of the tip of the greater cornu. It runs forwards above
the level of the cornu, forming a loop, convex upwards, which
lies deep to the hypoglossal nerve ; and it disappears under cover
of the posterior border of the hyoglossus muscle. The ascending
pharyngeal branch, which springs from the medial surface of
the lower end of the external carotid, ascends on a deeper plane,
between the external and internal carotids and the wall of the
pharynx, and will be followed at a later stage of the dissection.
The external maxillary and the occipital arise immediately
below the posterior belly of the digastric and almost at once
disappear under cover of the muscle ; not uncommonly they
arise under cover of its lower border. Before proceeding to

1 The lingual vein may join the common facial vein, in which case
the latter usually enters the internal jugular opposite the interval between the
hyoid bone and the thyreoid cartilage, as in the specimen depicted in Fig. 12.
The superior thyreoid vein either ends in the internal jugular or joins the
common facial vein opposite the thyreo-hyoid interval,
m 9 a

I 3 2

HEAD AND NECK

clean the branches of the external carotid, secure the internal

and external laryngeal branches of the superior laryngeal branch
of the vagus nerve. The internal branch will be found in the
posterfor part of the thyreo-hyoid interval below the greater
cornu of the hyoid bone and behind the posterior border of the
thyreo-hyoid muscle, beneath which it disappears. It is accom-

orn posterior facial vein

Int. jugular vein
Hypoglossal ner
Posterior facial ye
Lesser occipital N,
Hypoglossal nerve
Great auricular N,

Transverse
capular arterj
kl. scalenus an

iiibclaviaii arti
Subclavian v<

FIG 45. The Triangles of the Neck seen from the side. The clavicular head
of the sterno-mastoid muscle was small, and therefore a considerable part
of the scalenus anterior muscle is seen.

panied by the laryngeal branch of the superior thyreoid artery.

The external branch is more difficult to find ; but if the superior
thyreoid artery and the upper part of the common carotid are
displaced posteriorly, the nerve will be found, lying deep to them,
in the fascia which covers the anterior part of the inferior con-
strictor muscle.

Remove the fascia from the surface of the internal jugular

vein, which overlaps the anterior borders of the common

THE ANTERIOR PART OF THE NECK 133

and internal carotid arteries. Dissect in the interval between

the vein and the arteries and secure the vagus nerve, which
lies deeply.

Remove the remains of the fascia from the carotid arteries

and the internal jugular vein, but avoid injury to the hypo-
glossal nerve and its branches ; and note the presence of
the upper deep cervical lymph glands which lie on the
superficial surfaces of the great arteries and the internal
jugular vein. The glands are sometimes very large, and the
dissectors should remember that they receive lymph from the
face, the mouth and tongue, the posterior part of the nose and
the upper part of the pharynx. After the large vessels are
cleaned, remove the fascia from the branches of the external
carotid artery and the twigs they give off, so far as they lie in
the region of the carotid triangle. Commence with the superior
thyreoid. Immediately after its origin it gives off a small infra-
hyoid branch, then a laryngeal branch which accompanies the
internal laryngeal branch of the superior laryngeal nerve ; and,
just before it disappears under cover of the anterior belly of the
omo-hyoid, a sterno-mastoid branch arises from its posterior
border and runs downwards and backwards, along the upper
border of the omo-hyoid, across the superficial aspect of the
common carotid artery and the internal jugular vein. Next,
clean the lingual artery and note its small supra-hyoid branch.
The external maxillary artery gives off no branches in the carotid
triangle, but a sterno-mastoid branch of the occipital artery will
usually be found passing downwards and backwards, superficial
to the loop of the hypoglossal nerve. Push the lower border of
the parotid gland upwards, and immediately under cover of it,
at the level of the angle of the mandible, secure the accessory
nerve, as it emerges from under cover of the posterior belly of
the digastric and crosses superficial to the internal jugular vein.
It is sometimes accompanied by an additional branch to the
sterno-mastoid from the occipital artery.

The floor or medial boundary of the carotid triangle is

formed by the upper part of the thyreo-hyoid muscle, the
posterior part of the hyoglossus and the middle and inferior
constrictors of the pharynx. The latter two muscles cannot
be displayed at present, -but the thyreo-hyoid is exposed below
the greater cornu of the hyoid bone, and part of the hyoglossus
can be seen in the angle between the greater cornu of the hyoid
and the lower part of the posterior belly of the digastric.

The Muscular Triangle. When the deep fascia which

covers the muscular triangle is removed, portions of three
muscles are brought into view. Postero- superiorly is the
anterior belly of the omo-hyoid ; more anteriorly and on
the same plane is the sterno-hyoid ; and below and anterior to
the sterno-hyoid, but on a deeper plane, is a small part of the
sterno-thyreoid.

The muscles mentioned may be considered to form the

134 HEAD AND NECK

floor or medial boundary of the triangle, and, if this view is

taken, the structures they cover, which lie more deeply, are
under cover of the floor. Those structures must now be
exposed.

Dissection. Divide the anterior belly of the omo-hyoid along

the anterior border of the sterno-mastoid and turn it upwards
to its insertion into the hyoid bone. As that is done its twig of
supply from the loop called the ansa hypoglossi will be cut.
The ansa hypoglossi is formed by the union of the descending
branch of the hypoglossal nerve and the communicating branch
from the cervical plexus. Divide the sterno-hyoid as low down
as possible ; turn it upwards to its insertion into the body of the
hyoid bone and note its nerve of supply from the ansa hypoglossi.
Secure the nerve to the sterno-thyreoid from the ansa hypoglossi ;
then remove the fascia and expose the lower part of the thyreo-
hyoid muscle, the greater part of the sterno-thyreoid and the
anterior part of the thyreoid cartilage. Note that the sterno-
thyreoid is inserted into an oblique line on the outer surface of
the lamina of the thyreoid cartilage and that the thyieo-hyoid
springs from the same line and is inserted into the greater cornu
of the hyoid bone. The crico-thyreoid branch of the superior
thyreoid artery may be found passing downwards and forwards
along the upper end of the sterno-thyreoid, accompanied by the
external laryngeal nerve ; or the nerve and the vessel may lie
deep to the upper end of the muscle.

Divide the sterno-thyreoid as low down as possible and turn

it upwards to its insertion ; remove the fascia under cover of it
and expose the lobe of the thyreoid gland, enclosed in its fascial
sheath. Below it, a small part of the side of the trachea will be
seen.

The dissector should note that whilst the sterno-mastoid

remains undisturbed the posterior part of the lobe of the thyreoid
gland and its lower extremity are not exposed, but if the sterno-
mastoid is displaced backwards the whole of the lateral surface
of the lobe is brought into view. The dissector should note also
that, until the sterno-mastoid is displaced backwards, only a
small portion of the upper end of the common carotid and the
lower parts of the internal and external carotid arteries are
visible ; indeed, the common carotid may be entirely concealed.
Only a small part of the anterior border of the internal jugular
vein projects anterior to the sterno-mastoid in the upper angle
of the carotid triangle ; and it also is not uncommonly hidden
when the sterno-mastoid is well developed. During life, however,
when the muscle is soft and pliable the structures concealed by
it are readily exposed, for the muscle is easily displaced back-
wards after the fascia has been divided along its anterior border.

In dissecting-room subjects, in which the muscles have been

hardened by formol, it is not possible to obtain a proper view of
the course and relations of the common carotid artery and the
internal jugular vein, or to appreciate the relations of the first
part of the subclavian artery and the relations of the scalenus
anterior muscle, until the sterno-mastoid has been reflected.
Divide the external jugular vein immediately below its origin by

THE ANTERIOR PART OF THE NECK 135

the union of the posterior auricular vein with the communication

from the posterior facial vein, and turn it downwards. Divide
the great auricular nerve at the level of the angle of the mandible
and turn it backwards ; and turn backwards also the nervus
cutaneus colli, whose two terminal branches have been cut
already. The clavicular head of the sterno-mastoid was cut
when the clavicle was removed ; now divide the sternal head,
turn the muscle upwards towards its insertion. As the muscle is
turned upwards, sterno-mastoid branches of the transverse
scapular, superior thyreoid, and occipital arteries will be ex-
posed ; and if they interfere with the reflection of the muscle
they must be divided. Slightly above the level of the sterno-
mastoid branch of the occipital artery the accessory nerve will
be found passing through the deeper fibres of the muscle, and
care must be taken to avoid injury to it ; but it may be dissected
out of the muscle and left in position on the lateral surface of
the internal jugular vein.
eep Cervical Fascia. When the sterno-mastoid has been
reflected, a deep fascial plane of the neck is exposed in which
lie many lymph glands. Before carrying the dissection further
the dissector should reconsider the arrangement of the deep
cervical fascia. He has already seen that it forms a complete
sheath enclosing the muscles of the neck and the structures
^ which lie between and under cover of them. The general
*^ arrangement of the fascia is studied best on transverse
^ sections of the neck made at the level of the isthmus of the
r^ thyreoid gland and a short distance above the sternum. At
1^ the former level it is possible to recognise (i) a superficial
*^Javer; (2) a pretracheal layer; (3) a prevertebral layer; and (4)
L. ara-scial sheath which encloses the common carotid arteries,
the internal jugular vein and the vagus nerve, as they lie in
the angular interval between the sterno-mastoid laterally, the
thyreoid gland, the trachea, oesophagus medially, and the
prevertebral muscles posteriorly.

The first or superficial layer, as it is traced backwards,

splits to enclose the sterno-mastoid muscle (Fig. 47). Beyond
the sterno-mastoid it passes backwards to the anterior border
of the trapezius muscle, forming the roof of the posterior
triangle; then it splits again to enclose the trapezius, along
the surfaces of which it is prolonged till it blends with the
supraspinous ligaments and the ligamentum nuchae. The
lamella which covers the deep surface of the sterno-mastoid is
blended with the lateral surface of the carotid sheath. The
pretracheal layer, which has been dissected already in the
median plane, ensheaths the thyreoid gland and blends
in 96

>

i 3 6

HEAD AND NECK

postero-laterally with the medial surface of the carotid sheath.

The prevertebral layer covers the anterior surfaces of the
prevertebral muscles, and, passing laterally, blends with the
posterior aspect of the carotid sheath; then, turning round
the tips of the transverse processes of the vertebrae, it passes
backwards, covering the muscles which form the floor of the
posterior triangle ; and it becomes continuous with the sheaths
of the deep muscles of the back of the neck.

Laterally and posteriorly, the superficial layer of the deep

fascia passes upwards over the sterno-mastoid and the

trapezius to be at-
tached to the superior
nuchal lines and the
mastoid portions of
the temporal bones.
In the anterior cervi-
cal region it is at-
tached to the body
and the greater
cornua of the hyoid
bone, and then, as it
is prolonged further
upwards, it splits an-
teriorly to enclose
the submaxillary
gland, and posteriorly
to enclose the paro-
tid. It has been
noted already that
the lamella which
passes superficial to
the submaxillary gland is attached to the lower border , of
the mandible, and that which passes deep to the gland is
connected above to the mylo-hyoid line on the inner surface
of the mandible. The layer which passes superficial to the
parotid gains attachment to the zygoma and is prolonged
forwards to blend with the fascia covering the masseter.
The lamella which passes deep to the parotid covers its
postero-medial and antero-medial surfaces ; the posterior part
is attached above to the lower border of the tympanic plate,
and the anterior part to the posterior border of the petro-
tympanic fissure (O.T. Glaserian). It also gains an inter-

First layer of deep fascia

Pretracheal layer

Isthmus of thyreoid gland

Prevertebral fascia
First layer "
Second layer
Pretracheal la
Left innominate vein

Mediastinal tissue

FIG. 46. Diagra

"vical Fascia

in sagittal section.
THE ANTERIOR PART OF THE NECK 137

Capsule of thyreoid gland

First layer of deep fascia
Thyreoid gland

Sheath of thyreoid
gland formed by
pretracheal fascia

mediate attachment to the styloid process and to the posterior

border of the angle of the mandible. That portion is
relatively thick ; it lies in relation with the lower part of the
antero-medial surface of the parotid and is known as the
stylo-mandibular ligament.

When the superficial layer is traced downwards it is found

to split, between the cricoid cartilage and the sternum, into two
lamellae. The more superficial of the two lies superficial to
the sterno-mastoid and is at-
tached, below, to the upper
border of the sternum and the
upper border of the clavicle.
In the anterior region the
deeper lamella descends upon
the anterior surfaces of the
infra-hyoid muscles and is at-
tached, below, to the posterior
surface of the manubrium
laterally, it passes deep to the
sterno - mastoid and is fused
with the lateral border of the
carotid sheath. In the posterior
triangle the deeper lamella
ensheaths the posterior belly
of the omo-hyoid and binds it
down to the posterior border

Of the clavicle and the cartilage FIG. 47. Diagram of deep Cervical

Of the first rib. The Space fascia in transverse section at

. .. , the level of the thyreoid gland.

between the two lamellae has

been called the supra-sternal space. Its boundaries and con-

tents have been fully described already (p. 122).

The upper attachment of the pretracheal layer is to the

cricoid cartilage and to the laminae of the thyreoid cartilage,
below the insertion of the sterno-thyreoid muscle. At its
lower end it blends with the fibrous pericardium in the
middle mediastinum.

The prevertebral layer can be followed upwards to the

base of the skull, where it is attached, in the anterior cervical
region, to the posterior and medial margins of the jugular
foramen and to the basilar part of the occipital bone, anterior
to the insertions of the prevertebral muscles and posterior to
the superior constrictor of the pharynx. Below, it blends

138 HEAD AND NECK

with the fascia on the anterior aspect of the vertebral column

in the posterior mediastinal region.

The Carotid Sheath. The term carotid sheath is applied

to the fascia which surrounds and embeds the carotid arteries,
the internal jugular vein, and the vagus nerve. Part of it has
been removed already, and the dissector will have noted that
it is in no sense a membrane, but merely the fibro-areolar
tissue which fills the interval between the transverse processes
of the vertebrae posteriorly, the trachea, larynx, pharynx,
oesophagus, and the lobe of the thyreoid gland medially,
and the sterno-mastoid laterally ; that it is continuous with
the fascial planes in its immediate neighbourhood, and that

Capsule of thyreoid gland First layer of deep fascia

(black line) | Sheath of thyreoid gland

Infra-hyoid muscles !9&L\ (pretracheal fascia)

. Sterno-mastoid
Scalene muscle ^

Second layer of deep fascia

Omo-hyoid
Trapezius

FIG. 48. Diagram of the deep Cervical Fascia in a transverse section

of the lower part of the neck.

through it run the carotid arteries, the internal jugular vein,

and the vagus nerve, each in its own special compartment.

Dissection. Remove the areolar tissue and the glands which

lie under cover of the sterno-mastoid ; stitch together the two
parts of the divided anterior belly of the omo-hyoid muscle and
fix the muscle to the common carotid artery and the internal
jugular vein with one or two stitches ; then proceed to display
the structures which lie under cover of the sterno-mastoid. A
glance at the following list will convince the dissector that they
are very numerous.

Structures under cover of the Sterno-Mastoid.

Muscles. The upper part of the splenius capitis ; the

upper and posterior part of the posterior belly of the digastric;
the origins of the levator scapulae, the scalenus medius, the
longus capitis (O.T. rectus capitis anticus major), the rectus

THE ANTERIOR PART OF THE NECK 139

FIG. 49. Dissection to show the structures under cover of the Sterno-Mastoid
Muscle. The outline of the sterno-mastoid is indicated by the thick black
broken lines. The greater part of the internal jugular vein has been
removed to display the parts subjacent to it.

Digastric muscle (posterior belly).

Parotid gland.

Commencement of external - jugular

vein.

Internal jugul;ir vein.

Hypoglossal nerve.
Internal carotid artery.
External carotid artery.
Anterior facial vein.
Submental vessels.
Submaxillary gland.
Anterior belly of digastric muscle.
Mylo-hyoid muscle.
Laryngeal branch of superior thyreoid

artery and internal laryngeal nerve.

Superior thyreoid artery.
Upper end of thyreoid gland.
Ansa hypoglossi.
Sterno-thyreoid muscle.
Sterno-hyoid muscle.
Common carotid artery.
Vagus nerve.

21. Internal jugular vein.

22. External jugular vein.

23. Subclavian vein below transverse

scapular artery.

24. Subclavian artery.

25. Omo-hyoid muscle.

26. Long thoracic nerve.

27. First serration of serratus anterior

muscle.

28. Trapezius muscle.

29. Scalenus anterior muscle.

30. Scalenus medius muscle.

31. Upper part of brachial plexus.

32. Phrenic nerve.

33. Nervus cutaneus colli.

34. Great auricular nerve.

35. Longus capitis muscle.

36. Ascending cervical artery.

37. Accessory nerve.

38. Levator scapulae.

39. Splenius capitis muscle.

40. Sterno-mastoid muscle.

MO HEAD AND NECK

capitis lateralis and the scalenus anterior ; the intermediate

tendon of the omo-hyoid, and the lower and posterior part of
the sterno-hyoid and sterno-thyreoid.

Arteries. The upper part of the common carotid (the

lower part is still concealed by the lower part of the omo-
hyoid and the lower parts of the sterno-hyoid and sterno-
thyreoid muscles) ; the transverse scapular and its sterno-
mastoid branch ; the transverse cervical ; the sterno-mastoid
branch of the superior thyreoid ; the occipital and its sterno-
mastoid branches.

Veins. The greater part of the internal jugular vein ; the

lower transverse portion of the anterior jugular vein ; and,
occasionally, the lower end of the external jugular vein, when
that vessel dips forwards to its termination.

Nerves. The cervical plexus and its branches, including

the phrenic nerve ; part of the accessory nerve.

If the lower parts of the divided sterno-hyoid and sterno-

thyreoid muscles are displaced downwards, the lower part of
the common carotid and the commencement of the first part of
the subclavian artery will be exposed. Crossing the front of
the latter are the lower portion of the cervical part of the vagus
and a strand of sympathetic fibres called the ansa subclavia ;
on the left side, the subclavian artery and the ansa are con-
cealed by the commencement of the innominate vein. At
the same time the middle thyreoid vein will be exposed,
and the posterior border of the lobe of the thyreoid
gland also.

Dissection. Commence by cleaning the anterior rami of

the cervical nerves, from the second to the eighth, as they emerge
between the muscles attached to the tubercles of the transverse
processes of the cervical vertebrae. The first nerve, which turns
downwards anterior to the transverse process of the atlas, will
be exposed later. As the upper nerves are cleaned the dissectors
will find that the second is connected to the third, and the third
to the fourth, by looped strands, convex posteriorly, which
constitute the lower two loops of the cervical plexus. The
second nerve is connected with the first also by a loop, convex
anteriorly, which passes upwards anterior to the transverse
process of the atlas and posterior to the upper part of the internal
jugular vein. It can be exposed if the vein is pulled forwards ;
and the dissector must at the same time secure the twigs of con-
nection which pass from the medial side of the loop to the hypo-
glossal nerve and to the superior cervical ganglion of the sym-
pathetic trunk, which lies behind the upper part of the internal
carotid artery.

After the dissector has defined the loops of the plexus he

THE ANTERIOR PART OF THE NECK 141

should trace the remains of the lesser occipital, the great auricu-
lar, the nervus cutaneus colli and the supraclavicular branches,
which he displayed in the posterior triangle, to their origins
from the roots of the plexus. The communicating branches
which pass forwards to the descendens hypoglossi from the
second, and sometimes also from the third cervical nerve, must
be followed ; they may cross either superficial or deep to the
internal jugular vein. Then the phrenic nerve, which springs

Lesser occipital i R
Great auricular,

Nervus cutaneus colli

Branch to levator
scapulae

Branch to levator
scapulae

Descending trunk

Hypoglossal

To genio-hyoid

c c u Thyreo-hyoid nerve

Descendens hypoglossi

Ansa hypoglossi

eating to
fifth cervical

Phrenic

FIG. 50 Diagram of the Cervical Plexus and the Ansa Hypoglossi.

I, II, III, IV. Anterior rami of the upper four cervical nerves.

R. Branches to recti and longus capitis.

S. M. Branches to the sterno-mastoid.
C.C. Rami communicantes cervicales.
C.H. Communicating branch to hypo-
glossal.

This diagram shows that the descendens hypoglossi, the branch to the
thyreo-hyoid, and in all probability the branches to the genio-hyoid, are
composed of fibres given to the hypoglossal by the communicating twigs
it receives from the first cervical nerve.

from the fourth cervical nerve, and receives additional twigs

from the third and fifth nerves, must be followed downwards
and medially, till it disappears under cover of the lower part of
the internal jugular vein. It lies upon the surface of the scalenus
anterior and passes deep to the omo-hyoid muscle and the
transverse cervical and transverse scapular arteries. Running
upwards parallel with, and anterior to it, is the ascending cervical
branch of the inferior thyreoid artery.

Plexus Cervicalis. The cervical plexus is a looped plexus

formed by the first four cervical nerves. It lies in the upper

i 4 2 HEAD AND NECK

part of the side of the neck, under cover of the sterno-mastoid.

The upper loop of the plexus, which connects the first and
second nerves together, is directed forwards and lies between
the internal jugular vein anteriorly, and the transverse process
of the atlas posteriorly. The second and third loops, which
unite the second and third and the third and fourth nerves,
are directed backwards ; and they lie on the superficial surface
of the upper part of the scalenus medius muscle. The first
loop is connected with the upper ganglion of the sympathetic
trunk and with the hypoglossal nerve ; and the roots of the
second, third, and fourth nerves also are connected, by grey
rami, with the upper cervical sympathetic ganglion.

The branches of the plexus are divisible into two main

groups, the superficial and the deep. The deep branches are
separable into two groups : the anterior, which run forwards,
and the posterior, which run backwards ; and the superficial
branches are classified as ascending, transverse, and descending.
. The anterior group of deep branches includes : (i) The ram us
communicans cervicalis (p. 131), and (2) the phrenic nerve.
(3) Less important muscular branches, from the first loop to

(a) the rectus capitis lateralis ; () the rectus capitis anterior

(O.T. rectus capitis anticus minor) ; (V) the longus capitis
(O.T. rectus capitis anticus major). (4) Muscular branches,
from the third and fourth nerves, to the longus colli.

The posterior group of deep branches is formed by : (i) The

communicating branches to the accessory nerve. (2) Branches
of supply to : (a) the sterno-mastoid, from the second nerve ;

(b) the levator scapulae, from the third and fourth ; (c)
the trapezius, from the third and fourth ; (d) the scalenus
medius, from the second, third, and fourth.

The ascending group of superficial branches is formed by the

lesser occipital and great auricular nerves. The transverse
branch is the nervus cutaneus colli ; and the descending
branches are the supraclavicular nerves. All the superficial
nerves have already been traced in the earlier stages of the
dissection (pp. 34, 35). The small muscular branches
require no special notice, but the phrenic nerve requires
careful consideration.

Nervus Phrenicus. The importance of the phrenic nerve

depends upon the fact that it is the nerve of supply to the
chief muscle of respiration, the diaphragm. The majority of
its fibres spring from the fourth cervical nerve, but it receives

PLATE VI

FIG. 51.

THE ANTERIOR PART OF THE NECK 143

PLATE VI

FIG. 51. Dissection of the Head and Neck of the same subject
as that shown in Fig. 15, but the greater part of the parotid
gland, the greater part of the sterno-mastoid muscle, the
greater part of the external jugular vein, portions of other
veins, portions of the sterno-hyoid and sterno-thyreoid
muscles, and the submaxillary gland have been removed
to display deeper structures.

Supra-orbital artery and nerve.

Frontal artery and vein.

Lateral nasal branch of external

maxillary artery.

Superior labial branch of ex-

ternal maxillary artery.

Inferior labial branch of ex-

ternal maxillary artery.

External maxillary artery.

External maxillary artery.

Deep part of submaxillary gland.

Lingual artery.

Subrnental branch of external

maxillary artery.

Mylo-hyoid muscle.

Nerve to thyreo-hyoid muscle.

Internal laryngeal nerve.

Common facial vein.

Superior thyreoid vessels.

Common carotid artery and de-

scendens hypoglossi nerve.

Sterno-hyoid muscle.

Omo - hyoid muscle (anterior

belly).

Sterno-thyreoid muscle.

Thyreoid gland.

Middle thyreoid vein.

Trachea.

Inferior thyreoid vein.

Sterno-thyreoid muscle.

Sterno-hyoid muscle.

Subclavius muscle with nerve.

27. Cephalic vein.

28. Lateral anterior thoracic nerve.

29. Acromial branch of thoraco-

acromial artery.

30. Transverse scapular vessels.

3 1 . First serration of serratus anterior

muscle.

32. Subclavian artery.

33. Transverse cervical artery.

34. Upper root of long thoracic

nerve.

35. Trapezius.

36. Scalenus anterior.

37. Internal jugular vein.

38. Communicans hypoglossi nerve.

39. Ascending branch of transverse

cervical artery.

40. Internal carotid artery.

41. External carotid artery.

42. Hypoglossal nerve.

43. Occipital artery and sterno-

mastoid branch.

44. Lesser occipital nerve.

45. Digastric and stylo-hyoid muscles.

46. Third occipital nerve.

47. Greater occipital nerve and

occipital artery.

48. Posterior auricular artery and

vein.

49. Superficial temporal vessels and

auriculo-temporal nerve.

144 HEAD AND NECK

twigs from the third and, not uncommonly, from the fifth
nerve also. It descends from the neck through the superior
and middle mediastinal regions of the thorax, and, after
piercing the diaphragm, it is distributed on its lower surface.
Only the cervical portion of the nerve belongs to the dis-
sector of the neck ; the remainder is displayed by the dissector
of the thorax (p. 43, Vol. II.). In the neck, the nerve runs
downwards and medially, on the superficial surface of the
scalenus anterior, which forms its deep relation. It is
covered by skin, superficial fascia and platysma, deep fascia
and the sterno-mastoid; deep to the sterno-mastoid, it is
overlapped by the internal jugular vein, and it is crossed by
the omo-hyoid, the anterior jugular vein, and the transverse
cervical and transverse scapular arteries ; in addition, the left
nerve is crossed by the thoracic duct, and the right nerve
by the right lymph duct. At the root of the neck it passes
from the medial border of the anterior scalene to the
anterior surface of the first part of the subclavian artery ; on
the right side it crosses the artery, on the left it descends in
front of it ; it is covered anteriorly, on both sides, by the
clavicle and by the commencement of the innominate vein; and
it crosses either anterior or posterior to the internal mammary
artery. It gives off no branches in the neck, but it sometimes
receives a communication from the nerve to the subclavius.

After the dissector has completed the examination of the formation, the
relations, and the branches of the cervical plexus, he should replace the
divided infra-hyc-id muscles in position and study their attachments and
relations.

The Infra-hyoid Muscles are a series of flat, band-like

muscles which lie upon the trachea, thyreoid gland, and
larynx. They are disposed in two strata viz., the omo-hyoid
and the sterno-hyoid constituting a superficial layer ; and
the sterno-thyreoid and thyreo-hyoid a deep layer.

Musculus Omohyoideus. The omo-hyoid is a two-bellied

muscle. The posterior belly springs from the upper border of
the scapula and the upper transverse scapular ligament. It
crosses the posterior triangle of the neck, dividing it into
occipital and subclavian portions, and terminates, under cover
of the sterno-mastoid muscle, in an intermediate tendon.
The muscle is superficial to the brachial plexus, and the
tendon is superficial to the phrenic nerve and the scalenus
anterior. The tendon is held in position by a strong process

THE ANTERIOR PART OF THE NECK 145

of cervical fascia which is firmly attached below to the

sternum and the first costal cartilage. The anterior belly
emerges from under cover of the anterior border of the
sterno-mastoid, and takes an almost vertical course through
the anterior triangle. It is inserted into the lower border of
the body of the hyoid bone, at the lateral side of the sterno-

iterior facial
kl. mylohyoideus'
Common facial

vein-
Lingual vein...,

:sser occipital N..

reat auricular N

Nervus
cutaneus colli
:rnal jugular vein
Descending
cervical
nerves
Brachial
plexus
External,
jugular vein
Descendens _
hypoglossi .
Anterior Jj
jugular vein"p

Inferior*"
hyreoid veins "'

Platysma

External maxillary
artery

. Parotid gland
Submental lymph
gland
Submaxillary gland

Sterno-mastoid artery
-Ext. carotid artery

Sup. thyreoid artery

.Common carotid
artery
Lymph gland

Thyreo-glossal duct

M. omohyoideus
M. cricothyreoideus
M. sternohyoideus

Isthmus of thyreoid
gland

M. sternothyreoideus

FIG. 52. Dissection of the Front of the Neck. The right sterno-mastoid
has been removed.

hyoid. In the anterior triangle of the neck it forms the

boundary between the carotid and the muscular subdivisions,
and it lies superficial to the internal jugular vein, the
common carotid artery, the descendens hypoglossi, the
superior thyreoid artery, the external laryngeal nerve, the
attachments of the sterno-thyreoid and thyreo-hyoid muscles
to the lamina of the thyreoid cartilage; and immediately
VOL. in 10

146 HEAD AND NECK

below its insertion it covers part of the thyreo-hyoid

membrane. Both bellies are supplied by branches from the
ansa hypoglossi. Acting from the scapula it pulls the hyoid
bone downwards and slightly backwards.

Musculus Sternohyoideus. The sterno-hyoid muscle arises

from the posterior aspect of the medial end of the clavicle,
the posterior sterno-clavicular ligament, and the posterior
surface of the manubrium sterni. It is inserted into the
lower border of the body of the hyoid bone, between the
median plane and the insertion of the omo-hyoid. A short
distance above the sternum an oblique tendinous intersection
frequently divides it into two portions. The lower part of
the muscle is covered by the sterno-mastoid, and it is crossed
by the anterior jugular vein. Its principal deep relations are
the lower part of the common carotid artery and the sterno-
thyreoid muscle, which separates it from the lateral lobe of
the thyreoid gland. It is supplied by branches from the
ansa hypoglossi. It pulls the hyoid bone downwards.

Musculus Sternothyreoideus. The sterno-thyreoid muscle

lies under cover of the preceding and is broader but shorter.
It springs from the posterior aspect of the manubrium sterni
and from the cartilage of the first rib. Diverging slightly
from its fellow as it ascends, it is inserted into the oblique
line on the lateral face of the lamina of the thyreoid cartilage,
parallel with and immediately below the thyreo-hyoid. An
incomplete tendinous intersection may sometimes be noticed
interrupting its muscular fibres. In the neck, it is covered
in the greater part of its extent by the sterno-hyoid ; but the
posterior part of its insertion is covered by the anterior belly
of the omo-hyoid ; and the lower and anterior part is covered
by skin and fascia only. The nerve supply is derived from the
ansa hypoglossi. It pulls the thyreoid cartilage downwards.

Musculus Thyreofiyoideus. The thyreo-hyoid muscle lies

on the same plane as the sterno-thyreoid, and may be
regarded as its upward continuation. It takes origin from
the oblique line on the lateral surface of the lamina of the
thyreoid cartilage, and is inserted into the lower border of the
greater cornu of the hyoid bone, under cover of the omo-
hyoid muscle. It conceals part of the lamina of the
thyreoid cartilage and the lateral part of the thyreo-hyoid
membrane, and the aperture in the membrane through which
the laryngeal branch of the superior thyreoid artery and the

THE ANTERIOR PART OF THE NECK 147

internal laryngeal nerve enter the pharynx. It is supplied by

a twig from the hypoglossal nerve. It approximates the hyoid
bone to the thyreoid cartilage.

Dissection. The dissectors of the head and neck should now

proceed to study the relations of the common carotid and sub-
clavian arteries, the cervical part of the thoracic duct, and the
dome of the pleura, before those structures are disturbed by the
dissectors of the thorax. Whilst this is being done, the omo-
hyoid must be retained in position, but the upper and lower
portions of the other infra-hyoid muscles may be turned upwards
and downwards respectively.

Remove the remains of the fascial sheath from around the

common carotid artery and the adjacent part of the internal
jugular vein.. Separate the vein from the artery, and clean the
portion of the vagus nerve which lies between them on a posterior
plane. Note that, on the right side, the nerve crosses the anterior
surface of the subclavian artery, and there gives off its recurrent
branch ; and that, on the left side, it lies medial to the sub-
clavian artery, and in an anterior plane.

After the lower parts of the cervical portions of the vagi have
been cleaned, look for the terminal part of the thoracic duct, on
the left side, and for the right lymph duct, on the right side.
In seeking for the thoracic duct, pull the lower end of the left
internal jugular vein aside and displace the common carotid
artery forwards ; then look for the duct, as it turns laterally
from the border of the oesophagus, a little below the level of the
cricoid cartilage ; trace it, posterior to the internal jugular vein,
to its termination in the commencement of the innominate vein.
On the right side, look for the right lymph duct entering the
innominate vein in the angle of union of the internal jugular
and subclavian veins. Next, look for the cervical portion of the
sympathetic trunk, which descends posterior to the common
carotid. Clean the nerve trunk carefully and clean also the
inferior thyreoid artery, which crosses anterior or posterior to it,
at the level of the cricoid cartilage. Displace the common
carotid laterally, and in the angle between the borders of the
trachea and the oesophagus find the recurrent branch of the
vagus ; trace it upwards to the point where it disappears under
cover of the lobe of the thyreoid gland, and downwards to the
subclavian artery.

Arteria Carotis Communis. The common carotid artery

arises differently on the two sides. On the right side, it arises
as a terminal branch of the innominate artery, behind the
sterno-clavicular joint ; on the left side, it springs from the
aortic arch, in the superior mediastinum. The left artery
ascends to the back of the left sterno-clavicular articulation.
From the sterno-clavicular joint each common carotid artery
runs upwards, backwards, and slightly laterally to the level of
the upper border of the thyreoid cartilage, which lies opposite
the fibre-cartilage between the third and fourth cervical

in 1 a

148 HEAD AND NECK

vertebrae; there it ends by dividing into its two terminal

branches the internal and the external carotid arteries.

Superficial Relations. Above the level of the anterior

belly of the omo-hyoid the common carotid artery is covered
by the skin, the superficial fascia and the platysma, the deep
fascia and the anterior margin of the sterno-mastoid. It is
crossed, immediately above the omo-hyoid, by the sterno-
mastoid branch of the superior thyreoid artery, and, at a higher
level, by the superior thyreoid vein ; and it is overlapped by
the anterior margin of the internal jugular vein. In the
lower part of its extent it lies more deeply : its superficial
relations are, the skin and superficial fascia, the deep fascia

Thyreo-hyoid ligament M. sternohyoideus

Plica vocalis ^^g|^ . "<5^^ M - thyreohyoideus

Processus vocalis ^^^^i^l^^^^^^^^ Thyreoid cartilage
Arytaenoid cartilage^^^^^B^^^^^^ M. omohyoideus

Common carotid

Carotid sheath * ^ITlliif^^^^lMHn^* '^^WT Internal jugular

Vagus"

Scalenus anterior Sympathetic trunk

M. longus colli Vertebral artery

FIG. 53. Transverse section through the Neck at the level of upper
part of Thyreoid Cartilage.

and the sterno-mastoid; the anterior jugular vein, crossing

transversely, deep to the sterno-mastoid and above the upper
border of the clavicle ; the omo-hyoid, the sterno-hyoid, and
the sterno - thyreoid muscles. Deep to the muscles, the
branches of the ansa hypoglossi descend in front of its
sheath ; and the middle thyreoid vein crosses it to join the
internal jugular vein (Fig. 51).

Posterior to it lie the transverse processes of the cervical

vertebrae and the origins of the longus colli, longus capitis
and the scalenus anterior. The sympathetic trunk is directly
behind it, and the vagus is postero-lateral to it. The inferior
thyreoid artery crosses posterior to it, at the level of the cricoid
cartilage ; and the vertebral artery lies between it and the
transverse process of the seventh cervical vertebra. On the

THE ANTERIOR PART OF THE NECK 149

right side, the recurrent nerve crosses posterior to it, immedi-

ately above its origin ; and on the left side, the thoracic duct
turns laterally behind it, between it and the vertebral artery.
To its medial side, below, lie the trachea and oesophagus,
with the recurrent nerve in the angle between their adjacent
borders ; and to the medial side of its upper part are the
larynx and pharynx. The lobe of the thyreoid gland
lies either medial to the artery, separating it from the
oesophagus, pharynx, trachea, and larynx, or it forms a direct
anterior relation (Figs. 48, 53). Between its upper extremity
and the inferior constrictor muscle of the pharynx lies the
glomus caroticum.

M. sternohyoideus

artery

Anterior jugular vein

Superior thyreoid
Pharynx
Descendens
hypoglossi
Common carotid

Internal jugular

Vagus
Sympathetic
cricothyreoideus
Superior thyreoid artery
M. sternothyreoideus
Descendens hypoglossi
Omo-hyoid

Common carotid
Vagus

Internal jugular
Sympathetic
trunk
* Cervical nerve

M. longus colli Retro-pharyngeal space Vertebral artery

FIG. 54. Transverse section through the Neck at the level of the
Cricoid Cartilage.

As a rule, the terminal divisions are the only branches of

the common carotid, but occasionally the superior thyreoid
or the ascending pharyngeal artery arises from it, instead
of from the external carotid. That is more especially the
case when the division of the common carotid takes place at
a higher level than usual.

Glomus Caroticum. The glomus caroticum is a little, oval, reddish-

brown body, placed upon the deep aspect of the common carotid artery at
the point where it bifurcates. To expose it, therefore, the vessel must be
twisted round in such a manner that its posterior surface is turned forwards.
It is closely connected with the sympathetic filaments which twine around
the carotid vessels ; and in structure it is similar in its nature to the
glomus coccygeum, which rests upon the anterior aspect of the coccyx.
It is included, therefore, in the group of ductless glands. Entering it are
numerous minute arterial twigs, which take origin from the termination of
the common carotid and the commencement of the external carotid. The
in 10ft

HEAD AND NECK

function of the remarkable little body is quite unknown, but it belongs

to the system of chromophil organs.

Arteria Subclavia. The relations of the third part of the

M. .sternohyoideus
M. omohyoideu.s

M. sternothyreoideus

Sympathetic

M. constrictor

inferior

Thyreoid gland
dragged forwards

External
carotid artery
Internal jugular vein
scalenus medius

Inferior thyreoid
artery
Recurrent
nerve
(Esophagus

Common carotid
artery

Internal jugular vein

Pleu?

M. longus capitis
Vagus nerve
Phrenic nerve

ertebral vessels

M. scalenus
anterior
Dome of pleura

Brachial nerv
Subclavian
vessels

Transverse scapular and

cervical arteries
THORACIC DUCT

Inferior thyreoid vein

Innominate artery

Internal mammary artery and phrenic ner

Left innominate vein

FIG. 55. Deep Dissection of the Root of the Neck on the Left Side to show
the Dome of the Pleura and the relations of the Terminal Part of the
Thoracic Duct. The sterno-mastoid and the depressors of the hyoid and
larynx have been removed.

subclavian artery were examined during the dissection of the

posterior triangle (p. 37). The relations of the first and
second parts must now be studied. On the right side, a small
portion of the first part is already exposed between the lower

THE ANTERIOR PART OF THE NECK 151

end of the internal jugular vein and the common carotid

artery ; the remainder can be seen if the internal jugular vein
is drawn aside. On the left side, the first part of the artery is
concealed by the commencement of the innominate vein, which
must be pushed aside. On both sides, the second part of
the artery lies posterior to the scalenus anterior, which must
be left in position.

The subclavian artery is the first portion of the great

arterial trunk which carries blood for the supply of the upper
extremity. It arises differently on the two sides of the body.
On the right side, it takes origin, behind the sterno-clavicular
joint, as a terminal branch of the innominate artery. On
the left side, it arises from the aortic arch, in the superior
mediastinum. In both cases, it takes an arched course
laterally across the root of the neck, posterior to the scalenus
anterior and on the anterior surface of the cervical dome of
pleura, a short distance below its summit. At the outer
border of the first rib it becomes the axillary artery.

For descriptive purposes the artery is divided into three

parts. The first part extends from the origin of the vessel
to the medial margin of the scalenus anterior ; the second
portion lies posterior to that muscle ; and the third part
extends from the lateral border of the scalenus anterior to
the outer border of the first rib.

First Part. Owing to the difference of origin, the relations

of the first portion of the subclavian artery are not the same
on the two sides of the body. The first part of the right
subclavian extends obliquely upwards and laterally, and at its
termination at the medial margin of the scalenus anterior
it has reached a point above the level of the clavicle. It is
placed very deeply. Anteriorly, it is covered by the skin,
superficial fascia, platysma, deep fascia, and three muscular
strata viz., the clavicular origin of the sterno-mastoid, the
sterno-hyoid, and the sterno-thyreoid. Three veins and some
nerves are placed anterior to it. At the medial margin of
the scalenus anterior it is crossed by the internal jugular
and vertebral veins, whilst the anterior jugular vein, as it
passes laterally under cover of the sterno-mastoid, is separated
from it by the sterno-hyoid arid sterno-thyreoid muscles. The
nerves which cross anterior to it are the vagus, a loop from
the sympathetic (ansa subclavia), and in some cases cardiac
branches of the vagus and sympathetic as they run to the
in 1 c

152

HEAD AND NECK

thorax. At the lower margin of the artery the vagus nerve

gives off its recurrent branch.

The cervical dome of the pleura is both below and posterior

Basilar artery
- Vertebral artery

Vertebral artery

Vertebral artery
5th cervical vertebra
Scalenus anterior -
Transverse cervical artery -
Inferior thyreoid artery ~
Thyreo-cervical trunk -
Transverse scapular art. ..
Superior inter-
costal arte
Right common
carotid

Innominate /

artery /
Internal /

mammary
artery

Deep cervical artery

Inferior thyreoid artery

,-- Scalenus anterior
Transverse cervical
artery

Costo-cervical trunk
Transverse
"scapular artery
Superior intercostal art.
Subclavian artery

Left subclavian
- - artery

Left common
carotid

Internal

mammary

artery

FIG. 56. Diagram of Subclavian Arteries and their

branches.

to the artery, and the recurrent branch of the vagus nerve

hooks round below and ascends posterior to it. 1

On the left side, the first part of the subclavian ascends

almost vertically from its origin from the aortic arch, and,

1 If the lung has been removed by the dissector of the thorax the lower
and posterior relations should be verified by examination from the thoracic
side.

THE ANTERIOR PART OF THE NECK 153

reaching the root of the neck, it curves laterally across the

dome of the pleura to the medial margin of the scalenus
anterior. The relations of the cervical part are somewhat
different from those on the right side. The same fascial
and muscular layers, and the same nerves and veins, are
anterior to it. Owing to its different direction, however, the
nerves and veins are placed more or less parallel to it. Three
additional relations are established viz., the phrenic nerve and
the left innominate vein lie anterior to it ; and the thoracic
duct first passes upwards in relation to its medial or right
side, and then arches over it to reach the angle of junction
between the subclavian and internal jugular veins (Fig. 55).

The recurrent nerve on the left side hooks round the arch
of the aorta, and lies to the medial side of the subclavian
artery.

Second Part. The second portion of the subclavian artery

forms the highest part or summit of the arch, and rises from
half an incr^ to an inch above the level of the clavicle.

In that part of its course the vessel has not so many

superficial relations. Anteriorly, it is covered by (i) skin;
(2) superficial fascia and platysma; (3) deep fascia; (4)
clavicular head of the sterno-mastoid ; (5) scalenus anterior.
The phrenic nerve on the right side is also an anterior
relation, but it is separated from the artery by the medial
margin of the scalenus anterior. Posteriorly and inferiorly,
the vessel is in relation with the pleura, Sibson's fascia inter-
vening. The subclavian vein lies at a lower level than the
artery and on an anterior plane, and is separated from it
by the scalenus anterior.

The third part of the subclavian artery is described on

p. 41.

Branches of the Subclavian Artery. Four branches

spring from the subclavian trunk (Fig. 56). Three take
origin, as a general rule, from the first part of the artery,
and one from the second part. They are

II. Vertebral. <-

( Inferior thyreoid.
2. Thyreo-cervical. 1 Transverse cervical,

i Transverse scapular.
3. Internal mammary.

From the (, , /"Superior intercostal.

second part. (Costo-cervical. (Deep cervical.

In a great number of cases a branch of considerable size springs from

154 HEAD AND NECK

the third part of the subclavian artery. In some cases it is the descend-
ing branch of the transverse cervical, which then arises directly from the
subclavian. In other cases it is the transverse scapular artery.

Arteria Vertebralis. The vertebral artery is the first

branch of the subclavian. It springs from the upper and
posterior aspect of the trunk, about 6.2 mm. (a quarter of an
inch) from the medial margin of the scalenus anterior, on the
right side, and from the point where the vessel reaches the
root of the neck, on the left side. Only a small portion of it
is seen in the present dissection. It proceeds upwards, in the
interval between the longus colli and the scalenus anterior
muscles, posterior to the common carotid, and disappears into
the foramen transversarium of the sixth cervical vertebra. It
is placed very deeply, and is covered anteriorly by its com-
panion vein and the common carotid artery. Numerous large
sympathetic twigs accompany it.

The vertebral artery on the left side is posterior to the

internal jugular vein and the common carotid artery, and it
is crossed by the thoracic duct.

The vertebral vein issues from the aperture in the transverse

process of the sixth cervical vertebra. It passes downwards,
antero-lateral to its companion artery, and posterior to the
internal jugular vein, to open into the posterior aspect of the
commencement of the corresponding innominate vein. Near
its termination it crosses the subclavian artery. It receives
the deep cervical and the anterior vertebral veins.

Truncus Thyreocervicalis (O.T. Thyroid Axis). The

thyreo-cervical trunk is a short wide vessel, which arises from
the anterior aspect of the subclavian artery, close to the
medial margin of the scalenus anterior, and under cover of
the internal jugular vein. It lies between the phrenic and
vagus nerves, and almost immediately breaks up into its
three terminal branches viz., the inferior thyreoid, the trans-
verse scapular, and the transverse cervical.

Arteria Thyreoidea Inferior. The inferior thyreoid artery

takes a sinuous course to reach the thyreoid gland. First, it
ascends for a short distance along the medial border of the
scalenus anterior, and under cover of the internal jugular
vein ; then, at the level of the cricoid cartilage, it turns
suddenly medial wards and passes posterior to the vagus, the
sympathetic, and the common carotid artery, to reach the
posterior border of the thyreoid gland. There it gives off

THE ANTERIOR PART OF THE NECK 155

branches to the pharynx and larynx, and then descends along

the posterior border of the thyreoid gland, distributing
branches to its substance and to the trachea and the
oesophagus.

The following branches will be noticed arising from the

inferior thyreoid artery :

1. Ascending cervical.

2. Inferior laryngeal.

3. Tracheal.

5. CEsophageal.

6. Glandular.

7. Muscular.

4. Pharyngeal.

Arteria Cervicalis Ascendens. The ascending cervical artery

(Fig. 5 i) is a small but constant vessel which runs upwards, in
the interval between the scalenus anterior and longus capitis,
and gives branches to the muscles in front of the vertebral
column. It also gives off spinal branches, which enter the
vertebral canal upon the spinal nerves, and anastomose with
branches from the vertebral artery. The ultimate distribu-
tion of the spinal branches has been noticed already (p. 79).

Arteria Laryngea Inferior. The inferior laryngeal artery is

a small vessel which accompanies the recurrent nerve to the
larynx.

The trachea^ otsophageal, and pharyngeal branches supply

the trachea, the gullet, and the pharynx. They are of small
size, and anastomose with the bronchial and cesophageal
branches of the thoracic aorta. The glandular branches are
usually two in number. One ascends upon the posterior
aspect of the corresponding lobe of the thyreoid gland, whilst
the other is given to its base or lower end. They inosculate
with the corresponding vessels of the opposite side, and also
with the branches of the superior thyreoid artery. The
muscular branches are a series of irregular twigs given to
neighbouring muscles.

Ventz Thyreoidetz Inferior es. The inferior thyreoid veins do

not run in company with the arteries of the same name. Each
is a comparatively large vessel which comes from the corre-
sponding lobe and the isthmus of the thyreoid gland, and
descends upon the trachea under cover of the sterno-thyreoid
muscle. The veins of both sides enter the thorax, and
frequently unite to form a short common stem, which opens
into the left innominate vein. In other cases, however, the
right vein opens separately into the angle of union between
the two innominate veins. Both veins, as they proceed

i 5 6 HEAD AND NECK

downwards, receive tributaries from the larynx, trachea and

oesophagus.

The anterior vertebral vein accompanies the ascending

cervical artery, and opens into the vertebral vein as it issues
from the foramen transversarium of the sixth cervical vertebra.

Arteriae Transversse Scapulae et Colli. The transverse

scapular and the transverse cervical arteries have already
been examined in the greater part of their courses (p. 34).
After taking origin from the thyreo-cervical trunk, they both
pass laterally, across the scalenus anterior muscle and the
phrenic nerve, under cover of the clavicular head of the
sterno-mastoid. The transverse scapular crosses the anterior
scalene muscle close to its insertion, immediately above the
subclavian vein ; the transverse cervical is placed at a slightly
higher level.

The transverse scapular and transverse cervical veins have

already been seen joining the external jugular vein (p. 40),

Arteria Mammalia Interna. The internal mammary artery

springs from the lower and anterior aspect of the subclavian,
directly below the thyreo-cervical trunk. It passes downwards
to reach the thorax, lying upon the anterior surface of the
pleura, and posterior to the medial end of the clavicle and
the medial end of the subclavian vein. As it lies posterior
to the subclavian vein the phrenic nerve passes from its
lateral to its medial side, either anterior or posterior to it.
In the neck the internal mammary artery is not accompanied
by a vein.

Truncus Costocervicalis. On the right side the costo-

cervical trunk takes origin from the posterior aspect of the
second portion of the subclavian artery, close to the medial
border of the scalenus anterior. To bring it into view the
subclavian artery must be dislodged from its position. On
the left side, however, it proceeds, as a rule, from the first
part of the parent trunk. It is a short trunk which passes
upwards and backwards, over the apex of the pleura, to the
neck of the first rib, where it divides into the deep cervical
artery and the superior intercostal artery.

If the lung is removed from the thorax, the dissector

should take the opportunity of examining this artery from the
thoracic aspect.

Arteria Cervicalis Profunda. The deep cervical artery

passes dorsally, and disappears from view between the
THE ANTERIOR PART OF THE NECK 157

transverse process of the seventh cervical vertebra and the

neck of the first rib. It has been already noticed in the
dissection of the back of the neck (p. 67).

The deep cervical vein is a large vessel. It joins the

vertebral vein.

Arteria Intercostalis Suprema. The superior intercostal

artery turns downwards, anterior to the neck of the first rib,
between the first thoracic nerve and the first thoracic ganglion
of the sympathetic trunk. It gives a posterior intercostal
branch to the first space and ends as the posterior intercostal
artery of the second space (Fig. 56).

Vena Subclavia. The subclavian vein is the continuation

of the axillary vein into the root of the neck. It begins
at the outer border of the first rib, and arches medially
across the anterior surface of the lower end of the scalenus
anterior. At the medial margin of that muscle, and posterior
to the sternal end of the clavicle, it unites with the internal
jugular vein to form the innominate vein. In connection with
the subclavian vein note: (i) that the arch which it forms
is not so pronounced as the arch of the corresponding
artery; (2) that throughout its whole course it lies at a
lower level, and upon a plane anterior to the artery; and
(3) that it is separated from the artery by the scalenus
anterior and the phrenic nerve. In the whole of its course
the vein lies posterior to the clavicle.

The sheath of the subclavian vein is attached to the posterior surface of

the costo-coracoid membrane. The relation is of some practical importance ;
for, on account of it, a forward movement of the clavicle drags upon the
vein, and in cases where the vessel is wounded there is always a danger of
air being sucked into the vein by such a movement.

The tributary of the subclavian vein is the external jugular

vein, which joins it at the lateral margin of the scalenus
anterior.

Ductus Thoracicus et Ductus Lymphaticus Dexter. The

thoracic duct is the vessel by means of which the chyle, and
the lymph derived from by far the greater part of the body,
are poured into the venous system on the left side (p. 147).
Its terminal or cervical portion is displayed in the dissection of
the neck. It is a small, thin-walled vessel, frequently mistaken
for a vein, which enters the root of the neck at the left
margin of the oesophagus. It is there that it should be
sought for. At the level of the seventh cervical vertebra it

158

HEAD AND NECK

arches laterally and forwards, and then downwards, above
the apex of the pleura, and it enters the innominate vein in the
angle of the union of the internal jugular vein with the

External jugular vein

k Platysma reflected with skin

iff* Nervus cutaneus colli

Internal jugular vein

Supra-clavicular
nerves

M. omohyoideus

Transverse cervi<
vein

Brachial plexus

Scalenus anterioi
Trans, cervical a
Trans, scapular i
External jugular
Subclavius
Cephalic vein
Axillary vein

Anterior jugular vein

Clavicular facet on sternum ,

Left common carotid

Left innominate vein

First rib
\ ' Dome of left pleura
1 Thoracic duct
I Internal mammary artery
Phrenic nerve
FIG. 57. Deep Dissection of the Root of the Neck on the Left Side to show
the Dome of the Pleura and the relations of the Terminal Part of the
Thoracic Duct. Parts of the sterno-mastoid and the sterno-thyreoid
have been removed.

subclavian. As the thoracic duct courses laterally it lies at

a higher level than the subclavian artery, and passes posterior to
the common carotid artery, the vagus nerve, and the internal
jugular vein ; and anterior to the vertebral artery and vein
and the thyreo-cervical trunk or its inferior thyreoid branch ;

THE ANTERIOR PART OF THE NECK 159

and as it runs downwards to its termination it is separated

from the scalenus anterior by the transverse cervical and
transverse scapular arteries and the phrenic nerve. Further,
as it approaches the point at which it ends, it lies anterior
to the first part of the subclavian artery (Figs. 55, 56).

A valve composed of two semilunar segments guards its

entrance into the innominate vein.

The right lymph duct is the corresponding vessel on the

right side, but it is a comparatively insignificant channel
which conveys lymph from a much more restricted area. It
commences in the root of the neck, where it is formed by
the union of the broncho-mediastinal^ trunk with the sub-
clavian and jugular lymphatic trunks of the right side. It
terminates in the commencement of the innominate vein
by opening into it in the angle of union of the subclavian
and internal jugular veins. As in the case of the thoracic
duct, its orifice is guarded by a double valve. Through
the broncho-mediastinal trunk it receives lymph from the
intercostal glands which lie in the upper intercostal spaces
of the right side, and from the thoracic visceral lymph
glands of the right side ; and, through the right subclavian
and jugular lymph trunks, lymph is poured into it from the
right upper extremity and the right side of the head and
neck, respectively. It constitutes, therefore, the main lymph
drain for the following districts: (i) right upper limb ; (2)
right side of the head and neck; (3) upper part of right
thoracic wall ; (4) right side of diaphragm and upper surface
of liver; (5) thoracic viscera on right side of median plane,
viz., right side of the heart and pericardium and the right
lung and pleura. But not uncommonly the broncho-medi-
astinal, the right jugular and subclavian lymph trunks open
separately into the internal jugular, the subclavian or the inno-
minate vein.

Cervical Pleura. The pleural sac of each side, with the

apex of the corresponding lung, projects upwards into the
root of the neck, and the dissector should now examine the
height to which it rises, and the connections which it estab-
lishes. Its height, with reference to the first pair of costal
arches, varies in different subjects. In some cases it extends
upwards for two inches above the sternal end of the first
rib ; in others, for not more than one inch. The differences
depend on the degree of obliquity of the thoracic inlet.

i6o

HEAD AND NECK

Posteriorly, in the majority of cases, the apex of the pleura

corresponds, in level, with the neck of the first rib. It forms
a dome-like roof for each side of the thoracic cavity, and is
strengthened by a fascial expansion (frequently termed Sibson's
fascia), which covers it completely, and is attached, on the
one hand, to the transverse process of the seventh cervical

Parotid duct

Accessory parotid gland

/ M. pterygoideus internus

/, /

Mandible

ubmaxillary duct'
Mucous membrane

Sublingual gland

Tongue

M. mylohyoideus
M. digastricus (anterior belly)

Lingu 1 nerv
Mandible

-M. mylohyoideus
Surface of submaxi
^~~lary gland covered

by mandible
Surface covered by
integument and fasciae

FIG. 58. Dissection of the Parotid, Submaxillary, and Sublingual Glands.

vertebra, and, on the other, to the inner margin of the

first rib.

Note that it is in relation with : (i) the scalenus anterior;

(2) the scalenus medius ; (3) the subclavian artery; (4) the
vertebral artery ; (5) the costo-cervical trunk ; (6) the superior
intercostal artery; (7) the internal mammary artery; (8) the
innominate vein ; (9) the vertebral vein ; (10) the subclavian
vein; (n) the vagus nerve ; (12) the phrenic nerve ; (13) the
recurrent nerve, on the right side; (14) the first thoracic

THE ANTERIOR PART OF THE NECK 161

nerve; (15) the first thoracic ganglion of the sympathetic;

(16) the ansa subclavia (Vieussenii).

The scalenus anterior covers the antero-lateral part of the

dome, separating it from the subclavian vein, which ends at
the medial border of the muscle. Immediately above the
vein the subclavian artery crosses the dome, below its apex.
The internal mammary artery descends from the subclavian,
passes posterior to the subclavian vein, and is crossed, as it
lies behind the vein, by the phrenic nerve, which passes in
some cases anterior to, and in others posterior to the artery.
The costo-cervical trunk ascends from the subclavian and
crosses the apex of the dome ; its superior intercostal branch
descends, posterior to the apex, between the first intercostal
nerve on the lateral side, and the first thoracic sympathetic
ganglion on the medial side. The vagus nerve descends
anterior to the medial part of the subclavian artery, and, on
the right side, its recurrent branch turns round the lower
border of the artery ; the ansa subclavia lies to the lateral
side of the recurrent nerve.

PAROTID REGION.

It is not possible to examine the relations of either the

whole of the internal jugular vein or the external carotid
artery, or the whole of the cervical portion of the internal
carotid, until the parotid gland has been removed, the infra-
temporal and submaxillary regions have been dissected, and
the posterior belly of the digastric and the styloid process
have been detached and displaced forwards. It is important,
however, that the internal jugular vein should be retained in
position whilst those parts of the dissection are being pro-
ceeded with ; the dissector should therefore stitch the sub-
clavian vein to the anterior surface of the scalenus anterior,
and the lower part of the internal jugular vein to the first
part of the subclavian artery, before proceeding to the study
and removal of the parotid gland.

Glandula Parotis. The parotid gland is wedged into a

more or less triangular interval, the parotid space, which is
bounded anteriorly by the posterior borders of the masseter,
the ramus of the mandible, and the internal pterygoid, and
postero-medially by the anterior border of the sterno-mastoid,

VOL. in 11

162

HEAD AND NECK

the mastoid process, the posterior belly of the digastric, the

styloid process, and the stylo- hyoid muscle. The space
extends upwards to the external acoustic meatus, and it is
prolonged downwards into the carotid triangle, into which
the lower extremity of the gland descends, for a short
distance, beyond the angle of the mandible. The gland,
however, is more extensive than the space and passes for a
varying distance forwards, beyond the anterior border of the

1. Posterior facial vein

2. M. sternomastoideus

3. M. digastricus

4. Accessory nerve

5. Internal jugular

6. M. stylohyoideus

7. Glossopharyngeal //fe (H'W^ ,*'lV^ labl1 supenons

nerve

Maxillary sinus

M. zygomaticus
M. buccinatorius
M. temporal is

Palatine tonsil
Inferior alveolar vessels
and nerve

Pharynx

-M. stylopharyngeus
M. styloglossus
Internal carotid
Sympathetic
r agus and Hypoglossal

12 34567

FIG. 59. Transverse section through the Head at the level of the Hard
Palate. It shows the relations of the parotid gland, etc.

space, over the superficial surface of the masseter (Figs. 4, 58).

In accordance with the position which it occupies the
gland may be described as possessing four surfaces, two
extremities, and four borders. The surfaces are superficial
or lateral, postero-medial, antero-medial, and superior; the
extremities, upper and lower ; the borders, anterior, posterior,
medial, and superior. The medial border separates the
antero-medial from the postero-medial surface. The anterior
and posterior borders separate the lateral surface from the

PAROTID REGION

163

antero-medial and postero-medial surfaces, respectively. The

upper border circumscribes the upper surface and intervenes
between it and the other three surfaces.

The superficial surface is irregular in outline (Figs. 4 and

60). It is covered by skin, superficial fascia, platysma and
risorius, and deep fascia. Embedded in it are a few superficial
parotid lymph glands, which receive lymph from the anterior
part of the scalp, from the face, above the level of the mouth,
and from the lateral surface of the auricle. Posteriorly,
it is in relation with the mastoid process and the anterior

osterior part of
uerior border
superor

v Anterior part of superior border

-Surface in contact with external meatus

Anterior border

Duct of parotid
_ .Superficial surface

Posterior facial vein

Posterior border

FIG. 60. Parotid Gland, lateral view.

border of the sterno-mastoid muscle. Above, it touches the

posterior part of the lower border of the zygoma and the lower
surface of the external meatus.

From beneath the part in contact with the zygoma emerge

the auriculo-temporal nerve, the temporal branches of the
facial nerve, and the superficial temporal artery, on their way to
the scalp ; and the posterior facial vein disappears under cover
of it. Its lower extremity, which is wedged between the angle
of the mandible and the anterior border of the sterno-mastoid,
is usually in contact with one of the upper deep cervical glands,
whilst the cervical branch of the facial nerve, the posterior
facial vein, and a communication to the external jugular
vein emerge from it; the former two pass downwards and
forwards, and the latter one passes downwards and backwards,
m 11 a

164 HEAD AND NECK

From under cover of the anterior border, which rests upon

the masseter, the duct of the gland (Stensen's), the transverse
facial artery, and the zygomatic, buccal, and mandibular
branches of the facial nerve pass forwards ; and the transverse
facial vein disappears under cover of it.

The duct of the parotid gland (Stensen's), after appearing

from under cover of the anterior border of the gland, runs
forwards, across the masseter, at the level of a line drawn
from the lobule of the auricle to a point situated midway
between the red margin of the upper lip and the ala of
the nose. At the anterior border of the masseter it turns
inwards, at right angles to its former course, and after piercing
the sucking pad of fat, the buccinator fascia, the buccinator
muscle and the mucous membrane of the vestibule of the
mouth, it opens into the vestibule, on the apex of a papilla,
opposite the second molar tooth of the maxilla.

Immediately in front of the anterior border of the gland,

below the zygoma and above the duct, lies a small separated
portion of the gland substance called the accessory parotid its
duct opens into the main duct.

Dissection. The gland must be removed piecemeal as the

structures which pass through it are dissected out. The facial
nerve and its branches are the most superficial structures in the
substance of the parotid ; therefore they must be dissected first.
Trace the terminal branches backwards into the gland until they
join the main divisions, which are the upper and the lower.
The temporal and zygomatic branches spring from the upper
division ; the buccal, mandibular, and cervical spring from
the lower division. Follow the divisions backwards, across the
posterior facial vein, to their union with the trunk of the nerve,
which pierces the postero-medial surface of the gland ; then trace
the trunk, across the root of the styloid process, to the stylo-mastoid
foramen, and secure the branch which springs from it to supply
the posterior belly of the digastric and the stylo-hyoid muscles,
and the posterior auricular branch. As the trunk of the nerve
is being cleaned the posterior auricular branch of the external
carotid artery will probably be exposed, passing upwards and
backwards, along the upper border of the posterior belly of the
digastric, to the back of the external meatus, and crossing either
superficial or deep to the nerve. Next, remove the deeper parts
of the gland and expose the posterior facial vein, descending
towards the angle of the mandible. It receives the transverse
facial and the internal maxillary veins, and it gives off a com-
municating branch to the external jugular vein ; then it passes
out of the lower end of the gland and unites with the anterior
facial vein to form the common facial vein. Deep to the veins
will be found the upper end of the external carotid artery dividing
into its superficial temporal and internal maxillary branches ;

PAROTID REGION . 165

and the transverse facial and middle temporal offsets of the

superficial temporal will also be displayed.

When the remains of the deeper part of the gland have been
removed, the styloid process with the origin of the stylo-hyoid
muscle, and the posterior belly of the digastric will be exposed ;
and the internal jugular vein and the internal and external
carotid arteries will be seen disappearing under cover of the
digastric. If the occipital artery lies at its lower level, it also
will be noted as it runs upwards and backwards, along the lower
border of the digastric, crossing superficial to the two large
vessels, and to the accessory nerve, which emerges from under
cover of the digastric and passes downwards and backwards
across the internal jugular vein.

The dissector should now obtain a gland which has been

removed uninjured from the parotid space, or a cast of a
gland, and proceed to study the relations of the upper end
and the postero-medial and antero-medial surfaces.

The upper surface presents a deep concavity which is

usually separable into a larger lateral part which lies in
contact with the cartilaginous part of the external meatus,
and a smaller medial part which touches the bony wall of the
meatus (Fig. 61). The anterior boundary of the upper
end forms a sharp ridge, which lies in the narrow interval
between the capsule of the mandibular articulation and the
front of the external meatus.

The postero-medial surface is marked by a series of depres-

sions which correspond with the structures in the postero-
medial boundary of the parotid space. Above is a shallow
depression corresponding with the anterior border of the
mastoid process, and, below the latter, a groove caused by the
anterior border of the sterno-mastoid. More medially is a
shallow depression due to the posterior belly of the digastric
and the stylo-hyoid, and, still more medially and at a higher
level, a sulcus which corresponds with the position of the
styloid process. Below the level of the digastric groove the
postero-medial surface covers portions of the internal jugular
vein and the internal and external carotid arteries (Fig. 61).
The communication to the external jugular vein, the posterior
facial vein, and the cervical branch of the facial nerve emerge
from that part of the surface. Immediately above the digastric
groove, close to the medial border, the external carotid artery
enters the gland ; and, directly lateral to the upper end of the
groove for the styloid process, the facial nerve passes into the
gland substance (Fig. 62). The dissector should note that

in 11 b

166 HEAD AND NECK

the postero-medial surface of the gland is separated from the

upper parts of the internal jugular vein and the internal
carotid artery, and from the last four cerebral nerves by the
posterior belly of the digastric, the styloid process and the
muscles attached to it.

The medial border of the gland lies in the angle between

the postero-medial and the anterior boundaries of the parotid
space, where the styloid process, the stylo-hyoid muscle, and
the posterior belly of the digastric disappear under cover of
the posterior border of the internal pterygoid muscle ; and

Anterior part of superior borde

Area for cartilage of external meatus

Area for bone of external meatu

Posterior part of superior border

Mastoid area --3^^m

Styloid area ~.\ *
Facial nerve -4s-Sgft
Posterior auricular artery _^J
Ridge between digastric
and sterno-mastoid areas I

External carotid artery

I
I

Posterior border-'
Sterno-mastoid groove

Posterior facial vein

FIG. 6 1. Parotid Gland, postero-medial aspect.

from it a process, the pterygoid lobe, usually projects forwards,

for a short distance, between the internal pterygoid and the
medial surface of the ramus of the mandible. Through the
base of that process the external carotid passes from the
postero-medial to the antero-medial surface of the gland.

The antero-medial surface. The medial part of the

antero-medial surface is directed forwards and lies in relation
with the lower part of the posterior border of the internal
pterygoid, the stylo-mandibular ligament, and the posterior
border of the ramus of the mandible. The more lateral part is
directed medially and rests against the lateral surface of the
masseter. The antero-medial surface is pierced (i) by the
external carotid artery, (2) the posterior facial and the internal

PAROTID REGION 167

maxillary veins, (3) all the terminal branches of the facial

nerve except the cervical, and (4) by the duct of the gland.

As the dissector examines the parotid space he will note

that as the external carotid disappears under cover of the
posterior belly of the digastric it is placed so far forwards
that it is also under cover of the posterior border of the
mandible ; and it does not emerge from under cover of the
mandible until it reaches the level of the neck of the bone,
where it appears on the antero - medial surface of the
gland and divides into its two terminal branches. Further,
he will now readily recognise the impossibility of studying

Anterior part of

superior border',.

Posterior facial vein

Area for neck of mandible (
Transverse facial artery

Superficial temporal artery

Internal maxillary artery
Internal maxillary vein
Anterior border

Communication to ex- _

ternal jugular vein "^M

Posterior facial vein TT-^J External carotid artery

FIG. 62. Parotid Gland, antero-medial aspect.

the upper end of the cervical part of the internal carotid,

the upper part of the internal jugular vein, and the last
four cerebral nerves, until he is in a position to reflect the
posterior belly of the digastric and the styloid process ; and
as both of them are, to a certain extent, under cover of the
mandible it is obvious that the mandible must be removed.
That will be done during the dissection of the temporal and
infratemporal regions, which must now be proceeded with.

TEMPORAL AND INFRATEMPORAL REGIONS.

Fascia Temporalis. The temporal fascia is a strong,

glistening membrane which is stretched over the temporal
fossa, binding down the temporal muscle. Its upper margin

1 68 HEAD AND NECK

is attached to the upper temporal line on the lateral aspect

of the parietal bone, and anteriorly to the temporal line of the
frontal bone. As it approaches the zygomatic arch, it splits into
two laminae, which are separated from each other by a narrow
interval filled with fat. The two laminae are attached one to
the upper border of the zygomatic arch and the posterior
border of the zygomatic bone, and the other to the medial
surfaces of those two portions of bone. They can readily
be demonstrated by dividing the superficial layer close to its
attachment, and throwing it upwards ; by the handle of the
knife the attachment of the deep layer can then be made out.
In the upper part of its extent, the temporal fascia is com-
paratively thin and the fibres of the subjacent muscle may
be seen shining through it ; below, it is thicker, and owing
to the fat which is interposed between its laminae, it is
perfectly opaque. It is pierced immediately above the
posterior part of the zygomatic arch by the middle temporal
branch of the superficial temporal artery and by the middle
temporal vein (p. 48).

Musculus Masseter. The masseter is a thick quadrate

muscle which covers the ramus of the mandible. Its
fibres are arranged in two sets a superficial and a deep.
The superficial part of the muscle arises from the anterior two-
thirds of the lower border of the zygomatic arch, and its
fasciculi are directed downwards and backwards. The deep
part springs from the whole length of the medial aspect of the
zygomatic arch, and also from the posterior third of its lower
border. Its fibres proceed downwards. Only a small piece
of the upper and posterior part of the latter portion appears
on the surface. The masseter is inserted into the lateral
surface of the ramus of the mandible, over an area which
extends downwards to the angle, and upwards so as to include
the lateral aspect of the coronoid process. The masseter
raises the mandible and helps to protract it. The deeper
fibres which run downwards and forwards when the mandible
is protracted help to retract the protracted bone. The nerve
of supply is derived from the mandibular division of the
trigeminal nerve.

Dissection. Turn the upper part of the posterior margin of

the masseter forwards and secure its nerve and artery of supply
which pass to it through the incisura mandibularis, behind the
tendon of the temporal muscle. To display the temporal muscle,

TEMPORAL AND INFRATEMPORAL REGIONS 169

make the following dissection. Divide the deep part of the

temporal fascia along the upper border of the zygomatic arch
and remove it. The middle temporal artery and the zygomatico-
temporal nerve, which pierce it, must be disengaged from it and
preserved. Divide the zygomatic arch, behind and in front
of the masseter, and throw the arch, with the attached masseter,
downwards. As that is being done cut the artery and nerve of
supply out of the masseter muscle, leaving a small portion of
the muscular substance attached to them so that they may be
identified at later stages of the dissection. First make use of
the saw, and then complete the division by means of the bone
forceps. The posterior cut should be made immediately anterior
to the articular tubercle which lies in front of the mandibular
(O.T. glenoid) fossa and the head of the mandible ; the anterior
cut must extend obliquely through the zygomatic bone, from the
extreme anterior end of the upper margin of the arch, down-
wards and forwards to the point where the lower margin meets
the zygomatic process of the maxilla. When the division is
completed, and the nerve and artery to the masseter are detached,
the whole arch and the attached masseter may be readily thrown
downwards towards the angle of the mandible. The fleshy
origin of the deep portion of the masseter from the medial
surface of the zygomatic arch can then be seen. The dissection
is frequently complicated by a number of fibres from the temporal
muscle joining the deep part of the masseter. Leave the masseter
attached to the angle of the mandible, and clean the temporal
muscle.

Musculus Temporalis. The temporal muscle is fan-shaped.

It arises from the whole extent of the temporal fossa, from the
lower temporal line to the infratemporal crest on the great
wing of the sphenoid. It receives additional fibres also from
the deep surface of the temporal fascia. From their broad
origin the fasciculi converge towards the coronoid process
of the mandible. The anterior fibres descend vertically, the
posterior fibres at first pursue a nearly horizontal course, whilst
the intermediate fasciculi proceed with varying degrees of
obliquity. A tendon is developed upon its superficial aspect,
near its insertion, and the tendon is inserted into the summit
and anterior edge of the coronoid process. The deep part
of the muscle remains fleshy, and gains insertion to the medial
surface of the coronoid process by an attachment which reaches
as low down as the point where the anterior margin of the
ramus merges into the body of the mandible. The insertion
cannot be fully examined at present; it will be dealt with
later. The temporal muscle raises the mandible and retracts
it. It is supplied by a branch of the mandibular division of
the trigeminal nerve.

Dissection. Detach the coronoid .process from the mandible,

1 70 HEAD AND NECK

and turn it upwards with the attached temporal muscle. A

very oblique cut is required ; it should extend from the centre
of the incisura mandibulae above, downwards and forwards,
to the point where the anterior margin of the ramus meets the
body of the mandible. First use the saw, and then complete
the division with the bone forceps. The buccinator nerve
(O.T. long buccal) and its companion artery are in a position of
danger during this dissection, and must be carefully guarded.
They proceed downwards and forwards, under cover of the lower
part of the temporal muscle, and not infrequently the nerve
traverses the substance of the muscle. The coronoid process
and the temporal muscle must be thrown well upwards, and the
muscular fibres must be separated, by the handle of the knife,
from the bone forming the lower part of the temporal fossa, in
order that deep temporal nerves and arteries may be exposed,
as they ascend between the cranial wall and the muscle. At
this stage the middle temporal artery will also be exposed as it
extends upwards upon the squamous part of the temporal bone.
If it is injected branches will be found passing from it to the
temporal muscle. The zygomatico -temporal nerve should now
be traced to the point where it emerges from the minute aperture
on the temporal surface of the zygomatic bone. At that point
it lies under cover of the temporal muscle.

The infratemporal region (O.T. pterygo-maxillary) may now

be fully opened up by removing a portion of the ramus of the
mandible. Two horizontal cuts must be made one through
the neck of the mandible, and the other immediately above the
level of the mandibular (O.T. inferior dental) foramen. To
find the level of the foramen, thrust the handle of the knife
between the ramus and the subjacent soft parts, and carry it
downwards. Its progress will soon be arrested by the entrance
of the inferior alveolar vessels and nerve into the foramen, and
the lower border of the instrument will correspond with the line
along which the bone should be cut. Both incisions should
be made with the saw, until the lateral table of the bone is
cut through, and then the bone forceps may be employed to
complete the division. Lastly, remove the fat and areolar
tissue.

When the fat and areolar tissue are removed, the pterygoid
muscles will come into view. The external pterygoid extends
backwards to the neck of the mandible. The internal pterygoid,
embracing the anterior part of the external pterygoid muscle
between its two heads of origin, proceeds downwards and
backwards upon the deep surface of the ramus of the mandible.
The great blood vessel of the space the internal maxillary artery
passes forwards upon (frequently under cover of) the lower
head of the external pterygoid muscle. The nerves of the region
also will be found in close relationship to the same muscle.
Emerging from between its upper border and the cranial wall,
at the level of the infratemporal crest, are the masseteric and
the posterior deep temporal nerves posteriorly, and the anterior
deep temporal nerve anteriorly ; appearing from under cover of
its lower border are the inferior alveolar nerve, which descends
to the alveolar foramen of the mandible, and more anteriorly
the lingual nerve ; whilst emerging between the two heads of
the external pterygoid is the buccinator nerve. The spheno-

TEMPORAL AND INFRATEMPORAL REGIONS 171

mandibular ligament also will be seen. It is the thin strip of

membrane which lies medial to the inferior alveolar nerve.

Musculus Pterygoideus Externus. The external pterygoid

arises in the infratemporal fossa by two heads, an upper and
a lower. The upper head, which is the smaller, springs from
the infratemporal ridge and infratemporal surface of the great
wing of the sphenoid ; the lower head takes origin from the

M. temporalis

.Deep temporal artery

/Deep temporal nerve

Deep temporal artery

Deep temporal nerve

Masseteric nerve

M. buccinator

Superficial temporal artery

Auriculo-temporal nerve

M. pterygoideus externus
Middle meningeal artery
Mastoid process
External carotid

Accessory meningeal artery

Inferior alveolar artery

' Mylo-hyoid artery and nerve

1 Inferior alveolar nerve
Lingual nerve
M. pterygoideus internus

FIG. 63. Dissection of the Infratemporal Region.

lateral surface of the lateral pterygoid lamina. The muscle

diminishes in width as it passes backwards, and it is inserted
into the fovea on the anterior surface of the neck of the
mandible, and also into the capsule of the mandibular articu-
lation at the level of the anterior margin of the articular
disc of the joint. It protrudes and depresses the mandible
and pulls it towards the opposite side. It is supplied by a
branch of the mandibular division of the trigeminal nerve.

172 HEAD AND NECK

Musculus Pterygoideus Interims. The internal pterygoid

also is bicipital at its origin, and its two heads embrace the
origin of the lower head of the external pterygoid. The
superficial and smaller head of the internal pterygoid springs
from the lower and posterior part of the tuberosity of the
maxilla behind the last molar tooth, and also from the adjoin-
ing lateral surface of the pyramidal process (O.T. tuberosity)
of the palate bone; the deep head, hidden by the external
pterygoid, arises in the pterygoid fossa from the medial
surface of the lateral pterygoid lamina, and from the posterior
surface of the pyramidal process of the palate bone which
appears between the two pterygoid laminae. The two heads
of the muscle unite at the lower margin of the anterior part
of the external pterygoid, and the fibres proceed downwards
with a postero-lateral inclination, and gain insertion into the
angle of the mandible, and into the lower and posterior part
of the medial aspect of the ramus as high as the mandibular
foramen. The internal pterygoid raises the mandible, pro-
trudes it, and pulls it towards the opposite side. It is
supplied by a branch of the mandibular division of the tri-
geminal nerve.

Arteria Maxillaris Interna. The internal maxillary artery

is the larger of the two terminal branches of the external
carotid artery. It takes origin immediately posterior to the
neck of the mandible and passes forwards to the anterior
part of the infratemporal fossa, where it disappears from view
by dipping between the two heads of origin of the external
pterygoid muscle and entering the pterygo-palatine fossa. It is
divided into three parts, for convenience of description. The
first part runs, horizontally, between the neck of the mandible
and the spheno-mandibular ligament. It lies along the
lower border of the posterior part of the external pterygoid
muscle, and usually crosses the inferior alveolar nerve super-
ficially. The second part extends obliquely upwards and
forwards upon the lateral surface of the lower head of the
external pterygoid muscle, under cover of the insertion of the
temporal muscle. The third part dips between the two heads
of the external pterygoid into the pterygo-palatine fossa
(Fig- 63).

The arrangement described is that most frequently found,

but it is not uncommon to find the second part of the artery
lying in a deeper plane, viz. between the internal and external

TEMPORAL AND INFRATEMPORAL REGIONS 173

pterygoid muscles. In that case the vessel makes a bend

laterally, between the heads of the external pterygoid muscle
before entering the pterygo-palatine fossa.

The branches of the internal maxillary artery are classified

according to the portion of the vessel from which they spring.
Only one branch of the third part, viz. the posterior superior
alveolar artery, can be studied in this dissection. Those
arising from the first and second parts are :

FROM THE FIRST PART.

i. Arteria auricularis profunda.

i 2. Arteria tympanica.

| 3. Arteria meningea media.

4. Ramus meningeus accessorius.

5. Arteria alveolaris inferior.

FROM THE SECOND PART,

1. Arteria masseterica.

2. Kami pterygoidei.
3. Arterise temporales profundae.

4. Arteria buccinatoria.

Arteria Auricularis Profunda. The deep auricular artery

is a small vessel which pierces the anterior wall of the external
acoustic meatus to supply the skin which lines the meatus,
and also the superficial part of the tympanic membrane.

Artericz Meningea Media et Tympanica Anterior. The

middle meningeal and the anterior tympanic branches pass
upwards under cover of the external pterygoid muscle,
and, therefore, cannot be fully studied until that muscle is
reflected.

Arteria Alveolaris Inferior. The inferior alveolar artery

arises opposite the middle meningeal, and runs downwards,
along the lateral surface of the spheno-mandibular ligament,
to enter the mandibular foramen. It is generally accom-
panied by two venae comites, and it is placed posterior to the
inferior alveolar nerve. Just before entering the foramen,
the inferior alveolar artery gives off the slender mylo-hyoid
branch^ which runs downwards and forwards, with the corre-
sponding nerve, upon the deep aspect of the mandible, to the
digastric triangle of the neck.

The branches from the second part are given off for the
supply of the neighbouring muscles. The Masseteric passes
horizontally, posterior to the temporal muscle, with the nerve
of the same name, and has been seen entering the masseter
muscle. The Pterygoid Branches are irregular twigs to the

174 HEAD AND NECK

pterygoid muscles. The Deep Temporal Branches are two in

number anterior and posterior ; they pass upwards in fche
temporal fossa, between the bony wall of the cranium and the
temporal muscle. They supply twigs to the temporal muscle,
and they anastomose with the middle temporal artery. The
Buccinator Branch accompanies the buccinator nerve, and
is distributed to the buccinator muscle and the mucous
membrane of the cheek. It anastomoses with the external
maxillary (O.T. facial) artery.

Arteria Alveolaris Superior Posterior. The posterior

superior alveolar branch from the third part of the internal
maxillary artery, descends upon the posterior aspect of the
maxilla, and sends branches through the alveolar canals of
the maxilla for the supply of the upper molar and praemolar
teeth (Fig. 63). Some small twigs go to the gum, and
others supply the lining membrane of the maxillary sinus.

Plexus Pterygoideus et Vena Maxillaris Interna. The

veins of the infratemporal region are very numerous, but they
cannot be studied satisfactorily in an ordinary dissection.
They constitute a dense plexus, termed the pterygoid plexus,
around the external pterygoid muscle. Tributaries corre-
sponding to the branches of the internal maxillary artery open
into the network, whilst the blood is led away from its
posterior part by a short wide trunk, called the internal
maxillary vein. 1 That vessel accompanies the first part of
the internal maxillary artery into the parotid gland, where
it joins the posterior facial vein behind the neck of the
mandible.

The pterygoid venous plexus is connected with the

cavernous sinus by an emissary vein. It communicates with
the inferior ophthalmic vein, through the inferior orbital fissure,
and with the anterior facial vein by an anastomosing channel,
called the deep facial vein, which descends across the external
surface of the buccinator muscle.

Articulatio Mandibularis. Before the external pterygoid

muscle is thrown forwards, the mandibular joint must be
examined. It is a diarthrodial joint of the ginglymus type,
and its cavity is separated into an upper and a lower part
by an articular disc. In connection with it there are the
following ligaments :

1 The internal maxillary vein may be replaced by two venae comites.

TEMPORAL AND INFRATEMPORAL REGIONS 175

LIGAMENTS PROPER.

Capsula articularis.

Lig. temporo-mandibulare.

ACCESSORY LIGAMENTS.

2. Lig. spheno-mandibulare.

3. Lig. stylo-mandibulare.

Discus ARTICULARIS.

The articular capsule encloses the joint cavity. Above, it is

attached posteriorly, laterally and medially to the margin of
the mandibular fossa, and, anteriorly, to the anterior margin
of the articular tubercle. Below, it is attached to the neck of

Tuberculum articulare

Upper joint cavity

Discus articularis \
Lower joint cavity
Capsule \

Mastoid process

Styloid process

MANDIBLE

FIG. 64. Section through the Mandibular Joint.

the mandible ; and between its upper and lower attachments

it is connected with the margins of the articular disc.

The temporo-mandibular ligament is a strong triangular

band of the capsule attached, by its base, to the lateral surface
of the posterior part of the zygoma and to the tubercle at the
root of the zygoma. Its fibres run downwards and backwards
to the lateral margin of the neck of the mandible.

The spheno-mandibular ligament (O.T. internal lateral] is a

long membranous band which extends from the spine of the
sphenoid to the lingula of the mandible and to the sharp
medial margin of the mandibular foramen. It is not in direct
relationship with the joint. Above, it lies medial to the
external pterygoid muscle and the auriculo-temporal nerve;
lower down, the internal maxillary vessels intervene between

176 . HEAD AND NECK

it and the neck of the mandible ; whilst, still lower, the

inferior alveolar vessels and nerve are interposed between
it and the ramus of the mandible.

The stylo-mandibular ligament is a fibrous band, derived

from that portion of the deep cervical fascia which forms
a part of the capsule of the parotid gland. It is attached,
above, to the styloid process, and, below, to the angle and
posterior border of the ramus of the mandible, between the
internal pterygoid and masseter muscles.

An examination of the spheno-mandibular and stylo-

mandibular ligaments will show that very little is added to

the strength of the joint by

their presence. The security
of the joint depends not so
much upon its ligaments as
upon the strong muscles of
mastication, which keep the
head of the mandible in its
place.

The articular disc is an

/ oval plate of fibre-cartilage,
' with its long axis directed
transversely. It is inter-
'' posed between the condyle

FIG. 65. Diagram of the different o f t h e mandible below and

positions occupied by the head of the ,, j-u i r <r\ T 1

mandible and the discus articularis the mandlbular fossa (O.T.

as the mouth is opened and closed. glenoid) and the articular

tubercle (O.T. eminentia

articularis) above, and it divides the joint cavity into an upper

and a lower part, each of which is provided with a separate
synovial lining. To expose the disc, the temporo-man-
dibular ligament must be removed. The disc will then be
seen to be adapted to the two bony surfaces between which
it lies. Above, it is concavo-convex in correspondence with
the tuberculum articulare and the mandibular fossa of the
temporal bone ; whilst below, it is concave, and fits upon
the upper aspect of the condyle of the mandible. In the
centre it is thin, and in some cases it is perforated. Its
circumference is thick, more especially posteriorly. It should
be noted also that the external pterygoid muscle is partly
inserted into the capsule at its anterior border.

The synovial stratum which lines the capsule enclosing the

TEMPORAL AND INFRATEMPORAL REGIONS 177

upper cavity of the joint is of greater extent and looser than

that of the lower compartment. The greater extent of the
synovial stratum of the upper cavity of the joint is associated
with the larger size of the articular surface of the temporal
bone as contrasted with the condylar surface.

Movements. The movements which the mandible can perform at

the mandibular joint are the following: (i) depression; (2) elevation ;
(3) protraction ; (4) retraction ; (5) side to side or chewing movements.
When the mandible is depressed the articular disc and the condyle
move forwards in the mandibular fossa, and the condyle finally takes
up a position on the tuberculum articulare. The forward gliding of
the disc and condyle in the upper compartment of the joint is accom-
panied by another movement in the lower compartment of the joint,
which consists in a rotation of the condyle of the mandible on the
lower surface of the articular disc. Elevation of the mandible or closure
of the mouth is brought about by a reverse series of changes in both
compartments of the joint. There is some doubt about the position of
the transverse axis around which the movements of elevation and depres-
sion take place, but it is generally supposed to be situated at the level of
the mandibular foramina. Those are the points, therefore, of least move-
ment, and consequently in opening and shutting the mouth the inferior
alveolar vessels and nerves are not unduly stretched. In protraction and
retraction the movement is confined chiefly to the upper compartment
of the joint, and the condyle of the mandible, with the articular disc,
glides forwards and backwards upon the temporal articular surface. In
the side to side movements of the jaw the mandible is carried alternately
from one to the other side, as in the process of chewing.

The muscles on each side which are chiefly engaged in producing these
movements are the following: (i) depressors the platysma, the mylo-
hyoid, and the anterior belly of the digastric ; (2) elevators the masseter,
internal pterygoid, temporal ; (3) protractors the external pterygoid, and
to some extent the internal pterygoid and the superficial fibres of the
masseter ; (4) retractor the posterior fibres of the temporal and the deep
fibres of masseter ; (5) side to side movement is produced by the muscles
of opposite sides acting alternately.

Dissection. The condyle of the mandible must now be

disarticulated and thrown forwards with the attached external
pterygoid muscle. It is well to detach the articular disc with
the head of the bone, in order that it may be more thoroughly
examined. Care must be taken not to injure the auriculo-
temporal nerve, which lies in close proximity to the medial
aspect of the joint. When the disarticulation is complete, draw
the muscle forwards by gently pushing the condyle under the
internal maxillary artery.

When the external pterygoid has been reflected and the

areolar tissue medial to it has been cleaned away the following
structures will be exposed. The middle meningeal artery ; the
mandibular division of the Irigeminal nerve and its branches ;
the chorda tympani branch of the facial nerve, and, in a well-
injected subject, the tympanic and accessory meningeal branches
of the internal maxillary artery may be seen. Follow the
middle meningeal artery upwards. Just before it enters the
foramen spinosum it passes between the two heads of origin by
VOL. Ill 12

1 78 HEAD AND NECK

which the auriculo -temporal nerve springs from the back of

the posterior division of the mandibular nerve. Follow the
auriculo-temporal nerve backwards and note how close it lies
to the medial face of the capsule of the temporo-mandibular
joint, before it enters the parotid region and ascends behind
the condyle of the mandible to the temporal region. Next
clean the upper part of the inferior alveolar nerve. Then turn
to the lingual nerve ; first clean its surface, then pull it forwards
and secure the chorda tympani which joins its posterior border,
after passing medial to the inferior alveolar nerve. Note that
the mandibular nerve divides into anterior and posterior parts.
The posterior division gives off the two roots of the auriculo-
temporal nerve and then divides into the inferior alveolar and
lingual branches, whilst the anterior division supplies all the
muscles of mastication, except the internal pterygoid and sends
the sensory buccinator nerve to the mucous membrane and
skin over the buccinator muscle. Now secure the nerve to
the internal pterygoid muscle which springs from the anterior
part of the trunk of the mandibular nerve, and, if possible, the
small nervus spinosus which passes backwards and laterally to
the foramen spinosum.

Arterise Meningea Media et Tympanica et Eamus Menin-

geus Accessorius. The middle meningeal artery has already
been seen arising from the first part of the internal maxillary
artery. It passes upwards, medial to the external ptery-
goid muscle and lateral to the tensor veli palatini, and dis-
appears from view through the foramen spinosum, by which it
enters the cranial cavity (p. 118). It is usually embraced by
the two roots of the auriculo-temporal nerve.

The accessory meningeal artery and the tympanic artery generally arise
from the middle meningeal. The accessory meningeal inclines forwards and
upwards, and enters the cranial cavity by passing through the foramen
ovale ; the tympanic runs upwards and backwards, and reaches the
tympanum by passing through the petro-tympanic fissure (O.T. Glaserian).
In the tympanic cavity it anastomoses with the stylo-mastoid branch of
the posterior auricular artery.

Nervus Mandibularis. The mandibular branch of the tri-

geminal nerve arises, within the cranium, from the semilunar
(O.T. Gasserian) ganglion, and enters the infratemporal
region through the foramen ovale. It is composed of
sensory fibres, but it is accompanied through the foramen
by the small motor root of the trigeminal nerve ; and by the
union of the sensory and motor parts, immediately after
they gain the exterior of the cranium, a mixed nerve-trunk
results, which lies medial to the external pterygoid muscle and
lateral to the tensor veli palatini.

Immediately after its exit from the skull the mandibular

TEMPORAL AND INFRATEMPORAL REGIONS 179

nerve gives off the nervus spinosus and the nerve to the
internal pterygoid muscle, and, at a slightly lower level, it
divides into an anterior division, and a posterior division
which almost immediately breaks up into its lingual, alveolar
and auriculo-temporal divisions.

The nervus spinosus is a very slender twig which enters

the cranium by accompanying the middle meningeal artery

Tympanic plexus

Tympanic branch of
glosso-pharyngeal

Chorda tympani /

Auriculo-temporal
Inferior alveolar nerve

. Anterior deep temporal

uccinator nerve

Stylo-glossus
Mylo-hyoid nerve

Communication to hypoglos

Submaxillary ganglion

Hyoglossus

Genio-glossus

Mylo-hyoid muscle
Jranches of mylo-hyoid nerve -f

I si--

ental branch
Incisive branch
astric
FIG. 66. Diagram of Mandibular Nerve. (By Prof. A. M. Paterson. )
The tongue has been separated from its attachments and raised above
the level of the body of the mandible.

1. Ganglion geniculi

2. Carotico-tympanic nerve

6. Symp. root of otic ganglion

7.- Otic ganglion

12. Anterior division

13. Deep temporal

3. Lesser superficial petrosal . 8. Nerve to tensor tympani j 14. Lingual nerve

nerve 9. Nerve to tensor veli palatini 15. Masseteric branch

4. Internal carotid artery 10. Nerve to internal pterygoid 16. Pterygoid branch

5. Middle meningeal artery ! n. Mandibular nerve trunk

through the foramen spinosum. It supplies the dura mater,

and sends a twig into the tympanum.

The nerve to the internal pterygoid will be found, passing

forwards, under cover of the posterior border of the upper
end of the internal pterygoid muscle. In close relation to
its commencement is the otic ganglion.

The anterior division arises from the trunk of the man-

dibular nerve about 5 mm. below the foramen ovale. It
consists almost entirely of motor fibres derived from the

m 12 a

i8o HEAD AND NECK

motor root of the mandibular nerve ; but it contains also a

few sensory fibres which are afterwards distributed by its
buccinator branch.

It passes downwards and forwards on the medial side of

the external pterygoid muscle, and it gives off the following
branches :

1. Masseteric. 3. External pterygoid.

2. Two deep temporal. 4. Buccinator.

Nervus Massetericus. The masseteric nerve runs hori-
zontally above the external pterygoid muscle, and, after pass-
ing through the incisura mandibulae (O.T. sigmoid notch),
posterior to the temporal muscle, it enters the posterior and
upper part of the deep surface of the masseter. Before
reaching the masseter it gives one or two twigs to the
mandibular joint.

Nervi Temporales Profundi. There are usually two

deep temporal nerves, anterior and posterior. The posterior
nerve is the smaller of the two ; it frequently arises by a
common root with the masseteric. Both deep temporal
nerves pass laterally above the external pterygoid, and then
turn upwards on the medial wall of the temporal fossa. They
supply the temporal muscle.

Nervus Buccinatorius. The buccinator nerve (O.T. long

buccal) is the largest of the branches arising from the
anterior division. It proceeds laterally between the two
heads of the external pterygoid muscle, and then runs down-
wards and forwards under cover of the temporal muscle, and
under cover of the anterior border of the masseter also, to
reach the outer surface of the buccinator muscle. There it
unites with branches of the facial nerve to form the buccal
plexus, from which branches are distributed to the mucous
membrane and skin of the cheek.

The buccinator nerve is a sensory nerve, and all the sensory

fibres in the anterior division enter into its composition. A
few motor fibres, however, are also prolonged into it; they
leave it in two branches, viz., (i) in the nerve to the external
pterygoid, which, as a rule, arises in common with the buc-
cinator nerve; and (2) in the anterior deep temporal nerve
to the temporal muscle. The anterior deep temporal nerve
springs from the buccinator nerve, either before or after it
has reached the lateral surface of the external pterygoid, and
proceeds upwards to supply the anterior part of the temporal

TEMPORAL AND INFRATEMPORAL REGIONS 181

muscle (Fig. 63). In some cases the buccinator nerve pierces

the temporal muscle instead of passing under cover of it.

The posterior division of the mandibular nerve consists

mainly of sensory fibres, but it still contains a few motor
fibres which ultimately pass into its alveolar branch and
thence to the mylo-hyoid nerve.

Nervus Auriculo - Temporalis. The auriculo - temporal

nerve springs by two roots from the posterior division of
the mandibular nerve, under cover of the external pterygoid.
The two roots are composed of sensory fibres and each
receives a communication from the otic ganglion, by means of
.which it is brought, indirectly, into association with the glosso-
pharyngeal nerve. The roots embrace the middle meningeal
artery, and unite posterior to it to form a stem which runs
backwards between the neck of the mandible and the
spheno-mandibular ligament. At the interval between the ear
and mandible it turns upwards, in relation to the antero-medial
surface of the parotid gland, crosses the zygoma in company
with the superficial temporal artery, and enters the scalp,
where it breaks up into terminal branches (Fig. 51).

Its branches are: (i) one or two strong branches of

communication to the upper division of the facial nerve; (2)
a few slender filaments which enter the posterior aspect of
the mandibular joint; (3) some twigs to the parotid gland;
(4) terminal filaments to the skin over the temporal region
and summit of the head ; (5) auricular branches.

The auricular branches are usually two to the skin lining

the upper part of the interior of the external meatus, and two
to the integument over the upper and anterior part of the
auricle. The former gain the interior of the meatus by passing
between the osseous and cartilaginous portions of the canal.

Nervus Alveolaris Inferior. The inferior alveolar nerve

(O.T. inferior dental) is the largest branch of the posterior
division of the mandibular nerve. It emerges from under
cover of the external pterygoid, at the lower border of the
muscle, passes downwards along the lateral surface of. the
spheno-mandibular ligament, and enters the mandibular fora-
men. The inferior alveolar artery runs downwards posterior
to it, whilst the lingual nerve is anterior to it and upon a
somewhat deeper plane. The inferior alveolar is a sensory
nerve, but a few fibres from the motor root are prolonged
downwards within its sheath as far as the mandibular foramen.

in 12 b

182 HEAD AND NECK

At that point they separate off as the slender mylo-hyoid

nerve (Figs. 63, 68).

The mylo-hyoid nerve, accompanied by the artery of the

same name, pierces the spheno-mandibular ligament and
proceeds downwards and forwards, in a groove upon the
medial surface of the mandible, to the digastric triangle. A
narrow prolongation of the spheno - mandibular ligament
bridges over the groove and holds the nerve and vessel in
position. In the digastric triangle the mylo-hyoid nerve has
been dissected already (p. 129). It breaks up into numerous
branches for the supply of two muscles, viz., (i) the mylo-
hyoid, and (2) the anterior belly of the digastric (Fig. 68).

Nervns Lingualis. The lingual nerve is entirely sensory.

In the first part of its course, like the other branches of the
mandibular nerve, it lies medial to the external pterygoid
muscle. As it descends it appears at the lower border of
the muscle. Then it proceeds downwards and anteriorly,
between the internal pterygoid muscle and the mandible, and
enters the submaxillary region, where it will afterwards be
traced to the tongue. It lies anterior to and on a slightly
deeper plane than the inferior alveolar nerve. It gives off
no branches in the infratemporal region, but, whilst still
under cover of the external pterygoid, it is joined at an acute
angle by the chorda tympani branch of the facial nerve. Not
infrequently, also, a communicating twig passes between it
and the inferior alveolar nerve.

Chorda Tympani. The chorda tympani is a slender nerve

which arises from the facial in the canalis nervi facialis (O.T.
aqueduct of Fallopius). It gains the infratemporal region by
traversing the tympanic cavity and appearing through the
medial part of the petro-tym panic fissure (O.T. Glaserian),
whence it runs downwards and forwards, medial to the
spheno-mandibular ligament. It is joined by a slender
filament from the otic ganglion, and it unites with the lingual
nerve a short distance below the upper end of the latter.

Dissection. The student should now endeavour, by means

of a Key's saw, a chisel, and the bone forceps, to remove the
outer table of the mandible, and thus open up the mandibular
canal.

Structures within the Mandibular Canal. The mandibular

canal is traversed by the inferior alveolar vessels and nerve,
which give off twigs to the roots of the molar and praemolar

TEMPORAL AND INFRATEMPORAL REGIONS 183

teeth. Both the artery and the nerve terminate by dividing

into a mental and an incisor branch.

The mental artery and nerve appear on the face through

the mental foramen, and have been examined already ; the
incisor artery and nerve pass forwards to the symphysis and
send up twigs to the canine and incisor teeth. The vessel
anastomoses, in the bone, with the corresponding artery of
the opposite side.

SUBMAXILLARY REGION.

The superficial area of the submaxillary region has been

dissected already, under the name of the submental triangle
of the digastric triangle (p. 127). It is now necessary to
carry the dissection to a deeper plane, in order to expose a
number of parts in connection with the tongue and floor of
the mouth. The structures to be displayed are :

1. Submaxillary gland and its duct.

2. Sublingual gland.

3. Side of the tongue, and the mucous membrane of the mouth.

Mylo-hyoid.
Digastric.

Stylo-hyoid.

Hyoglossus.

Stylo-glossus.

Genio-hyoid.

Genio-glossus.

Mylo-hyoid.

4. Muscles.

Glosso-pharyngeal.

6. Submaxillary ganglion.

7. Lingual artery and veins.

8. Part of the external maxillary artery.

9. Stylo-hyoid ligament.

Dissection. To prepare the part for dissection, it is necessary

to throw back the head to its full extent, and turn it slightly to
the opposite side. If the stuffing in the mouth has not been
previously removed, it should be taken out now. When that
has been done, divide the external maxillary artery and the
anterior facial vein at the point where they cross the lower
border of the mandible. Next, detach the anterior belly of the
digastric from its attachment to the anterior part of the medial
aspect of the lower border of the mandible ; and then, with the
saw, cut through the mandible lateral to the median plane. 1

1 If the part is soft and pliable there may be no necessity to make this
division of the bone,
m 12 c

r8 4

HEAD AND NECK

It is essential that the division of the anterior part of the mandible

should be slightly lateral to the median plane on each side, in
order that the median part of the bone, with the attachments of
the genioid muscles, may be left intact.

After the division of the bone has been completed the lower
border of the lateral part of the mandible must be everted,

M. semispinalis ca
Posterior auricular

ununication frcm posterior facial vein

Int. jugular vein
Hypoglossal nerve
Posterior facial
Lesser occipital N.
Hypoglossal nerve
Great auricular N.

Suprascapul

FIG. 67. The Triangles of the Neck seen from the side. The clavicular head
of the sterno-mastoid muscle was small, arid therefore a considerable part
of the scalenus anterior muscle is seen.

turned slightly upwards, and fixed in position with hooks. When

that has been done the boundaries and contents of the sub-
maxillary region can be examined.

Part of the region has already been seen as the digastric

portion of the anterior triangle of the neck, but it will now be
obvious that the region occupied by the submaxillary gland is
much more extensive than the digastric triangle ; for, although

SUBMAXILLARY REGION 185

both are bounded anteriorly and posteriorly by the anterior and

posterior bellies of the digastric muscle, the upper boundary of
the digastric triangle is the lower border of the mandible, whilst
the submaxillary region extends upwards to the level of the
mylo-hyoid ridge on the inner surface of the mandible.

After the mandible has been turned upwards the dissector

should proceed, in the first place, to examine the relations of
the digastric and stylo -hyoid muscles, then the mylo-hyoid
muscle, and afterwards he must study the submaxillary and
sublingual glands and the deeper structures which are found in
the medial boundary of the submaxillary region.

Musculus Digastricus. The digastric muscle limits the

submaxillary region inferiorly, and separates it from the
carotid and submental triangles (Figs. 67, 68).

The anterior belly of the digastric springs from the inner

part of the lower border of the mandible, close to the
symphysis ; the posterior belly arises from the mastoid notch
of the temporal bone, on the medial side of the mastoid
process. The two bellies converge upon the upper border of
the hyoid bone, where they are united by an intermediate
tendon, which is attached to the hyoid bone, at the junction
of the body with the greater cornu, by a strong loop of fibrous
tissue developed from the deep cervical fascia. Posterior to
the loop, through which it plays, the intermediate tendon
passes through the cleft lower end of the stylo-hyoid muscle.

Relations. The anterior belly is covered by the skin,

superficial fascia and the platysma, and the deep fascia. It
is overlapped by the anterior border of the submaxillary gland,
and its deep surface is in contact with the mylo-hyoid muscle.
Its anterior border is the posterior boundary of the submental
triangle, and its posterior border is the anterior boundary of
the digastric triangle.

The relations of the posterior belly are more numerous

and important. Posteriorly, it is covered by the mastoid
process and the attachments of the sterno- mastoid and
splenius capitis muscles. Between the mastoid process and
the angle of the mandible it forms part of the postero-medial
boundary of the parotid space and is covered by the parotid
gland ; next, it is covered by the angle of the mandible and
the insertion of the internal pterygoid muscle. As it lies in
the anterior triangle it is covered by the skin, the superficial
fascia and platysma, and the deep fascia ; it is crossed by
the anterior facial vein, and is overlapped by the posterior
part of the submaxillary gland.

i86

HEAD AND NECK

30 i 2 3 4

29

23
FlG. 68. Deep dissection of the Infratemporal and Submaxillary Regions.

Masseter muscle.
Mandible.

Stylo-glossus muscle.
Stylo-pharyngeus muscle and glosso-

pharyngeal nerve.
Parotid gland.

Stylo-hyoid and digastric muscles

External maxillary artery.
Lingual artery.
Internal carotid artery and descending

branch of hypoglossal nerve.

Internal jugular vein.
External carotid artery.
Superior thyreoid artery.
Sterno-mastoid muscle.
External laryngeal nerve.
Sterno-hyoid muscle.
Omo-hyoid muscle.
Thyreo-hyoid muscle.

18. Laryngeal branch of superior thyreoid

artery and internal laryngeal nerve.

19. Hyoglossus muscle.

20. Deep part of submaxillary gland and

duct of gland.

21. Anterior belly of digastric muscle.

22. Submental branch of external maxillary

artery.

23. Mandible.

24. Inferior alveolar artery and nerve.

25. Mylo-hyoid nerve.

26. Mylo-hyoid muscle.

27. Position of last molar tooth of man-

dible.

28. Lingual nerve.

29. Internal pterygoid muscle.

30. Inferior alveolar nerve, and mylo-hyoid

branch with inferior alveolar artery.

It is superficial to the internal jugular vein, the internal

and the external carotid arteries, the external maxillary artery,

SUBMAXILLARY REGION 187

the middle constrictor of the pharynx, and the lower and

posterior part of the hyoglossus muscle. The accessory
nerve passes backwards and downwards between it and the
internal jugular vein, and the occipital artery passes upwards
and backwards under cover of its lower border, superficial
to the accessory nerve. The hypoglossal nerve descends
vertically on its deep surface in the angle between the
internal jugular vein and the internal carotid artery, and
the glosso-pharyngeal nerve passes forwards and downwards
between it and the internal carotid. The posterior auricular
artery runs upwards and backwards along the posterior part
of its upper border under cover of the postero-medial surface
of the parotid, and the stylo-hyoid muscle descends along the
same border (Fig. 68).

The posterior belly is supplied by the facial nerve, and the

anterior belly is supplied by the mylo-hyoid branch of the
inferior alveolar nerve.

If the digastric acts from its posterior attachment it

depresses the mandible. If the mandible is fixed and the
diagastric acts from its anterior attachment it helps to pull
the head backwards. If both the bellies act simultaneously
the hyoid bone is raised.

Musculus Stylohyoideus. The stylo-hyoid muscle is a

small muscular bundle which springs from the posterior
border and lateral surface of the middle third of the styloid
process and descends along the upper border of the posterior
belly of the digastric. It divides below into two slips
which embrace the intermediate tendon of the digastric
and are then inserted into the hyoid bone, at the junction
of the greater cornu with the body. Its main relations
are practically the same as those of the posterior belly of the
digastric, but it is not under cover of the mastoid process,
the sterno-mastoid, and the spienius muscles. It is supplied
by the facial nerve. It raises the hyoid bone and draws it
backwards.

Dissection. Turn the anterior part of the submaxillary

gland backwards, and clean the posterior part of the mylo-hyoid
muscle, which lies deep to it. Note that a process, the deep part
of the gland, springs from the medial surface of the superficial
part and passes forwards, deep to the mylo-hyoid. Dissect the
external maxillary artery out of the deep sulcus in the posterior
part of the gland, without injuring its submental branch, which
runs forwards, along the lower border of the mandible ; then

1 88 HEAD AND NECK

displace the posterior part of the gland forwards and expose

the hypoglossal nerve immediately above the greater cornu of
the hyoid bone, and, at a higher level, the lingual nerve. Both
nerves lie on the lateral surface of the hyoglossus muscle.
Hanging from the lower border of the lingual nerve is the small
submaxillary ganglion, from which several branches pass to the
gland. Note again the deep part of the gland, springing from
the medial surface of the superficial part, and also the duct of
the gland emerging from the superficial part of the gland and
passing forwards, with the deep part, between the mylo-hyoid
muscle laterally and the hyoglossus medially. Then study
the position and relations of the superficial portion of the gland.
The relations of the deep part will be seen after the mylo-hyoid
is reflected.

Glandula Submaxillaris. The submaxillary salivary gland

consists of a superficial larger portion and a deep smaller
portion. The superficial portion is lodged in a space which
is bounded anteriorly by the anterior belly of the digastric ;
posteriorly by the posterior belly of the digastric, the stylo-hyoid,
and the stylo-mandibular ligament ; below by the deep fascia
of the neck ; laterally by the medial surface of the body of
the mandible and the lower part of the medial surface of
the internal pterygoid muscle ; and medially by the mylo-
hyoid and hyoglossus muscles. The fascial relations of the
gland have been described already (p. 123). The dissector
should .note now that, in accordance with the contour of the
space in which it lies, he can recognise that the superficial
part of the gland possesses an anterior and a posterior
extremity, and three more or less well-defined surfaces,
inferior, lateral, and medial. The posterior extremity abuts
against the stylo-mandibular ligament, which separates it from
the parotid, and it overlaps the stylo-hyoid and posterior
belly of the digastric. It is cleft by a groove in which
lies the external maxillary artery. The anterior extremity
rests on the anterior belly of the digastric muscle.

The inferior surface is covered by the layer of deep

cervical fascia which extends upwards from the greater cornu
of the hyoid bone to the lower border of the mandible ; it
is crossed posteriorly, under cover of the deep fascia, by the
anterior facial vein. Along its upper border lie the majority
of the submaxillary lymph glands ; the external maxillary
artery turns round between it and the lower border of the
mandible, at the anterior border of the masseter ; and the sub-
mental branch of the external maxillary artery runs forwards
in the angle between it and the mandible.
SUBMAXILLARY REGION

189

The lateral surf ace is in relation, posteriorly, with the lower

part of the medial surface of the internal pterygoid, and
anteriorly with the medial surface of the body of the mandible,
below the mylo-hyoid ridge. The external maxillary artery,
as it lies in the groove in the posterior end of the gland,
and before it turns round the lower border of the man-
dible, runs forwards and downwards between this surface

Parotid duct

Accessory parotid gland

M. pterygoideus
internus

Mandible
imaxillary duct
Mucous membrane
Sublingual gland

Tongue

M. mylohyoideus
M. digastricus (anterior belly)

Lingual nerve
/Mandible

M. mylohyoideus
Surface of submaxil-
lary gland covered
by mandible
Surface covered by
integument and fasciae
FIG. 69. Dissection of the Parotid, Submaxillary, and Sublingual Glands.

and the internal pterygoid ; and the mylo-hyoid artery and

nerve lie between it and the body of the mandible before
they pass, more anteriorly, to the medial surface of the gland.
The medial surface is in relation with the mylo-hyoid and
hyoglossus, the lingual nerve and the submaxillary ganglion,
and the hypoglossal nerve. It overlaps the stylo-hyoid
muscle, both bellies of the digastric, and, sometimes, the
greater cornu of the hyoid bone. The deep part of the
gland and the duct both spring from the medial surface

1 90 HEAD AND NECK

before they pass forwards between the mylo-hyoid and the

hyoglossus muscles (Fig. 71).

The nerve supply of the gland is derived from the lingual

nerve, the submaxillary ganglion, and the sympathetic plexus
on the external maxillary artery ; its vascular supply consists
of small glandular branches from the external maxillary
artery.

The relations of the deep part of the gland and the duct
will be investigated after the mylo-hyoid has been reflected.

Dissection. Displace the superficial part of the gland and

the submental branch of the external maxillary artery backwards ;
cut the mylo-hyoid vessels and nerve, and turn the anterior belly
of the digastric downwards ; then clean the mylo-hyoid muscle
and examine its attachments.

Musculus Mylohyoideus. The mylo-hyoid muscle is a

thin sheet of muscular fibres, which arises from the mylo-
hyoid line upon the medial surface of the body of the
mandible, by an origin which extends from the last molar
tooth to the symphysis. Its fibres are directed downwards,
medially and forwards, and present two different modes of
insertion. The posterior fibres are inserted into the body of
the hyoid bone ; they, however, form a comparatively small
part of the muscle. Most of the fibres are inserted into a
median raphe which extends between the symphysis of
the mandible and the body of the hyoid bone. The two
mylo-hyoid muscles, therefore, stretch across from one side
of the body of the mandible to the other, in front of the
hyoid bone, and constitute a floor for the anterior part of the
mouth which is frequently termed the diaphragma oris. The
mylo-hyoid muscle is supplied by the mylo-hyoid branch of
the inferior alveolar nerve. It elevates the hyoid bone, the
tongue and the floor of the mouth in the movement of
swallowing.

Dissection. Cut the mylo-hyoid muscle a little below its

origin from the mylo-hyoid ridge and turn it downwards and
forwards. Be careful not to injure the mucous membrane of
the mouth, which lies in contact with the upper surface of the
muscle near its origin.

Parts exposed by trie Reflection of the Mylo-hyoid (Fig.

70). Part of the tongue, and a number of structures
associated with it are now brought into view. First, note
the mucous membrane stretching from the tongue to the

SUBMAXILLARY REGION

191

inner side of the mandible ; then, identify the various muscles.

The hyoglossus, a portion of which was previously visible
behind the mylo-hyoid, is fully exposed. It is a quadrangular
sheet of fleshy fibres which extends from the hyoid bone to
the side of the tongue. Mark its position, because all the
structures in the region now under consideration have a more
or less intimate relationship to it. Thus, posterior and also
superficial to its upper part, the stylo-glossus muscle will be
recognised, whilst anterior to it are the genio-glossus and the

M. styloglossus

M. stylopharyngeus
Glosso-pharyngeal
nerve

Deep part of submaxillary gland pulled backwards

/ Submaxillary ganglion

Submaxillary duct (Wharton's)

Cut edge of mucous membrane

.Sublingual gland

Sublingual artery

Genio-
glossus

M. geniohyoideus

Lingual artery
Middle constrictor

Lingual artery

Hypoglossal nerve
v Supra-hyoid artery

FIG. 70. Dissection of Submaxillary Region.

genio-hyoid. The genio-hyoid muscle occupies the antero-

inferior part of the region, whilst the anterior part of the
genio-glossus is seen in the interval between the genio-hyoid
and the hyoglossus. Upon the surface of the hyoglossus, the
lingual and hypoglossal nerves, the connecting loop between
them, the deep portion of the submaxillary gland, with the
submaxillary duct, and the submaxillary ganglion, are to be
dissected. The lingual nerve occupies the highest level, and
passes forwards upon the muscle, near its insertion into the
tongue. The hypoglossal nerve, with its vena comitans and the
lingual vein, crosses the muscle close to the hyoid bone,

I 9 2

HEAD AND NECK

whilst the deep part of the submaxillary gland and the sub-
maxillary duct (Wharton's) occupy an intermediate place.
Although the submaxillary ganglion is very small, its relations
are so precise that it is very easily found. By seizing the
lingual nerve and dissecting carefully in the interval between
it and the deep part of the submaxillary gland, the dissector
will expose the ganglion, and its roots and branches of dis-
tribution (Fig. 70). Upon the genio-glossus, anterior to the

Inferior nasal concha (O.T. inferior turbinal)

M. pterygoideus internus f ^

M. pterygoideus externus, / /

x^mJ^^mmmlmrsaMj I HMMMHM ' ' ' ^UBMOHMBl/l fl. fe. AfekWMMMMBBU

-M. temporali

M. styloglossus

Inferior alveolar
vessels and nerve

Lingual nerve

External
maxillary artery
Superficial part of
Libmaxillary gland
Submaxillary duct
Deep part
submaxillary gland
Hypoglossal nerve

Lingual artery

M. hyoglossus '
M. mylohyoideus
Digastric tendon

M. geniohyoideus

Tongue

Inferior alveo
vessels and n
in the mandib
ular cana'
External
maxillary arU

M. mylohyoid
Lingual nerve
Deep part of
submaxillary gland
K Submaxillary duct

Hypoglossal nerve
Lingual artery
M. digastricus
hyoglossus

M. geniohyoideus

FIG. 71. Frontal section through the Tongue and Submaxillary Region
in a plane posterior to the molar teeth.

hyoglossus, the sublingual gland^ with its artery of supply

will be seen. If the stylo-hyoid and the posterior belly of
the digastric are displaced backwards, certain structures will
be seen passing under cover of the posterior margin of the
hyoglossus muscle. They are : (i) the glosso-pharyngeal
nerve, immediately below the stylo-glossus muscle ; (2) the
stylo-hyoid ligament, a little lower down ; and (3) the lingual
artery, close to the hyoid bone (Fig. 68).

Musculus Hyoglossus. The hyoglossus is a quadrate, flat

muscle which arises from the whole length of the greater cornu,

SUBMAXILLARY REGION 193

and also from the body of the hyoid bone. Its fibres pass
upwards to the posterior part of the side of the tongue,
medial to the stylo-glossus. The hyoglossus is supplied by
the hypoglossal nerve. It helps to depress the tongue and to
pull its anterior part backwards.

Musculus Stylo-glossus. The stylo-glossus muscle is an

elongated fleshy slip which takes origin from the anterior aspect
of the styloid process, near its tip, and, to a slight extent, from
the upper part of the stylo-hyoid ligament also. It passes down-
inferior meatus of nose
Maxillary sinus

Ton

ublingual gland
Submaxillary \\
d

Lingual nerve

M. genioglossus

M. geniohyoideus

Greater
palatine artery
and nerve
Vestibule of
mouth

M. buccinatorius
_____ Arteria profundz
" linguae

Sublingual gland

Inferior alveolar
artery and nerve
in the mandibula
canal
M. mylohyoideus

Platysma
M. digastricus (anterior belly)

FIG. 72. Frontal section through the Closed Mouth in the plane
of the second molar teeth.

wards and forwards, and its fibres may be traced upon the
side of the tongue as far as the tip. Some of them decus-
sate with the fasciculi of the hyoglossus muscle. It pulls
the tongue backwards, and its nerve of supply is derived from
the hypoglossal nerve.

Musculus Geniohyoideus. The genio-hyoid muscle is

placed close to the median plane, in contact with its fellow of
the opposite side. It is a short muscle which arises from the
lower mental spine upon the posterior surface of the symphysis
of the mandible, and extends downwards and backwards to

VOL. Ill 13

194 HEAD AND NECK

gain insertion into the anterior aspect of the body of the

hyoid bone. It is supplied by the hypoglossal nerve. It pulls
the hyoid bone upwards and forwards.

The Deep Part of the Submaxillary Gland. It has been

noted already that the small, deep part of the submaxillary
gland springs from the medial surface of the superficial part, at
the posterior border of the mylo-hyoid muscle. It will now be
obvious that it passes forwards and upwards, between the
mylo-hyoid laterally and the hyo-glossus and genio-glossus
medially, until it comes into contact with the sublingual gland.
It is accompanied by the lingual nerve and the submaxillary
duct, both of which lie on its medial surface (Fig. 72).

Ductus Submaxillaris. The duct of the submaxillary

gland (O.T. Wharton's duct) emerges from the medial surface
of the main part of the gland, and proceeds, with the deep
part of the gland, forwards and upwards upon the hyo-
glossus muscle. At first it lies between the lingual nerve
above and the hypoglossal nerve below. Reaching the
surface of the genio-glossus muscle, it is crossed laterally,
and then below and medially, by the lingual nerve. Then it
passes to the medial side of the sublingual gland, and gains the
floor of the mouth, where it opens by a small orifice placed
on the summit of a papilla which lies close to the side of the
frenulum linguae.

The wall of the duct is much thinner than that of

the parotid duct. If a small opening is made in it, the
dissector will experience little difficulty in passing a fine probe
or bristle along it into the mouth.

Glandula Sublingualis. The sublingual gland lies in the

floor of the mouth, and is the smallest of the larger salivary
glands. It is almond-shaped, about one inch and a half
long ; and its relations are very definite. Its prominent upper
border can be seen within the mouth, beneath the anterior
part of the tongue, where it is covered by a fold of mucous
membrane termed the plica sublingualis (Fig. 105). Medially^
it rests upon the genio-glossus, musr!^ _wj~pfc^ laterally, it lies
against the medial aspect of the body of the mandible,
immediately lateral to the symphysis and above the mylo-
hyoid line. Below^ it is supported by the mylo - hyoiH
muscle. Its anterior extremity reaches the median plane,
above the anterior border of the genio-glossus, and is in
contact with its fellow of the opposite side. The duct of

SUBMAXILLARY REGION 195

the submaxillary gland and the lingual nerve are prolonged

forwards, medial to the sublingual gland.

Numerous small ducts (the number varying from eight

to twenty) proceed from the sublingual gland. As a rule,
they open into the mouth on the summit of the plica sub-
lingualis (Birmingham).

Nervus Lingualis. In the dissection of the infratemporal

region, the lingual nerve was seen passing downwards between
the ramus of the mandible and the internal pterygoid muscle.
As it descends, it inclines forwards, and, after passing
over the attachment of the superior constrictor muscle of
the pharynx to the posterior end of the mylo-hyoid line, it
lies below and posterior to the last molar tooth (Fig. 68),
between the mucous membrane of the mouth and the body of
the mandible. At that point it is in danger of being hurt
by the clumsy extraction of one of the lower molars, and
there also it may be divided by the surgeon, from the inside
of the mouth. In its further course the nerve keeps close
to the side of the tongue, crossing the styloglossus and the
upper part of the hyoglossus, and, beyond that, the sub-
maxillary duct. Its terminal branches are placed immedi-
ately under cover of the mucous membrane of the mouth,
and it can be traced as far as the tip of the tongue.

The branches which proceed from the lingual nerve in the

submaxillary region are of two kinds (i) twigs of com-
munication ; (2) branches of distribution.

( i. Two or more to the submaxillary ganglion.

Twigs of I 2. One or two which descend along the anterior
Communication, j border of the hyoglossus muscle to unite with

\ the hypoglossal nerve.

D ^ ( l ' Slender filaments to the mucous membrane of the

c * mouth and gums.

TV , ?i ,. 1 2. A few twigs to the sublingual gland.

Distribution. [ ^ E ^nches to the tongue.

The lingual branches pierce the substance of the tongue,

and then incline upwards to supply the papillated mucous
membrane over the anterior two-thirds of the organ.

Ganglion Submaxillare. The small submaxillary ganglion

lies upon the upper part of the hyoglossus muscle, in the interval
between the lingual nerve and the deep part of the sub-
maxillary gland. In size, it is not larger than the head of a
large pin; and, when freed from the connective tissue surround-
ing, it will be seen to be suspended from the lingual nerve

196 HEAD AND NECK

by two short branches, which enter its upper border, and are
separated by a distinct interval. The posterior connecting
twig is frequently replaced by two or three filaments, which
form the sensory and secretory roots of the ganglion, whilst
the anterior connecting branch must be looked upon as a
twig given by the ganglion to the lingual nerve.

Like the other ganglia developed in connection with the

branches of the trigeminal nerve, the submaxillary ganglion has
three roots viz., (i) a sensory root from the lingual nerve ; (2)
a secretory root from the chorda tympani ; and (3) a sympathetic
root from the plexus around the external maxillary artery.

From its lower border several minute twigs proceed ; they

are distributed (i) to the submaxillary gland and duct; (2)
to the sublingual gland, from the branch given by the
ganglion to the lingual nerve ; and (3) to the mucous
membrane of the mouth.
Nervus Hypoglossus. The hypoglossal nerve has been
traced, in the dissection of the anterior triangle, to the point
where it disappears under cover of the mylo-hyoid muscle
(p. 130). It is now seen passing forwards upon the
hyoglossus muscle, above the hyoid bone and below the level
of the deep part of the submaxillary gland. At the anterior
border of the hyoglossus it gains the surface of the genio-
glossus muscle, into the substance of which it sinks ; and
finally it breaks up into branches which supply the muscular
substance of the tongue. Upon the hyoglossus muscle it
is accompanied by the lingual vein.

The branches which spring from the hypoglossal nerve in

the region of the floor of the mouth are very numerous, and
are distributed entirely to muscles. It supplies (i)thestylo-
glossus j (2) the hyoglossus ; (3) the genio-glossus ; (4) the
genio-hyoid ; and (5) the intrinsic muscles of the tongue.

In addition, it communicates freely with the lingual

nerve. The more apparent of the connections take the form
of one or more loops which lie on the lateral surface of the
anterior part of the hyoglossus. Other communications with
the lingual nerve are effected in the substance of the tongue.

Dissection. The hyoglossus should now be carefully de-

tached from the hyoid bone, and thrown upwards towards the
tongue, but the structures which lie upon the superficial surface
of the muscle need not be divided. By the reflection of the
hyoglossus muscle the following structures will be fully dis-
played, and must be cleaned (i) the profunda linguae artery

SUBMAXILLARY REGION 197

and the veins which accompany it ; (2) the dorsales linguae

arteries and veins ; (3) the posterior part of the genio-glossus ;

(4) the origin of the middle constrictor of the pharynx ; and

(5) the attachment of the stylo-hyoid ligament.

Musculus Genioglossus. The genio-glossus is a flat tri-

angular muscle, the medial surface of which is in contact with
its fellow of the opposite side, in the median plane. It arises
by a short pointed tendon from the upper mental spine on
the posterior aspect of the symphysis of the mandible, and,
from that point, its fleshy fasciculi spread out in a fan-like
manner. By far the greater part of the muscle is inserted
into the tongue, by an insertion which extends throughout
the whole length of the organ, from the tip to the base ;
below the tongue, a few fibres reach the side of the pharynx.
The genio-glossus is supplied by twigs from the hypoglossal
nerve. It can project the tip of the tongue forwards and
depress the whole organ in the floor of the mouth.

Arteria Lingualis. As the lingual artery is now fully

exposed, it can be conveniently studied at this stage.
It springs from the anterior aspect of the external carotid,
and is separable into two parts viz., (i) a part extending
from its origin to the posterior border of the hyoglossus
muscle; (2) a part lying in relation to the upper border of
the hyoid bone, and extending to the anterior border of the
hyoglossus, where it divides into two terminal branches, the
sublingual and the deep artery of the tongue (Figs. 68, 70).

The first part has been fully examined in a previous

dissection. It lies in the carotid triangle of the neck, and
is therefore comparatively superficial. It is crossed, super-
ficially, by the hypoglossal nerve, and lies, medially, against
the middle constrictor.- The second part passes forwards along
the upper border of the greater cornu of the hyoid bone,
and is covered by the hyoglossus muscle, which intervenes
between it and the hypoglossal nerve. The nerve, how-
ever, is placed at a slightly higher level. The deep or
medial relations of the artery, in the second stage of its
course, are the middle constrictor of the pharynx and the
genio-glossus.

The branches of the lingual artery are :

1. Supra-hyoid, from ihz first part (p. 133).

2. Dorsales linguae, from the second part.

3. Sublingual.

4. Profunda.
in 13 a

198 HEAD AND NECK

Rami Dorsales Lingua. The dorsales linguae branches

are generally two or more in number. They pass upwards,
under cover of the hyoglossus muscle, to end in twigs to the
mucous membrane covering the pharyngeal part of the dorsum
of the tongue. Some twigs are supplied also to the muscular
substance of the organ, and a few may be traced backwards
into the palatine tonsil.

Arteria Sublingualis. The sublingual artery springs from

the end of the second part of the lingual artery and emerges
from under cover of the anterior border of the hyoglossus ;
then it ascends, upon the genio-glossus, to the sublingual
gland, which it supplies. It gives branches to the surround-
ing muscles ; and it anastomoses with its fellow of the
opposite side and, through the mylo-hyoid muscle, with the
submental branch of the external maxillary artery.

Arteria Profunda Lingua. The deep artery of the tongue

ascends almost vertically, upon the genio-glossus, overlapped
by the anterior border of the hyoglossus ; when it reaches
the under surface of the tongue, it runs towards the tip and
ends in terminal branches. To expose it divide the mucous
membrane along its course ; then it will be seen to lie close
to the attachment of the frenum of the tongue, and to
be continued forwards in the interval between the genio-
glossus and the inferior longitudinal muscle. Its course
is tortuous, to allow for the protrusion or elongation of the
tongue ; and it gives off numerous branches.

Venae Linguales. The lingual artery may be accompanied

by two small venae comites which lie beside it under cover of
the hyoglossus; but the main vein of the tongue crosses
the lateral surface of the hyoglossus below the hypoglossal
nerve ; and another smaller vein, the vena comitans hypoglossi,
runs backwards above the hypoglossal nerve. At the posterior
border of the hyoglossus the lingual vein is joined by the
vena comitans hypoglossi and the venae comites of the artery,
if they are present ; then it passes backwards to end either in
the common facial vein or the internal jugular vein.

Ligamentum Stylohyoideum. The stylo-hyoid ligament is

the last structure to be examined in this dissection. It is a
fibrous cord which springs from the tip of the styloid process
and passes antero-inferiorly to be attached, under cover of
the hyoglossus muscle, to the lesser cornu of the hyoid
bone. It is not uncommon to find it partially ossified ; in

SUBMAXILLARY REGION 199

other cases it may assume a ruddy hue and contain muscular

fibres.

OTIC GANGLION AND TENSOR VELI PALATINI.

During the dissection of the submaxillary region the

dissector noted a nerve ganglion, the submaxillary ganglion,
connected with the lingual branch of the mandibular nerve ;
and, when he was examining the infratemporal region, refer-
ence was made to the otic ganglion, which is associated
with the trunk of the mandibular nerve and the branch which
it supplies to the internal pterygoid muscle. The otic
ganglion and its connections should now be displayed, and
afterwards the tensor veli palatini muscle should be cleaned
and followed from its origin downwards to the hamulus of the
medial pterygoid lamina.

Dissection. Cut the lingual and inferior alveolar nerves

immediately below their origins ; evert the upper part of the
mandibular nerve, and define the otic ganglion ; then divide
the internal pterygoid, along the posterior border of the lateral
pterygoid lamina ; depress the lower part of the muscle and
clean the tensor veli palatini, which lies medial to the middle
meningeal artery, the otic ganglion and the mandibular nerve,
and separates them from the lateral surface of the auditory tube.

Ganglion Oticum. The otic ganglion is a minute, oval

body, not easily found. It lies immediately below the
foramen ovale, between the mandibular nerve laterally, the
tensor veli palatini medially, and the middle meningeal artery
posteriorly ; it is intimately associated with the origin of the
nerve to the internal pterygoid (Fig. 66).

The otic ganglion is usually described as receiving motor, sensory, and

sympathetic roots. The motor root is supplied by the nerve to the internal
pterygoid muscle ; the sympathetic root comes from the plexus around the
middle meningeal artery. In addition to those roots, the lesser superficial
petrosal nerve enters the posterior border of the ganglion, and conveys
sensory fibres to it.

The following are the branches which proceed from the otic ganglion :

C A twig which passes downwards and forwards to the

Branches of I tensor veli palatini. (O.T. Tensor palati.)
distribution. | A twig which proceeds upwards and backwards to

^ supply the tensor tympani.

( One or more fine filaments to one or both of the roots

Connecting J of the auriculo-temporal nerve,
branches. 1 A minute communicating r filfftiJeYil ; 'rt$ ' the chorda

^ tympani.
m 13 b

2OO

v/i iiVvnrii / Sf Hi if

HEAD AND NECK

Musculus Tensor Veil Palatini. The tensor of the soft

palate is a flat, triangular muscle which is closely applied to
the deep surface of the internal pterygoid muscle. It arises
from the scaphoid fossa at the root of the medial pterygoid
lamina, from the posterior border of the lower surface of the
great wing of the sphenoid, from the spine of the sphenoid,
and from the lateral aspect of the auditory tube (O.T.
Eustachian). It descends to the lower end of the medial
pterygoid lamina, and ends in a tendon which turns hori-
zontally, under the hamulus, into the soft palate, where its
attachments will be seen later when the soft palate is dissected.

THE GREAT VESSELS AND NERVES

OF THE NECK.

As soon as the dissection of the infratemporal and the

submaxillary regions is completed, the dissector should turn
to the study of the external carotid artery and its relations.
Arteria Carotis Externa. The external carotid artery is
one of the two terminal branches of the common carotid. It
commences at the level of the upper border of the thyreoid
cartilage, opposite the fibre-cartilage between the third and
fourth cervical vertebrae ; and, after running upwards and
backwards to the. level of the neck of the mandible, it
terminates, between that portion of bone and the upper part
of the antero-medial surface of the parotid gland, by dividing
into two terminal branches the superficial temporal and the
internal maxillary arteries. At its commencement it lies
anterior and medial to the internal carotid artery ; and it is
called external because it is distributed mainly to the parts
on the exterior, of the skull. It is, at first, comparatively
superficial in the upper part of the carotid triangle ; next, it
passes under cover of the lower part of the postero-medial
surface of the parotid gland, and the posterior belly of the
digastric and the stylo-hyoid muscles. At the upper border
of the stylo-hyoid it enters a groove in the medial border of
the parotid, through which it passes to the upper part of the
antero-medial surface of the gland, behind the neck of the
mandible, where it terminates (Figs. 51, 73, 74).

Relations. As it lies in the carotid triangle it is covered

by the skin, superficial fascia and platysma, branches of the

GREAT VESSELS AND NERVES OF NECK 201

nervus cutaneus colli and the cervical branch of the facial

nerve, and the deep fascia. Beneath the deep fascia it is
crossed superficially by the common facial and lingual veins

Accessory

Ganglion
nodosum

Pharyngeal
branch

Superior laryngeal
Hypoglossal

Descendens hypoglossi
Ascending pharyngeal
Internal carotid

Glosso-pharyngeal
Superficial temporal

Internal maxillary

Branch to
thyreo-hyoid
Internal
laryngeal

Common carotid

FIG. 73. Diagram of Carotid System of Vessels in the Neck, with the
Glosso-pharyngeal, Vagus, Accessory, and Hypoglossal Nerves.

and the hypoglossal nerve ; and, at the upper end of the

triangle, it is concealed by the lower end of the parotid gland,
and it is crossed, from behind forwards, by the posterior facial
vein. After it leaves the carotid triangle it is overlapped by

202 HEAD AND NECK

the angle of the mandible, and is crossed by the posterior

belly of the digastric and the stylo-hyoid. At its termina-
tion it is concealed by the upper part of the parotid and is
crossed by branches of the facial nerve.

To its medial side lies the wall of the pharynx with the
external and internal laryngeal branches of the superior
laryngeal nerve intervening in the region of the carotid
triangle. The medial relations, at a higher level, will be
seen to greater advantage at a later stage, when the styloid
process is detached and displaced. They are the pharyngeal
branch of the vagus, the stylo-pharyngeus, the glosso-pharyngeal
nerve, and the styloid process or the stylo-hyoid ligament.
Those structures lie to its medial side as they pass obliquely
between it and the internal carotid, which has gradually
attained a plane posterior and medial to that in which the
external carotid lies.

In the whole of its extent the external carotid is accom-

panied by numerous sympathetic nerve fibres,, derived from
the upper cervical sympathetic ganglion ; they constitute the
external carotid plexus, which distributes offsets along all the
branches of the artery.
Branches. The branches of the external carotid artery are
the superior thyreoid, the lingual, and the external maxillary,
from its anterior aspect ; the occipital and the posterior
auricular, from its posterior aspect ; the ascending pharyngeal,
from its medial side ; and the superficial temporal and the
internal maxillary are its terminal branches.

Arteria Thyreoidea Superior. The superior thyreoid

artery arises, within the carotid triangle, from the anterior
aspect of the external carotid close to its origin. It runs
downwards and forwards, under cover of the omo-hyoid,
sterno-hyoid, and sterno-thyreoid muscles, to the apex of the
corresponding lobe of the thyreoid gland, where it ends by
breaking up into three terminal branches.

The following branches proceed from it :

Hyoid.
2. Superior laryngeal.

4. Crico-thyreoid.

5. Terminal glandular.

3. Sterno-mastoid.

Ramus Hyoideus. The hyoid branch is a small twig, which

springs from the superior thyreoid in the carotid triangle.
It runs along the lower border of the hyoid bone, under cover
of the thyreo-hyoid muscle, and anastomoses with its fellow

GREAT VESSELS AND NERVES OF NECK 203

of the opposite side, and with the hyoid branch of the

lingual artery.

Arteria Laryngea Superior. The superior laryngeal artery

is a larger vessel. It springs from the superior thyreoid
in the carotid triangle, and, associating itself with the internal
laryngeal nerve, it pierces the thyreo-hyoid membrane, enters
the pharynx, and descends to the larynx (Fig. 68).

Arteria Sternocleidomastoidea. The sterno-mastoid branch

is a small vessel which runs downwards and backwards, across
the carotid sheath, along the upper border of the anterior
belly of the omo-hyoid muscle, to reach the deep surface of
the sterno-mastoid muscle, into which it sinks. It gives, in
addition, minute twigs to the depressor muscles of the larynx.

Ramus Cricothyreoideus. The crico -thyreoid artery runs

medially, upon the crico-thyreoid ligament, and anastomoses with
its fellow of the opposite side. It has already been noticed
in the dissection of the middle line of the neck (p. 129).

Rami Glandulares. The glandular rami are the three

terminal branches. They spring from the main trunk at
the apex of the lobe of the thyreoid gland. The largest
branch is distributed on the medial surface of the lobe ; the
smallest branch ramifies on its lateral surface; whilst the
third branch runs downwards upon the anterior border of the
lobe, and then along the upper border of the isthmus towards
its fellow of the opposite side. The medial and lateral
branches are not uncommonly replaced by a posterior trunk
which runs along the posterior border of the lobe. The
anastomosis between the thyreoid arteries of the two sides is
by no means free.

Vence Thyreoidece. Superiores. The superior thyreoid veins

emerge from the gland and form a trunk which receives
tributaries corresponding in a great measure with the branches
of the artery. It crosses the upper part of the common
carotid artery and joins the internal jugular vein.

Arteria Lingualis. The lingual artery springs from the

external carotid at the level of the greater cornu of the
hyoid bone in the carotid triangle. It runs along the upper
border of the greater cornu. As its name indicates, it is
the artery of supply to the tongue. It has already been
dissected in the carotid triangle and the submaxillary region,
and the details of its course and relations are given on
p. 197.

204 HEAD AND NECK

Arteria Maxillaris Externa (O.T. Facial Artery). The

Superficial temporal vessels

\ In

Cut surface of massete

Cut surface of ramus of mandible

External maxillary artery f

:ommunication from post.

Common facial veir

Inferior surface of submaxillary gland"

Superior thyreoid artery

-Styloid process

Facial nerve (cut)

External carotid
nternal carotid

Glossopharyngeal nerve

Stylo-pharyngeus
- Stylo-glossus

Internal pterygoicl (cut)

-External maxillary artcr

Hypoglossal nerve

Digastric and stylo-hyoii

Posterior auricular vein

Lingual artery

Lingual vein
-External jugular vein

Descendens hypoglossi

Nervus ctitaneus colli

FIG. 74. Dissection to show the relations of the External Carotid Artery
and the deep part of the External Maxillary Artery. The parotid gland
and the posterior part of the ramus of the mandible and the muscles
attached to it have been removed. The terminal branches of the facial
nerve have been cut and the terminal parts left in situ.
In this specimen the greater part of the posterior facial vein joined the

external jugular vein. The lingual vein joined the common facial vein ; and

the origin of the external maxillary artery was deep to the posterior belly of

the digastric muscle.

cervical part of the external maxillary artery can be studied

GREAT VESSELS AND NERVES OF NECK 205

at the present stage of the dissection. The artery arises

from the anterior aspect of the external carotid, immedi-
ately above the lingual, in the upper part of the carotid
triangle, and passes vertically upwards, on the lateral surface
of the middle constrictor muscle of the pharynx, to the
angle of the mandible, where it disappears under cover
of the posterior belly of the digastric and the stylo-hyoid
muscle. At that point the superior constrictor is medial
to it and separates it from the palatine tonsil. At the
upper border of the stylo-hyoid it enters a deep groove
in the posterior part of the submaxillary gland, in which it
runs downwards and forwards between the lateral surface of
the gland and the internal pterygoid muscle, then turning
round the lower border of the mandible at the anterior border
of the masseter it enters the face (Fig. 74). For details of
its course in the face see p. 16.

The named branches which spring from the external

maxillary artery before it enters the face are :

1. Ascending palatine. 3. Glandular.

2. Tonsillar. 4. Submental.

Arteria Palatina Ascendens. The ascending palatine

branch is given off for the supply of the soft palate, but
it distributes branches to the palatine tonsil and auditory
(O.T. Eustachian) tube also. It ascends between the stylo-
pharyngeus and stylo-glossus muscles, and will be better seen
when the styloid process is reflected (p. 2 1 o).

Ramus Tonsillaris. The tonsillar branch runs upwards

between the internal pterygoid and stylo-glossus muscles, then
turns medially, pierces the superior constrictor, and enters
the palatine tonsil.

The glandular branches are given to the submaxillary

gland, as the external maxillary artery passes through it.

Arteria Submentalis. The submental artery is a branch

of some size. It arises close to the lower border of the
mandible, and runs towards the chin, superficial to the mylo-
hyoid muscle. Near the symphysis it changes its direction,
and is carried upwards over the lower border of the mandible,
to end in branches for the muscles and integument of the
chin and lower lip. In the submaxillary region it gives
numerous twigs to the surrounding muscles and glands, and
anastomoses with the sublingual artery by branches which

2O6

HEAD AND NECK

pierce the mylo-hyoid muscle. It anastomoses, in the face,
with the inferior labial branches of the external maxillary
and the mental branch of the inferior alveolar.

Vena Facialis Anterior. The cervical portion of the

anterior facial vein has already been seen (p. 130) passing
backwards and downwards, superficial to the submaxillary

Superficial
temporal artery
Internal maxil-
lary artery

Posterior auricu-
lar artery

External carotid

Occipital artery

Sterno-mastoid artery

Hypoglossal nerve
Ascending pharyngeal artery

Internal carotid artery

Descendens hypoglossi

Superior thyreoid artery

Sterno-mastoid artery

Submental

artery

External maxillary
artery

Hyoid bone

Lingual artery
Inferior hyoid artery

Internal laryngeal artery

Prominentia laryngea
Sterno-hyoid

Common carotid artery

Omo-hyoid

FIG. 75. Diagram of the External Carotid Artery and its Branches.
The right half of the mandible is tilted up.

gland. After receiving tributaries corresponding to the

branches of the corresponding part of the external maxillary
artery, it joins the posterior facial vein. The short trunk
thus formed is termed the common facial vein, and it pours its
blood into the internal jugular at the level of the hyoid bone.
Arteria Occipitalis. The occipital artery springs from the
posterior aspect of the external carotid artery, at the same level
as the external maxillary. It takes the lower border of the
posterior belly of the digastric muscle as its guide, and runs

GREAT VESSELS AND NERVES OF NECK 207

upwards and backwards, under cover of the sterno-mastoid

muscle, and, generally, under cover of the lower border of the
posterior belly of the digastric, to reach the interval between
the mastoid portion of the base of the skull and the transverse
process of the atlas. Thence onwards, it has been studied in
the dissection of the scalp and the back of the neck (pp. 47,
56). The first part of the vessel crosses the internal carotid
artery, the vagus nerve, the accessory nerve, the internal
jugular vein, and the hypoglossal nerve, which hooks round it.

The only branches which spring from the occipital artery

in the region under consideration are: (i) muscular twigs;
and (2) a meningeal branch.

The muscular twigs are given to the neighbouring muscles.

One of them, the sterno-mastoid branch^ is larger than the
others and very constant, runs parallel with the accessory
nerve, and sinks, with it, into the substance of the sterno-
mastoid muscle.

A meningeal branch associates itself with the internal

jugular vein, and can be followed upwards upon it to
the jugular foramen, through which it passes into the
cranium.

Arteria Auricularis Posterior. The posterior auricular

artery will be found above the level of the posterior belly of
the digastric, and, like the occipital, it takes origin from the
posterior aspect of the external carotid artery. In the first
part of its course it is placed deeply, and runs upwards and
backwards, between the styloid process of the temporal bone
and the postero-medial surface of the parotid gland, to reach
the interval between the mastoid process and the back of
the auricle. Then it accompanies the posterior auricular nerve
in the superficial fascia of the scalp, where its course has already
been studied, in the dissection of the scalp (p. 47).

As it runs upwards and backwards the posterior auricular

artery gives off (i) muscular twigs ; (2) a few branches to the
parotid gland ; and (3) the stylo-mastoid artery.

Arteria Stylomastoidca. The stylo-mastoid artery is a

slender vessel which enters the stylo-mastoid foramen. In
the interior of the temporal bone it has an extensive dis-
tribution. It supplies twigs to the mastoid cells and to the
tympanic cavity, and is carried onwards, in the canalis facialis
(O.T. Fallopian), to anastomose with the petrosal branch of
the middle meningeal.

2o8 HEAD AND NECK

Arteria Maxillaris Interna. The commencement of the

internal maxillary artery, from the termination of the external
carotid, between the neck of the mandible and the antero-
medial surface of the parotid gland, has been seen already, and
the artery has been traced through the infratemporal region
to the pterygo-palatine fossa, where its terminal branches will
be dissected at a later period.

Arteria Temporalis Superficialis. Like the internal

maxillary, the superficial temporal artery commences between
the neck of the mandible and the antero-medial surface of
the parotid gland. It passes upwards, and, as it emerges
from under cover of the upper end of the parotid gland, it
pierces the parotid fascia, crosses superficial to the posterior
end of the zygomatic arch, and enters the superficial fascia of
the scalp, in which it ascends, on the superficial surface of the
temporal fascia, and anterior to the auricle (Figs. 51, 76). It
breaks up into two branches, frontal and parietal. The two
branches anastomose with each other and with their fellows of
the opposite side. The frontal branch anastomoses with the
supra-orbital and frontal branches of the ophthalmic also, and
the parietal branch anastomoses with the posterior auricular
and the occipital arteries. Whilst it is still under cover of
the parotid it gives branches to the gland ; anterior auricular
branches to the auricle ; the transverse facial, which passes
along the lower border of the zygomatic arch, across the
masseter. As the superficial temporal crosses the zygoma it
gives off a zygomatico-orbital branch, which runs to the lateral
border of the orbit, and a middle temporal branch, which
perforates the temporal fascia and anastomoses in the tem-
poral fossa with the deep temporal branches of the internal
maxillary. The course of the middle temporal branch (Fig.
76) and the distribution of the terminal branches have been
followed in earlier stages of the dissection (pp. 48, 169).
Dissection. Divide the posterior belly of the digastric
immediately below its origin, and turn it downwards and
forwards towards the hyoid bone ; then examine the stylo-
pharyngeus muscle. It may be necessary to cut the occipital
and posterior auricular arteries in order to gain free access to
the deeper parts, but that should not be done unless it is un-
avoidable. Care must be taken whilst cleaning the stylo-
pharyngeus to avoid injuring the glosso-pharyngeal nerve,
which turns round its posterior border and crosses its superficial
surface.

GREAT VESSELS AND NERVES OF NECK 209

Musculus Stylopharyngeus. The stylopharyngeus is the

longest of the three slender muscles which spring from the
styloid process. It arises from the deep or medial surface
of the process, close to its root, and extends downwards and

Superficial temporal

Frontal branch of
'ophthalmic artery
Supra-orbital branch of
ophthalmic artery

Middle temporal
Transverse facial

Angular
Lateral nasal

Infra-orbital
Superior labial

Inferior labial

(O.T. inferior
abial.) See p. 1.8

Buccinator branch of internal maxillary

'

External maxillary

FIG. 76. Arteries of the Face.

forwards to gain the side of the pharynx, where it dis-

appears under cover of the upper border of the middle
constrictor muscle. Whilst under cover of the middle con-
strictor its fibres blend with those of the pharyngo-palatinus,
and, with them, are inserted into the posterior border of the
corresponding lamina of the thyreoid cartilage. It is supplied
VOL. in 14

210 HEAD AND NECK

by the glosso-pharyngeal nerve. If the dissector removes the

fascia at the posterior part of the thyreo-hyoid space he will
expose the lower fibres of the middle and the upper fibres
of the inferior constrictor, and in the interval between them,
on a deeper plane, the lateral surface of the lower part of
the stylo-pharyngeus. It is an elevator of the larynx.

Dissection. Snip through the base of the styloid process

with the bone forceps, and throw it and the attached muscles
downwards and forwards. The upper parts of the internal
carotid artery and internal jugular vein are now exposed, and
the ascending pharyngeal and ascending palatine arteries can
be followed to the base of the skull.

If the external carotid is pushed forwards and the internal

carotid is pulled backwards the ascending pharyngeal artery
will be seen, in a well-injected subject, lying in the areolar
tissue between the two carotid arteries and on a deeper plane.
It must be cleaned and followed to the base of the skull.

Arteria Pharyngea Ascendens. The ascending pharyngeal

artery springs from the medial surface of the external carotid
artery, close to its lower end, and is its smallest branch. It
ascends along the lateral border of the pharynx, lying between
the stylo-pharyngeus laterally and the constrictors of the
pharynx medially, first in a plane between the external and
internal carotid arteries, and then to the medial side of the
internal carotid. As it passes upwards it gives pharyngeal
branches to the wall of the pharynx, and premrtebral branches
to the prevertebral muscles. At the base of the skull it gives
off meningeal branches, which enter the cranial cavity through
the hypoglossal canal, the jugular foramen, and the foramen
lacerum ; and palatine branches, which pierce the pharyngeal
aponeurosis, above the upper border of the superior con-
strictor, and descend, along the levator veli palatini, to the
soft palate. Offsets from the latter branches are given to
the auditory tube (O.T. Eustachian) and to the palatine
tonsil.

Arteria Palatina Ascendens. After the ascending pala-

tine artery has passed between the stylo-glossus and the stylo-
pharyngeus (see p. 205), it ascends, along the side of the
pharynx, to the petrous part of the temporal bone. There
it pierces the pharyngeal aponeurosis, and then it accompanies
the levator veli palatini to the soft palate. It helps to supply
the soft palate, the palatine tonsil, the wall of the pharynx,
and the auditory tube.
GREAT VESSELS AND NERVES OF NECK 211

Dissection. After the ascending pharyngeal artery has been

examined, the internal carotid artery, the glosso-pharyngeal,
vagus, accessory, and hypoglossal nerves, and the superior
cervical ganglion, with their various connections and branches,
must be dissected. A dense and tough fascia envelops them,
and a great amount of patience is required to trace the branches
of the nerves through it. One nerve the pharyngeal branch
of the vagus which proceeds downwards and forwards, upon
the superficial or lateral aspect of the internal carotid, is especially
liable to injury, and must therefore be borne in mind from the
very outset of the dissection. The internal laryngeal and the
external laryngeal nerves have been previously displayed in the
anterior triangle of the neck. If they are traced upwards, they
will lead to the superior laryngeal branch of the vagus, which
lies in relation with the deep aspect of the internal carotid artery.
Near the base of the skull all the nerve-trunks will be found
making their appearance, close together, in the interval between
the internal jugular vein and the internal carotid artery ; whilst

erior to the vein the rectus lateralis muscle and the first
of the cervical plexus will be seen.

Arteria Carotis Interna. The internal carotid artery is

one of the two terminal branches of the common carotid,
and it commences, therefore, at the level of the upper border
of the thyreoid cartilage. From that point it proceeds upwards
in the neck, in a vertical direction, until it reaches the
base of the skull; there it disappears from view by entering
the carotid canal of the petrous portion of the temporal bone.
Through the carotid canal it reaches the interior of the
cranium. The internal carotid artery can therefore be very
appropriately divided into three parts viz., (i) a cervical;
(2) a petrous; and (3) an intracranial. The cervical part
alone comes under the notice of the student in the present
dissection.

In the first part of its extent the internal carotid artery

lies in the carotid triangle, and is therefore comparatively
superficial. It is covered by the integument, platysma, and
fascia, and is overlapped by the sterno-mastoid muscle and
the anterior border of the internal jugular vein. It is crossed
by the hypoglossal nerve, the occipital artery and its sterno-
mastoid branch, and the lingual and common facial veins. The
descendens hypoglossi descends on its superficial surface.

As it proceeds upwards, it passes under cover of the lower

end of the parotid gland and then at a higher level under
cover of the posterior belly of the digastric, the stylo-hyoid,
the stylo-pharyngeus, and the styloid process, which separate
it from the postero-medial surface of the parotid gland. It
in 14 a

212
HEAD AND NECK

will be noted also that three nerves and three arteries cross the
vessel superficially, viz. :

1. The hypoglossal nerve.

2. The glosso-pharyngeal nerve.

3. The pharyngeal branch of the

vagus nerve.

Accessory

Descendens hypoglossi

Ascending pharyngeal
Internal carotid

1. The occipital artery.

2. The sterno-mastoid branch of

the occipital artery.

3. The posterior auricular artery.

losso-pharyngeal
ficial temporal

lal maxillary

External
carotid

Posterior
auricular

Occipital
Branch
hyreo-hyoid

Common carotid

FlG. 77. Diagram of Carotid System of Vessels in the Neck, with the
Glosso-pharyngeal, Vagus, Accessory, and Hypoglossal Nerves.

The hypoglossal nerve, as already noted, crosses it in the

carotid triangle ; the other nerves cross it under cover of the
posterior belly of the digastric. The occipital artery crosses

GREAT VESSELS AND NERVES OF NECK 213

it at the level of the lower border of the posterior belly of the

digastric, the posterior auricular, at the level of the upper
border of that muscle, and the sterno-mastoid branch of the
occipital artery at the point where the hypoglossal nerve
turns forwards.

The relationship of the external carotid artery to the

internal carotid is a varying one. At first the external
carotid lies antero-medial to the internal carotid ; but soon,
owing to its inclination backwards, it comes to lie superficial
to the internal carotid. The following structures intervene
between the two vessels :

1. Styloid process.

2. Stylo-pharyngeus muscle.

3. Glosso-pharyngeal nerve.

4. Pharyngeal branches of vagus

and sympathetic.

5. A portion of the parotid gland.

Posterior to the internal carotid are the longus capitis

(O.T. rectus capitis anticus major) and the sympathetic
trunk ; postero-laterally are the glosso-pharyngeal, the vagus,
the accessory and the hypoglossal nerve ; and still more
laterally and posteriorly is the internal jugular vein. On
its medial aspect the internal carotid is related to the con-
strictors of the pharynx, the ascending pharyngeal artery and
the levator veli palatini.

Before leaving the internal carotid artery, note that,

near the base of the skull, four nerves appear in the interval
between it and the internal jugular vein ; they are the glosso-
pharyngeal, the vagus, the accessory, and the hypoglossal.

Vena Jugularis Interna. The internal jugular vein is the

largest venous channel of the neck. It enters the neck through
the postero-lateral compartment of the jugular foramen, where
it is directly continuous with the transverse blood sinus of
the cranium. From the jugular foramen it proceeds down-
wards, until it reaches the posterior aspect of the medial end
of the clavicle, where it joins the subclavian vein to form the
innominate vein (Fig. 78). Its commencement in the jugular
foramen shows a slight dilatation, termed the bulb, the lumen of
which remains at all times patent owing to the connection of
walls of the bulb to the margins of the foramen. The skull cap
should be removed and a probe should be passed from the
transverse sinus into the internal jugular vein, to demonstrate
the continuity of the two channels.

Relations. At its commencement the internal jugular

m 14 &

2I 4

HEAD AND NECK

PLATE VII

FIG. 7 8. Dissection of the Head and Neck of the same subject

as that shown in Fig. 15, but the greater part of the parotid
gland, the greater part of the sterno-mastoid muscle, the
greater part of the external jugular vein, portions of other
veins, portions of the sterno-hyoid and sterno-thyreoid
muscles, and the submaxillary gland have been removed
to display deeper structures.

1. Supra-orbital artery and nerve.

2. Frontal artery and vein.

3. Lateral nasal branch of external

maxillary artery.

4. Superior labial branch of ex-

ternal maxillary artery.

5. Inferior labial branch of ex-

ternal maxillary artery.

6. External maxillary artery.

7. External maxillary artery.

8. Deep part of submaxillary gland.

9. Lingual artery.

10. Submental branch of external

maxillary artery.

11. Mylo-hyoid muscle.

12. Nerve to thyreo-hyoid muscle.

13. Internal laryngeal nerve.

14. Common facial vein.

15. Superior thyreoid vessels.

16. Common carotid artery and de-

scendens hypoglossi nerve.

17. Sterno-hyoid muscle.

18. Omo - hyoid muscle (anterior

belly).

19. Sterno-thyreoid muscle.

20. Thyreoid gland.

21. Middle thyreoid vein.

22. Trachea.

23. Inferior thyreoid vein.

24. Sterno-thyreoid muscle.

25. Sterno-hyoid muscle.

26. Subclavius muscle with nerve.

27. Cephalic vein.

28. Lateral anterior thoracic nerve.

29. Acromial branch or thoraco-

acromial artery.

30. Transverse scapular vessels.

3 1 . First serration of serratus anterior

muscle.

32. Subclavian artery.

33. Transverse cervical artery.

34. Upper root of long thoracic

nerve.

35. Trapezius.

36. Scalenus anterior.

37. Internal jugular vein.

38. Communicans hypoglossi nerve.

39. Ascending branch of transverse

cervical artery.

40. Internal carotid artery.

41. External carotid artery.

42. Hypoglossal nerve.

43. Occipital artery and sterno-

mastoid branch.

44. Lesser occipital nerve.

45. Digastric and stylo-hyoid muscles.

46. Third occipital nerve.

47. Greater occipital nerve and

occipital artery.

48. Posterior auricular artery and

vein.

49. Superficial temporal vessels and

auriculo-temporal nerve.
PLATE VII

FIG. 78.

yew

GREAT VESSELS AND NERVES OF NECK 215

vein lies postero-lateral to the upper end of the cervical

part of the internal carotid artery, from which it is partially
separated by the last four cerebral nerves. As it descends
it assumes a more directly lateral relationship, first to the
internal carotid and then to the common carotid, overlapping
each vessel to a slight extent anteriorly; and it is enclosed,
with them and the vagus nerve, in a common sheath of deep
cervical fascia, the nerve lying in its own compartment of the
sheath between the vein laterally and the arteries medially,
and in a posterior plane (Figs. 47, 48, 53).

The superficial or lateral relations of the vein in the upper

part of its extent are the styloid process, with the stylo-

ryn

Thyreo-hyoid membrane

Plica vocalis
Processus vocalis
Arytaenoid cartilage

Platysma
Posterior wall

of phar
Retropharyn-
geal space

Carotid shea
Scalenus anterior

M. longus colli

M.

M. sternohyoideus

. thyreohyoideus

Thyreoid cartilage
M. omohyoideus

ecessus piriformis
Superior thyreoid
Descendens
hypoglossi
^Common carotid
Internal jugular

Vagus

Vertebral artery

Sympathetic trunk

FIG. 79. Transverse section through the Neck at the level of upper
part of Thyreoid Cartilage.

pharyngeus and stylo-hyoid muscles, and the posterior belly

of the digastric, which separate it from the upper part of the
postero-medial surface of the parotid gland. In that part
of its extent it is crossed superficially, along the upper border
of the posterior belly of the digastric, by the posterior
auricular artery, and at the lower border of the digastric
by the accessory nerve, passing downwards and backwards,
and by the occipital artery, passing upwards and backwards,
superficial to the nerve. At a slightly lower level it is con-
cealed by the lower part of the postero-medial surface of the
parotid, and it is crossed by the sterno-mastoid branch of
the occipital artery. After it emerges from under cover of
the parotid, it lies under cover of the anterior border of the
m 14 c

2l6
HEAD AND NECK

sterno-mastoid, except in the region of the upper part of the

carotid triangle, where it may project forwards, beyond the
anterior border of the muscle, for a short distance. It is
separated from the sterno-mastoid by numerous deep cervical
lymph glands; and under cover of the muscle it is crossed
superficially, at the level of the upper part of the thyreoid
cartilage, by the communicans cervicalis from the cervical
plexus, and, at the level of the cricoid cartilage, by the
intermediate tendon of the omo-hyoid, the sterno-mastoid
branch of the superior thyreoid artery and the nerve to the
posterior belly of the omo-hyoid. Below the omo-hyoid it
is covered by the posterior border of the sterno-hyoid, and is

Sheath of dura mater

around vagus and

accessory nerves

Ganglion nodosum

Internal jugular vein

Superior laryngeal nerve

Accessory nerve

Vagus nerve

Sheath of dura mater around

glosso-pharyngeal nerve

Inferior petrosal sinus

Internal carotid artery

Glosso-pharyngeal nerve

Pharyngeal branch of
vagus

Internal laryngeal nerve

External laryngeal nerve

FIG. 80. Diagram of the relation of parts in the Jugular Foramen.

crossed by the anterior jugular vein ; and at its termination

it lies posterior to the sternal end of the clavicle.

Posteriorly, it is in relation with the rectus capitis lateralis ;

the rectus capitis anterior (O.T. anticus minor) ; and the loop
between the first and second cervical nerves. At a lower
level its posterior relations are the transverse processes of the
cervical vertebrae and the muscles attached to their anterior
tubercles, viz., the longus capitis (O.T. rectus capitis anticus
major) and the scalenus anterior. Between its posterior
surface and the scalenus anterior are the ascending cervical
artery, the phrenic nerve, and, crossing superficial to the latter,
the transverse cervical and the transverse scapular arteries.
On the left side the terminal part of the thoracic duct also

GREAT VESSELS AND NERVES OF NECK 217

crosses the phrenic nerve posterior to the internal jugular vein.

At the medial border of the scalenus anterior the thyreo-
cervical trunk is posterior to it, and, at a lower level, the
first part of the subclavian artery and the dome of the pleura.

The right vein is usually the larger of the two; and as

they approach the root of the neck both veins incline slightly
to the right, with the result that, on the right side, the lower
part of the vein is separated from the common carotid artery
by a small triangular interval bounded below by the subclavian
artery, whilst on the left side the vein overlaps the anterior
aspect of the common carotid artery.

Tributaries. Immediately below its commencement the

internal jugular vein is joined by the inferior petrosal sinus,
and then, successively, by offsets from the pharyngeal plexus,
by the lingual veins, the common facial vein, and the superior
and middle thyreoid veins. In some cases it is joined near
its upper end by a vena comitans which runs with the occipital
artery; and, occasionally, near its lower end, it receives the
lymph trunks which usually open into the commencement of
the innominate vein.

Dissection. Slit open the lower part of the vein and examine
the valve which lies close to its extremity. It consists of two
or three semilunar flaps which prevent regurgitation of blood
from the innominate vein into the internal jugular.

Nervi G-losso-pharyngeus, Vagus et Accessorius. After

the removal of the brain the glosso-pharyngeal, vagus, and
accessory nerves were seen leaving the cranial cavity,
through the middle compartment of the jugular foramen, in
the interval between the commencement of the internal
jugular vein postero-laterally and the inferior petrosal sinus
antero-medially (p. in, and Fig. 81, p. 218). The dissector
should again examine the interior of the cranial cavity and
refresh his memory as to the manner in which the nerves
enter the foramen. The glosso-pharyngeal occupies the most
anterior position, and it is cut off from the others by a
separate, tube-like sheath of dura mater. The accessory is
placed posterior to the vagus, and both are included within
the same sheath of dura mater. They therefore traverse
the foramen in close contact with each other. Reaching
the exterior of the skull, the three become associated with
the hypoglossal nerve ; and the four nerves lie, for a short
distance, in the interval between the internal jugular vein

2l8

HEAD AND NECK

and the internal carotid artery, but soon they choose

different routes. The accessory inclines backwards, superficial
or deep to the internal jugular vein ; the glosso-pharyngeal
runs forwards, superficial to the internal carotid, and under
cover of the posterior belly of the digastric ; at a lower
level, the hypoglossal also turns forwards across the internal
and external carotid arteries; and the vagus proceeds

Oculo-motor nerve

Trochlear nerve

Sensory root of the trigeminnl nerve

Motor root of the trigeminal
erve

Abducent nerve

otor root of facial

nerve

Cut edge of the

tentoriuin

- Sensory root of

facial nerve
Acoustic nerve
Right transverse
sinus

Glosso-pharyngeal
nerve
Vagus nerve

Accessory nerve

Vertebral artery
Hypoglossal nerve
First spinal nerve
\ccessory nerve

FIG. 8 1. Section through the Head a little to the right of the Median Plane.
It shows the posterior cranial fossa and the upper part of the vertebral
canal after the removal of the brain and the medulla spinalis.

vertically downwards, first between the internal jugular vein

and the internal carotid artery, and then between the vein
and the common carotid artery (Fig. 79).

In an ordinary dissection it is impossible to follow out many of the

minute twigs which take origin from the last four cerebral nerves in the
region of the basis cranii. To do so it is necessary to possess a perfectly
fresh part which has been specially prepared by having the soft parts
toughened with spirit and the bone softened by immersion in a weak
solution of acid. Even then the dissection is a difficult one, but it should
be undertaken by the advanced student, in the event of his being able to
obtain a part for the purpose.

GREAT VESSELS AND NERVES OF NECK 219

In the following description of the nerves the account

of the branches which can in all cases be traced is printed in
ordinary type, whilst that of those requiring special dissection
is printed in small type.

Nervus Glosso-pharyngeus. The glosso-pharyngeal nerve

inclines downwards and forwards and crosses the internal
carotid artery superficially. At first it lies medial to the
styloid process and the stylo - pharyngeus muscle, then it
hooks round the lower border of the muscle and curves
forwards across its superficial surface to gain the base of
the tongue. In the dissection of the subm axillary region,
its terminal part was seen disappearing under cover of the
hyoglossus muscle, where it ends in lingual branches (Fig. 68).

In the present dissection an attempt should be made to

secure the following branches :
1. Communicating branch from

the facial.

2. Nerve to the stylo-pharyngeus.

3. Pharyngeal.

4. Tonsillar.

5. Lingual.

The communicating branch from the facial springs from the nerve to
the posterior belly of the digastric, and, as a rule, emerges from amidst the
fibres of that muscle to join the glosso-pharyngeal close to the lower part of
the jugular foramen.

The stylo-pharyngeal nerve is a small twig which enters the

muscle of the same name. The greater part of its fibres,
however, are continued through the muscle to the mucous
membrane of the pharynx.

T\\Q pharyngeal branches consist of (i) one or two small

twigs which perforate the superior constrictor to reach the
mucous membrane of the pharynx; and (2) a larger nerve
which comes off higher up and passes with the pharyngeal
branch of the vagus to the pharyngeal plexus. It frequently
divides into two or more branches.

The tonsillar branches proceed from the glosso-pharyngeal

near the base of the tongue. They form a plexus, over the
palatine tonsil, termed the circulus tonsillaris, and give twigs
to the mucous membrane of the isthmus faucium and the soft
palate as well as to the tonsil. Aff~o~ft-*~A

The terminal or lingual branches will oe lolloped in the

dissection of the tongue.

There are still other points in connection with the glosso-pharyngeal

nerve which require mention. At the lower part of the jugular foramen
two small ganglia are formed upon its trunk, and from the lower of the two

220 HEAD AND NECK

certain minute branches are given off. The upper ganglion is called the
ganglion superius ; the lower one is termed the ganglion pet rosnin.

The superior ganglion is a small ganglionic swelling, which involves

only a portion of the fibres of the nerve trunk. It is placed in the
upper part of the bony groove in which the nerve lies as it proceeds through
the jugular foramen. No branches arise from it;

The petrous ganglion is a larger swelling, which involves the entire

nerve-trunk, and lies at the opening of the jugular foramen, between the
vagus nerve and the inferior petrosal sinus (which intervenes between it
and the anterior border of the foramen). Its length is not more than four or
five millimetres. Three branches of communication enter or proceed from
it and connect it with (i) the superior cervical sympathetic ganglion ; (2)
the auricular branch of the vagus ; and (3) the jugular ganglion of the
vagus.

In addition to the twigs mentioned, the tympanic nerve takes origin

from the petrous ganglion.

Nervus Tympanicus. The ultimate destination of the tympanic nerve

may be regarded as the otic ganglion, but it takes a very circuitous route
to gain that structure, and it gives off branches on the way. It enters a small
foramen on the ridge which separates the jugular fossa from the carotid
foramen on the lower surface of the petrous bone, and it is conducted by
a narrow canal to the tympanic cavity. It crosses the medial wall of that
chamber, grooving the promontory. Having gained the anterior part of the
tympanum, it enters the bone a second time, and runs in a minute canal,
which tunnels the petrous bone below the upper end of the channel which
lodges the tensor tympani muscle. In that part of its course the tympanic
nerve is joined by a branch from the ganglion geniculi of the facial nerve,
and, after the junction is effected, it is termed the lesser superficial petrosal
nerve.

The canal in which the lesser superficial petrosal nerve is lodged opens,
by a small aperture, into the cranial cavity, upon the anterior surface of the
petrous bone, immediately lateral to the hiatus canalis facialis. Through
the aperture the nerve enters the cranial cavity, and it almost immediately
leaves it by passing downwards in the interval between the great wing of
the sphenoid and the petrous part of the temporal bone, or through the
canaliculus innominatus, or through the foramen ovale. Outside the skull
it joins the otic ganglion.

In the tympanic cavity the tympanic nerve gives branches of supply

(i) to the mucous membrane of the tympanum ; (2) to the lining
membrane of the mastoid cells ; and (3) to the mucous membrane of the
auditory tube (Eustachian). It is connected with the sympathetic plexus
on the internal carotid artery by the superior and inferior carotico-tympanic
branches which pierce the substance of the petrous part of the temporal
bone and form with the tympanic nerve the tympanic plexus.

Nervus Vagus. The vagus nerve passes through the

middle compartment of the jugular foramen in company with
the accessory nerve both being included within the same
sheath of dura mater. In the neck, it pursues a vertical
course, lying, at first, between the internal jugular vein and
the internal carotid artery, and afterwards between the same
vein and the common carotid artery, enclosed within the
sheath which envelops the vessels, but on a plane posterior

GREAT VESSELS AND NERVES OF NECK 221

to them. Its posterior relations, therefore, are similar to

those of the common and internal carotid arteries (pp. 117,
211). At the root of the neck it enters the thorax, and has
different relations on the two sides. On the right side it
crosses the first part of the subclavian artery ; on the left side,
after crossing anterior to the thoracic duct, it proceeds down-
wards between the left common carotid and subclavian
arteries, posterior to the left innominate vein. For its
thoracic relations see Vol. II. p. 127.

The vagus, like the glosso-pharyngeal, has two ganglia in

connection with its upper part. These are the ganglion
jugulare and the ganglion nodosum.

Ganglion Jugulare (O.T. Ganglion of Root). The jugular ganglion is

situated within the jugular foramen. It is a rounded swelling which is
connected by communicating twigs with several of the nerves in the
neighbourhood, and it gives off two branches of distribution.

Branches of Communication. (i) With the facial nerve; (2) with the
petrous ganglion of the glosso-pharyngeal ; (3) with the accessory ; (4) with
the superior ganglion of the sympathetic.

Branches of Distribution. (i) Meningeal ; (2) Auricular nerve.

The meningeal branch is a minute twig which runs upwards through

the jugular foramen, and, dividing into two branches, is distributed to
the dura mater in the posterior cranial fossa.

The auricular nerve (O.T. Arnold's nerve) obtains a filament of com-

munication from the petrous ganglion of the glosso-pharyngeal, and passes
backwards, upon the lateral surface of the bulb of the internal jugular vein,
to enter a minute aperture on the posterior part of the lateral wall of the
jugular fossa. A narrow canal then conducts it through the substance
of the temporal bone, and, on its way, it crosses the canalis facialis a
short distance above the stylo-mastoid foramen. It is thus brought into
close relation with the facial nerve and is connected with it by an
ascending and a descending branch of communication. Finally, it appears
on the surface of the skull, in the interval between the mastoid process and
the external acoustic meatus, where it communicates with the posterior
auricular branch of the faciaL It supplies the skin on the posterior aspect
of the outer surface of the wall of the meatus, the skin covering the lower
half of the inner surface of the wall of the meatus, and the lower half of
the tympanic membrane.

Ganglion Nodosum. After emerging from the jugular

foramen, the vagus nerve is joined by the cerebral portion of
the accessory nerve, and swells out into the ganglion nodosum
(O.T. ganglion of trunk).

The ganglion nodosum is an elongated reddish-coloured

swelling, about 18 mm. (three-quarters of an inch) in length,
which is developed upon the stem of the vagus, 12.5 mm.
(half an inch) below the base of the cranium. Strong
branches of communication pass between it and the first

222 HEAD AND NECK

loop of the cervical plexus, and the superior cervical ganglion

of the sympathetic. Further, the hypoglossal nerve is gener-
ally closely bound to it by fibrous attachment, in the midst
of which some interchange of nerve filaments takes place.

Branches of Distribution of the Cervical Part of the

Vagus. The branches which spring from the vagus as it
traverses the neck are the following: (i) pharyngeal ;
(2) superior laryngeal ; (3) recurrent; (4) cardiac.

Ramus Pharyngeus. The pharyngeal branch springs

from the upper part of the ganglion nodosum and runs
downwards and forwards, superficial to the internal carotid
artery, to end in the pharyngeal plexus. It is frequently
replaced by two branches, of which the upper is the larger.

Nervus Laryngeus Superior. The superior laryngeal

nerve, a much larger branch, arises from the middle of the
ganglion nodosum. It passes downwards and forwards, but
differs from the pharyngeal branch by passing deep to the
internal carotid artery. Whilst in that situation it ends by
dividing into the internal laryngeal and external laryngeal
nerves, both of which have been previously seen in the dis-
section of the anterior triangle (p. 132).

Before it divides, the superior laryngeal effects communications, by

means of fine twigs, with the superior cervical ganglion of the sympathetic,
and it also receives one or two filaments from the pharyngeal plexus.

The internal laryngeal nerve runs to the interval between

the hyoid bone and the thyreoid cartilage ; there, after
disappearing under cover of the posterior border of the
thyreo - hyoid muscle, it pierces the membrane of the same
name, and enters the pharynx, and then descends to the
larynx.

The external laryngeal nerve is a very slender branch, which

inclines downwards and forwards to reach the crico-thyreoid
muscle, in which it ends.

It supplies a few filaments to the inferior constrictor of the pharynx and

a fine twig to the superior cardiac branch of the sympathetic, whilst it
receives a communicating branch from the superior cervical ganglion of
the sympathetic.

Nervus Recurrens. The recurrent nerve arises differ-

ently on the two sides. On the right side, after springing
from the vagus as the latter crosses the first part of the
subclavian artery, it hooks round the artery and ascends to
its termination. On the left side, it arises from the vagus,

GREAT VESSELS AND NERVES OF NECK 223

in the thorax, and hooks round the aortic arch. In the

neck, each recurrent nerve ascends in the groove between
the trachea and oesophagus, along the medial side of the
corresponding lobe of the thyreoid gland, and, passing
posterior or anterior to the inferior thyreoid artery, it dis-
appears, as the inferior laryngeal nerve, under cover of the
lower border of the inferior constrictor muscle, and enters
the larynx.

Before the recurrent nerve reaches the larynx it gives

off several branches viz., (i) cardiac branches; (2) twigs
to the trachea and oesophagus ; and (3) a few filaments to the
inferior constrictor, as it passes under cover of its lower margin.

Cardiac Branches. Two cardiac branches arise from the

vagus in the neck. On the right side, both of them enter
the thorax by passing posterior to the subclavian artery, and
they end in the deep cardiac plexus. On the left side, the upper
nerve joins the deep cardiac plexus, whilst the lower nerve
enters into the formation of the superficial cardiac plexus.

Nervus Accessorius. The accessory nerve consists of two

parts a spinal and a cerebral. In the jugular foramen the
cerebral portion is connected by one or two fine twigs with the
jugular ganglion of the vagus, and below the base of the
skull it leaves the spinal part and joins the vagus.

The cerebral part of the accessory nerve contributes to the vagus

the greater proportion of its motor fibres. They pass over the surface
of the ganglion nodosum, and are continued into the pharyngeal and
into the superior laryngeal nerves. Some of the fibres are carried down
the stem of the vagus into the cardiac branches and also into the recurrent
nerve.

The spinal part of the accessory is directed backwards

below the level of the transverse process of the atlas. It
crosses the internal jugular vein, and disappears into the
sterno-mastoid muscle. Its further course has been studied
already (pp. 41 and 133). It is distributed to two muscles
viz., the sterno-mastoid and the trapezius.

Plexus Pharyngeus. The pharyngeal plexus is a mesh-

work of fine nerve filaments, which is formed upon the wall
of the pharynx at the level of the middle constrictor muscle.
The pharyngeal branches of the vagus, glosso-pharyngeal,
and superior cervical ganglion of the sympathetic enter into
its construction, and one or more minute ganglia are
developed in connection with it. Its terminal twigs are given

224 HEAD AND NECK

to the muscles and mucous membrane of the pharynx, and

one branch (the ramus lingualis vagi) connects the plexus
with the hypoglossal nerve.

Nervus Hypoglossus. The hypoglossal nerve makes its

exit from the cranium through the hypoglossal canal
(O.T. anterior condyloid foramen). It pierces the dura mater
in two separate parts, which unite into one stem at the external
orifice of the bony canal. As it issues from the canal it lies
deeply, medial to the internal jugular vein and the internal
carotid artery ; immediately afterwards it inclines laterally, and,
taking a half spiral turn around the ganglion nodosum of the
vagus, it appears between the two vessels, and descends between
them to the lower border of the posterior belly of the digastric
muscle, where it passes into the carotid triangle. Its close
connection with the ganglion nodosum of the vagus has
been noted already (p. 221). In the carotid triangle, it hoefe
round the lower end of the occipital artery, below its sterno-
mastoid branch, and, turning forwards, it crosses superficial to
the occipital, the internal and external carotid arteries and the
loop of the lingual artery. Then it passes across the medial
sides of the posterior belly of the digastric and the stylo-hyoid,
and enters the digastric triangle, where it disappears medial
to the mylo-hyoid ; and at the anterior border of the hyoglossus
it enters the root of the tongue.

Branches of Communication. Near the base of the skull the hypoglossal

nerve is connected with (i) the superior cervical ganglion ; (2) the vagus ;
and (3) the first cervical nerve ; as it turns round the occipital artery
it receives (4) the ramus lingualis vagi from the pharyngeal plexus ; and on
the surface of the hyoglossus it communicates with (5) the lingual nerve
by one or more branches (p. 195).

Branches of Distribution. (i) The meningeal branch arises

in the upper part of the canalis hypoglossi, and, regaining the
interior of the cranium, it is distributed to the dura mater
around the foramen magnum. (2) Vascular twigs are said to
be supplied to the deep aspect of the internal jugular vein.
(3) The descendens hypoglossi, which conveys fibres of the
first cervical nerve to the infra-hyoid muscles. (4) The nerve
to the thyreo-hyoid, which also consists of first cervical nerve
fibres. (5) The terminal branches, which supply the genio-
hyoid and all the intrinsic and extrinsic muscles of the tongue,
except the glosso-palatinus.

Dissection. In the preceding dissections of the neck the

greater part of the cervical sympathetic, and the branches which

GREAT VESSELS AND NERVES OF NECK 225

proceed from it, have been displayed. The inferior ganglion,

which lies deeply, in the hollow between the transverse process
of the seventh cervical vertebra and the neck of the first rib, is
still to a certain extent concealed, and must now be displayed.
Dislodge the subclavian artery from its place on the first rib
behind the scalenus anterior muscle, and turn it medially. To
do that efficiently, it will be necessary to cut the costo-cervical
artery at its origin. Great care must be taken to preserve un-
injured the fine nerves which proceed downwards anterior to
the first part of the subclavian artery. If more space for the
dissection is required, the anterior part of the first rib may be
removed by the bone-forceps, but, as a general rule, that will
not be necessary.

Truncus Sympathicus in the Neck. The cervical part of

the sympathetic trunk takes a vertical course through the neck,
anterior to the roots of the transverse processes of the vertebrae.
It lies between the internal and common carotid arteries
anteriorly and the longus capitis (O.T. rectus capitis anticus
major) and longus colli muscles posteriorly. Above, it is pro-
longed upwards in the form of a stout, ascending nerve-trunk,
the nervus caroticus internus, which accompanies the internal
carotid artery into the carotid canal ; below, it becomes con-
tinuous, over the neck of the first rib and posterior to the
apex of the pleura, with the thoracic portion of the sympa-
thetic trunk. Only three ganglia are developed upon the
cervical part of the trunk and no white rami communicantes
from the cervical nerves enter either the trunk or the ganglia.

Ganglion Cervicale Superius. The superior cervical gang-

lion, the largest of the three ganglia, is an elongated fusiform
body which varies somewhat in size. It is placed upon the
upper part of the longus capitis, opposite the second and
third cervical vertebras, and posterior to the carotid sheath.
From its upper end the stout nervus caroticus internus passes
into the carotid canal^ whilst its lower end tapers downwards
into the trunk. Numerous branches issue from it ; some of
them connect it with neighbouring nerves, whilst others are
distributed in various ways.

The connecting branches are: (i) slender grey rami

communicantes which connect it with the upper four cervical
nerves ; (2) twigs to both ganglia of the vagus ; (3) to the
petrous ganglion of the glosso-pharyngeal ; and (4) to the
hypoglossal. It is not connected with the accessory.

The branches of distribution are: (i) nervus caroticus

internus; (2) nervi carotici externi ; (3) rami laryngo-
pharyngei ; (4) nervus cardiacus superior.

VOL. in 15

226 HEAD AND NECK

Nervus Caroticus Interims. The internal carotid nerve

passes from the upper end of the ganglion into the carotid
canal. Its distribution will be considered later (p. 241).

Nervi Carotid Externi. Two to six filaments, called

external carotid branches, run to the external carotid artery,
and form a loose interlacement around it called the external
carotid plexus from which a branch is given to the glomus
caroticum, and prolongations are continued on all the branches
of the artery. The part continued upon the external maxillary
artery supplies the sympathetic root to the submaxillary
ganglion, whilst the subdivision upon the middle meningeal
artery furnishes the corresponding root to the otic ganglion,
as well as the external superficial petrosal nerve, which runs
to the ganglion geniculi of the facial nerve.

Rami Laryngo-pharyngei. The laryngo-pharyngeal branches

join the pharyngeal plexus and the superior laryngeal nerve.

Nervus Cardiacus Superior. The superior cardiac nerve is

a long slender branch which springs, by several roots, from
the ganglion, and then proceeds downwards, posterior to the
carotid artery. At different stages of its course it is joined
by other branches of the sympathetic, by a branch from the
vagus, and also by filaments from the external laryngeal and
recurrent nerves. The right superior cardiac nerve is con-
tinued into the thorax by passing posterior or anterior to the
subclavian artery, and it ends in the deep cardiac plexus. The
left superior cardiac nerve follows the left common carotid
artery in the thorax, and, after crossing the left side of the
arch of the aorta, ends in the superficial cardiac plexus.

Ganglion Cervicale Medium. The middle cervical ganglion

is the smallest of the three ganglia of the neck. It is placed
opposite the sixth cervical vertebra, in close proximity to
the inferior thyreoid artery, upon which it not infrequently
rests. Its branches are: ( i ) grey rami communicantes, which
pass between the contiguous margins of the scalenus anterior
and longus colli muscles and connect the ganglion with the
fifth and sixth cervical nerves \ (2) thyreoid branches, which
run to the thyreoid gland, along the inferior thyreoid artery,
and form connections with the external laryngeal and recurrent
nerves ; (3) the middle cardiac nerve.

On both sides the middle cardiac nerve enters the thorax

and is lost in the deep cardiac plexus. On the right side,
it passes posterior or anterior to the subclavian artery ; on

GREAT VESSELS AND NERVES OF NECK 227

the left side, it is continued downwards between the common

carotid and subclavian arteries.

Ganglion Cervicale Inferius. The inferior cervical ganglion

is lodged in the interval between the transverse process of the
seventh cervical vertebra and the neck of the first rib. In that
position it lies posterior to the vertebral artery. It is by no
means uncommon to find it more or less completely fused,
over the neck of the first rib, with the first thoracic ganglion.
The connection between it and the middle cervical ganglion is
generally in the form of two or more slender nerve cords.
One of the cords passes anterior to the subclavian artery,
loops round below it and ascends behind it. That loop is
termed the ansa subclavia (Vieussenii).

The branches of the inferior cervical ganglion are :

1. Grey rami communicantes to the seventh and eighth cervical nerves.

2. Rami vasculares.

3. Nervus cardiacus inferior.

The vascular rami are fine branches which form a plexus

around the subclavian artery and its branches. Those
around the vertebral artery are remarkable for their large size.

The inferior cardiac nerve, on both sides, enters the deep

cardiac plexus.
THYREOID GLAND TRACHEA (ESOPHAGUS.

After the vessels and nerves of the neck have been studied
the dissectors should examine the thyreoid gland, the trachea,
and the oesophagus.

Glandula Thyreoidea. The thyreoid gland is a highly

vascular, solid body, which clasps the upper part of the
trachea and extends upwards for some distance upon each
side of the larynx. It is enclosed in a sheath of the pre-
tracheal layer of the cervical fascia, which is attached above
to the front and sides of the larynx. It possesses also its
own proper fibrous capsule, which is continuous with the
stroma of the gland. Between the sheath and the capsule
the arteries of supply ramify before they enter the gland
substance, and the emerging veins anastomose with one
another to form the various thyreoid veins. It varies greatly
in size in different subjects ; and -in females and children it
is always relatively larger than in adult males. It consists of
in 15 a

228

HEAD AND NECK

three well-marked subdivisions, viz., two lobes joined across

the median plane by the isthmus. Each lobe is somewhat
conical in form ; its base lies at the level of the fifth or the
sixth tracheal ring, whilst its apex rests against the side of
the thyreoid cartilage. Its superficial or lateral surface is full

\nterior facial vein

M. mylohyoideus

Common facial
vein

Lingual vein
Lesser occipital N.,
Great auricular N.
Nervus
cutaneus colli
iternal jugular vein
Descending
cervical ""}
nerves |

BrachialV
plexus \ i
External---!-.
jugular vein ,|
Descendens m
hypoglossi
Anterior
jugular vein

Inferior
thyreoid veins

Platysma

External maxillary
artery
BL_ Parotid gland

Submental lymph
eland

Submaxillary glanc

Sterno-mastoid arte:

Ext. carotid artery

Sup. thyreoid arter

Common carotid
artery
Lymph gland

Thyreo-glossal duci
M. omohyoideus
M. cricothyreoideu
M. sternohyoideus

Isthmus of thyreoic
gland

M. sternothyreoidei

FIG. 82. Dissection of the Anterior Part of the Neck.

mastoid has been removed.

The Right Sterno-

and rounded ; it is covered superficially by the sterno-

thyreoid, sterno-hyoid, and omo-hyoid muscles, and is
overlapped by the anterior border of the sterno-mastoid
(Fig. 83, p. 230). Its deep or medial surface is adapted
to the parts upon which it lies, viz., to the side of the
trachea, the cricoid cartilage, and the thyreoid cartilage.
Its. posterior border is in relation with the lateral margins of

THYREOID GLAND 229

the oesophagus and the pharynx, and the recurrent nerve.

In most cases it overlaps the common carotid artery. Its
anterior border is connected with the anterior border of the
opposite lobe by the isthmus. Above the isthmus it is in
relation with the anterior terminal branch of the superior
thyreoid artery, and, below the isthmus, with the commence-
ment of the inferior thyreoid vein.

The isthmus of the thyreoid gland has already been seen

in the dissection of the middle line of the neck. It is a
band of varying width which Ires anterior to the second, third,
and fourth rings of the trachea, and, therefore, nearer the
lower than the upper ends of the two lobes.

An additional lobe, the pyramidal or middle lobe, is

frequently present. It is an elongated slender process which
springs from the isthmus, on one or other side of the median
plane (more usually on the left side), and extends upwards
towards the hyoid bone. It may be connected to the hyoid
bone by fibrous tissue, or by a narrow slip of muscular fibres
called the levator glandulcz thyreoidece. That little muscle, in
some cases, has an attachment to the thyreoid gland independ-
ently of the pyramidal process. The thyreoid gland is firmly
connected by fascia to the parts upon which it lies, and
therefore follows the larynx in all its movements.

The dissector should note the great vascularity of the

thyreoid gland. Four large arteries, and occasionally a fifth
smaller vessel, convey blood to its substance. At the apex
of each lobe a superior thyreoid branch of the external
carotid artery divides into three branches which supply the
gland ; the two inferior thyreoid branches, from the thyreo-
cervical trunks of the subclavian arteries, distribute their
terminal branches to the basal portions and deep surfaces of
the two lobes. The occasional artery is the thyreoidea ima,
a branch of the innominate or, more rarely, of the common
carotid or the aortic arch. It ascends, upon the anterior
aspect of the trachea, to reach the isthmus of the thyreoid
gland. These thyreoid arteries anastomose with one
another.

The veins which drain the blood away from the thyreoid
gland are still more numerous. They arise, in part, by
tributaries which spring from a venous network on the
anterior surface of the gland, but chiefly by branches which
emerge from its substance. They are three in number on
in 156
2 3 o HEAD AND NECK

each side viz., the superior thyreoid, the middle thyreoid,

and the inferior thyreoid. The superior and middle thyreoid
veins cross the common carotid artery and join the internal
jugular; the inferior thyreoid vein descends on the trachea.
At the root of the neck it usually joins its fellow of the
opposite side to form a common stem which opens into the
left innominate, in the thorax.

Trachea and (Esophagus. The cervical portions of the

windpipe and the gullet may now be studied. Both the
trachea and the oesophagus begin at the level of the cricoid
cartilage, anterior to the sixth cervical vertebra. From that

Trachea

Thyreoid gland
Recurrent nerve ^- "^"K^P*?--/ M< sternotn y reoideus

--^>- t ' " > ^'^>3L^ ^ m " stern ohyoideus and

Common carotid artery >^\ ^^-f^^jtSm S^^tst 1 *--- ' omohyoideus

'Sffii^^ ^^fcClV- WL Nfcw Sterno-mastoid

Internal jugular vein ^^p

Vagus nerve '" ^H,

- ^L - "--,* >*"" '" a> "~" ^ ecurrent m

ferior thyreoid artery ' ,- \ r >?\ ""-.Vertebral vein

Vertebral vein

Vertebral artery / (Esophagus ist thoracic vertebra

Longus colli

PIG. 83. Transverse section through the Thyreoid Gland, Trachea, and

Gullet, at the level of the first Thoracic Vertebra.

point they extend downwards, anterior to the vertebral

column, to the thoracic cavity.

The trachea, or windpipe, is a wide tube which is kept

constantly patent by the cartilaginous curved bars embedded
in its walls. The bars do not form complete circles ; pos-
teriorly they are deficient, and, in consequence, the posterior
surface of the trachea is flattened. The trachea is con-
tinuous above with the larynx, and, throughout its course in
the neck, it is placed in the median plane of the body. The
anterior relations of the trachea have already been fully
discussed in the account of the parts which occupy the
middle line of the neck (p. 127). Posteriorly, it rests upon
the gullet. A common carotid artery and the corresponding

TRACHEA AND CESOPHAGUS 231

lobe of the thyreoid gland lie upon each side of it, the lobe
of the gland being closely applied to its upper part. A
recurrent nerve ascends, on each side, in the angle between
the trachea and oesophagus.

The oesophagus or gullet is a narrow tube, with thick

muscular walls, which extends from the pharynx to the
stomach. In the cervical part of its course it lies between the
trachea and the longus colli muscles, and as it descends
it inclines slightly to the left, so that it comes more closely
into relation with the lobe of the thyreoid gland and the
carotid sheath upon the left side than with the same structures
on the opposite side (Figs. 54, 83, 108, 109).

The dissector may terminate his dissection of the neck by

an examination of the scalene muscles and the rectus capitis
lateralis muscle.

SCALENE MUSCLES AND RECTUS LATERALIS.

Musculi Scaleni. The scalene muscles constitute the fleshy

mass which is seen extending from the transverse processes
of the cervical vertebrae to the upper two costal arches.
They are three in number, and are named, from their relative
positions, anterior^ medius, and posterior.

Musculus Scalenus Anterior, The scalenus anterior is a

well-defined muscle which is separated from the scalenus
medius by the roots of the brachial plexus and the subclavian
artery. It arises from the anterior tubercles of the transverse
processes of the third, fourth, fifth and sixth cervical vertebrae,
and, tapering somewhat as it descends, it is inserted into the
scalene tubercle on the inner margin of the first rib, and
also into the superior surface of the same bone between the
grooves for the subclavian artery and vein (Fig. 84).

The upper part of its anterior surface is concealed by the

sterno-mastoid, and the lower part by the clavicle. The
common carotid artery ascends along its medial border.
Between it and the sterno-mastoid lie (i) the internal jugular
vein; (2) the intermediate tendon of the omo-hyoid ; (3) the
phrenic nerve, passing downwards and forwards ; and (4) the
transverse cervical and transverse scapular arteries, passing
backwards and laterally, superficial to the phrenic nerve.
Between it and the clavicle lies the subclavian vein.

Its posterior surface is in relation, above, with the tips of

232

HEAD AND NECK

the lower cervical transverse processes, and below, with the

apex of the pleura, the second part of the subclavian artery,
and its costo-cervical branch. The lateral border touches the
roots of the brachial plexus, and the medial border is in
relation with the thyreo-cervical artery, its inferior thyreoid
branch, and with the vertebral artery (Fig. 54).

Serratus posterior
superior (insertion)

Scalenus posterior
(insertion)

Scalenus medius (insertion)

Serratus anterior (origin)

Serratus anterior
(origin)

Scalenus anterior (insertion)

Subclavius
(origin)

Pectoralis minor (occasional or

FIG. 84. Muscle-Attachments to the Superior Surface of the

First Rib, and the Outer Surface of the Second Rib.

A, First rib ; B, Second rib.

Musculus Scalenus Medius. The scalenus medius is a
more powerful muscle than the scalenus anterior. It springs
from the posterior tubercles of all the cervical transverse
processes (with the exception, in some cases, of the first),
and it is inserted into a rough oval impression which marks
the upper surface of the first rib, between the tubercle of
the rib and the groove for the subclavian artery (Fig. 84).

SCALENE MUSCLES 233

It forms part of the floor of the posterior triangle of the

neck. Its superficial surface is in relation with the brachial
plexus and the third part of the subclavian artery. Its
posterior border touches the levator scapulae ; and the dorsal
scapular nerve and the descending branch of the transverse
cervical artery pass between it and that muscle. The lower
part of its anterior border is in relation with the apex of
the pleura, and the upper two roots of the long thoracic
nerve pierce the substance of the muscle.

Musculus Scalenus Posterior. The scalenus posterior is

generally inseparable, at its origin, from the scalenus medius.
It is the smallest of the three, and springs by two or three
slips from the transverse processes of a corresponding number
of the lower cervical vertebrae, in common with the scalenus
medius. It is inserted into the upper border of the second
rib, immediately anterior to the insertion of the levator
costae and behind the large rough area which marks the
origin of the serratus anterior (Fig. 84).

The scalene muscles are supplied by twigs from the

anterior branches of the cervical nerves^ particularly the lower
four. They elevated the ribs to which they are attached
and are, therefore, muscles of thoracic respiration.

Dissection. The little muscle termed the rectus capitis

lateralis should now be cleaned, and its attachments defined.
It lies in the interval between the transverse process of the atlas
and the jugular process of the occipital bone, posterior to the
commencement of the internal jugular vein. The anterior
ramus of the first cervical nerve will be seen emerging from
under cover of its medial margin.

Rectus Capitis Lateralis. The rectus lateralis arises from

the anterior part of the upper surface of the extremity of the
transverse process of the atlas, and is inserted into the under
surface of the jugular process of the occipital bone. It is
supplied by a twig from the anterior ramus of the first cervical
nerve.

Dissection. By the time that the dissectors of the head and

neck have arrived at this stage of their work, the dissectors of
the thorax have, in all probability, finished their dissection.
If that is the case, the head and neck may be removed from the
trunk by cutting through the vertebral column at the level of
the intervertebral fibre-cartilage between the third and fourth
thoracic vertebrae. By this proceeding the upper three thoracic
vertebrae, with the attached portions of the first, second, and
third pairs of ribs, are removed with the neck. The scalene
muscles and the longus colli are therefore preserved intact.

234 HEAD AND NECK

THE LATERAL PART OF THE MIDDLE

CRANIAL FOSSA.

The structures contained within the middle cranial fossa

may now be examined or re-examined. In carrying out this
dissection, the head should be supported on a block so that
the floor of the cranial cavity looks upwards. The follow-
ing are the structures which must be displayed :

1. Cavernous venous sinus.

2. Internal carotid artery.

3. Middle meningeal artery.

4. Accessory meningeal artery.

5. The two roots of the Trigeminal nerve, with the Semilunar

ganglion and the three main divisions of the trigeminal

nerve.

6. Oculo-motor nerve (3rd cerebral).

7. Trochlear nerve (4th cerebral).

8. Abducent nerve (6th cerebral).

9. Internal carotid plexus of the sympathetic.

10. Greater superficial petrosal nerve.

11. Lesser superficial petrosal nerve.

Dissection. The dura mater has already been removed from

one half of the middle cranial fossa (pp. 109, no), and on that
side it is necessary only to differentiate again the structures
which lie in the cavernous sinus ; on the other side the dura
mater must be stripped from the medial part of the lateral
portion of the middle cranial fossa. Enter the knife at the
anterior clinoid process, and carry it backwards to the apex of
the petrous bone. This incision must go no deeper than is
necessary to divide the dura mater, and must be made immedi-
ately to the lateral side of the openings in the membrane through
which the oculo-motor, the trochlear, and trigeminal nerves
pass. It is very important to preserve those apertures intact,
so that the proximal ends of the nerves may be held in position
during the dissection. The incision through the dura mater
may now be carried backwards and laterally along the upper border
of the petrous bone in the line of the superior petrosal sinus, and,
forwards and laterally, along the posterior margin of the small wing
of the sphenoid. After the incisions are made, raise the dura
mater with great care, for it is intimately connected with the
nerves which lie subjacent to it. Thus, where it forms the
lateral wall of the cavernous sinus, it is closely applied to the
oculo-motor and trochlear nerves, and it is firmly attached to
the ophthalmic division of the trigeminal nerve, whilst over the
petrous bone it is united to the surface of the semilunar ganglion,
and the greater and lesser superficial petrosal nerves are immedi-
ately beneath it. The edge of the knife, therefore, must be kept
close to the membrane, and a small portion of the membrane
may be left upon the nerves. The part which is left can be
removed afterwards as the nerves are defined.

LATERAL PART OF MIDDLE CRANIAL FOSSA 235

Sinus Cavernosus. The cavernous sinus has been opened

by the above dissection. It is a short, wide venous channel,
which extends, along the side of the body of the sphenoid bone,
from the lower and medial end of the superior orbital fissure
(O.T. sphenoidal fissure) to the apex of the petrous portion
of the temporal bone. Anteriorly, blood is conducted into it
by the ophthalmic veins and the spheno-parietal sinus ; whilst
posteriorly, the blood" is drained away by the superior and
inferior petrosal sinuses. But it has still other connections.
Thus, it receives blood from the lower part of the lateral
surface of the brain by the superficial middle cerebral vein
and some small inferior cerebral veins. It is united with
the corresponding sinus of the opposite side by means of the

1N T. CAROTID I NFUNDlBULUiv,

OCULOMOTOR

TROC HLEAR N

FIG. 85. Section through the Cavernous Sinus.

(After Merkel, somewhat modified. )

anterior and posterior intercavernous sinuses (p. 107). Lastly,

one or more emissary veins leave its lower aspect ; one passes
out of the cranium by the foramen ovale, or it may be
through the foramen Vesalii, and ends in the pterygoid venous
plexus ; and others accompany the internal carotid artery,
through the foramen lacerum and the carotid canal, and end
in the pharyngeal plexus.

The cavernous sinus is formed in the same manner as

the other venous sinuses. The two layers of the dura mater
are separated from each other, and the interval is lined with
a delicate membrane. An intricate network of interlacing
trabeculae occupies the lumen of the channel, and it is on
that account that the term " cavernous " is applied to the
sinus. The cavernous sinus has a special importance on
account of its being traversed by the internal carotid artery ;

HEAD AND NECK

the internal carotid plexus; the oculo-motor, trochlear, and

abducent nerves; and the ophthalmic division of the tri-
geminal nerve. The precise relations which those structures
bear to its walls will be described later ; in the meantime it is
necessary only to note that two, viz., the internal carotid
artery and the abducent nerve, lie more distinctly within the
interval between the two layers of the dura mater than the
others, but that they are shut out from the blood channel by
the delicate lining membrane of the sinus. The oculo-motor
and trochlear nerves, and the ophthalmic division of the

Oculo-motor nerves
Trochlear nerve^^

Ophthalmic
nerve
Abducens
nerve

Infundibulum
Hypophysis

Optic nerve

Internal carotid artery

Oculo-motor nerve

Pterygoid fossa
Choana

Vomer

FIG. 86. Frontal section through the Cavernous Sinus to show the position
of the Nerves in its wall. Note the branch given to the hypophysis
(O.T. pituitary body) by the internal carotid artery.

trigeminal nerve, are closely applied to the lateral wall of

the sinus (Figs. 85, 86, 87, 92).

Nervus Trigeminus. The two roots of the trigeminal nerve

have already been seen passing between the two layers of
the dura mater, at the apex of the petrous portion of the
temporal bone, under the anterior margin of the tentorium.
Now that the dura mater has been raised from the lateral
part of the middle cranial fossa, the further relations of those
nerve-roots within the cranium may be studied. It will be
noticed that the loosely connected and parallel funiculi of
the portio major, or sensory root, at once begin to divide
and join with each other so as to form a dense plexiform

LATERAL PART OF MIDDLE CRANIAL FOSSA 237

arrangement, whilst, at the same time, the nerve-root increases

somewhat in breadth. The interlacement, thus brought
about, occupies the smooth depression which marks the
anterior aspect of the apex of the petrous portion of the
temporal bone, and it sinks into the semilunar ganglion (O.T.
Gasserian).

M. levator palpebrse superioris

M. rectus superior

M. obliquus superior
Lacrimal gland

M. rectus lateralis

Sixth nerve

Ciliary ganglion
Naso-ciliary nerve

Ophthamic division
of trigeminal nerve
Maxillary division
of trigeminal nerve
Motor root of
trigeminal nerve

Semilunar ganglion/ /

Trochlea

M. obliquus
superior

M. rectus
inferior

M. rectus medialis

- Trochlear nerve
Abducens nerve

Optic nerve

Oculo-motor

| 'nerve

Abducens nerve
Mandibular division of trigeminal nerve Trochlear nerve

FIG. 87. Dissection of the Orbit and the Middle Cranial Fossa. Both
roots of the fifth nerve, with the semilunar ganglion, are turned laterally.

The Semilunar Ganglion (O.T. Gasserian) is somewhat

crescentic in form. It lies upon the sutural junction between
the apex of the petrous bone and the great wing of the
sphenoid bone. There it is enclosed within a recess or space,
called the cavum Meckelii, formed by a separation of the two
layers of the dura mater. The concavity of the ganglion is
directed postero-medially, and it is upon that aspect that it
receives the interlacing fibres of the sensory root of the
trigeminal nerve ; the convexity of the ganglion is directed

238 HEAD AND NECK

antero-laterally and from it emerge the three main divisions

of the trigeminal nerve. They are (i) the first, or
ophthalmic division ; (2) the second, or maxillary division ;
and (3) the third, or mandibular division. The medial
border of the ganglion is connected with the internal carotid
sympathetic plexus by filaments of communication.

The/0r//0 minor, or motor root, of the fifth nerve should now

be followed. Before the nerve passes into MeckePs cave the
motor root lies along the medial side of the large sensory
root, but it soon changes its position and then lies beneath
the sensory part. To display that relationship, draw the
cut ends of the two roots through the aperture in the dura
mater which leads into Meckel's cave, and, gently dislodging
the semilunar ganglion from its place, turn it forwards and
laterally so as to expose its deep surface. The small and
firm motor root can readily be recognised lying in a groove
on the deep surface of the ganglion ; if it is displaced
from the groove, it will be seen to have no connection with
the ganglion, but to be continued onwards towards the foramen
ovale. It ultimately joins the mandibular division of the
trigeminal nerve. The junction may take place within the
cranium, in the foramen ovale, or immediately outside the
skull.

Dissection. The three principal divisions of the trigeminal

nerve may next be examined. Begin with the mandibular
division, which is the largest. It proceeds directly downwards,
and almost immediately leaves the cranial cavity through the
foramen ovale.

Whilst isolating the mandibular division and defining the

bony aperture through which it makes its exit, look carefully
for the accessory meningeal artery, which enters the cranium
through the same foramen. If the injection has been forced
into the vessel it can easily be detected. An emissary vein
which connects the cavernous sinus with the pterygoid venous
plexus also passes through the foramen ovale.

The maxillary division is composed entirely of sensory

fibres. It runs forwards, in relation to the lower and lateral
part of the cavernous sinus, and, after a short course within
the cranium, makes its exit through the foramen rotundum.
Near its origin it gives off a fine meningeal branch to the dura
mater of the middle fossa of the cranium.

The ophthalmic division is the smallest of the three branches

of the trigeminal nerve, and, like the maxillary, it is com-
posed entirely of sensory fibres. It passes forwards, in the

LATERAL PART OF MIDDLE CRANIAL FOSSA 239

lateral wall of the cavernous sinus, and ends, close to the

superior orbital fissure, by dividing into three terminal branches.
As it traverses the sinus it is accompanied by the oculo-
motor and trochlear nerves, both of which occupy a higher
level. Like the other two divisions of the trigeminal nerve,
the ophthalmic nerve gives off a meningeal branch ; it is a
small twig which passes into the tentorium cerebelli.
The terminal branches of the ophthalmic division of the
trigeminal nerve are the naso-ciliary, the lacrimal, and the
frontal. The naso-ciliary, as a rule, takes origin first ;
the lacrimal is given off soon after; and then the stem of
the nerve is continued onwards as the frontal. The three
branches enter the orbit through the superior orbital fissure.

Nervus Oculomotorius (Third), et Nervus Trochlearis

(Fourth), et Nervus Abducens (Sixth). It has been noted
already that the oculo-motor nerve pierces the dura mater within
the small triangular area, in the middle cranial fossa, which
lies immediately anterior to the crossing of the attached and
free margins of the tentorium (p. 108). It has been noted
also that the trochlear (fourth) nerve pierces the dura mater
in the posterior fossa under the free margin of the tentorium.
Both proceed forwards in the lateral wall of the cavernous
sinus. The oculo-motor nerve occupies the highest level,
then comes the trochlear nerve, and immediately below that
the ophthalmic division of the trigeminal nerve. The three
nerves, therefore, present a numerical order from above down-
wards. The abducent nerve, which pierces the dura mater
in the posterior fossa, at the lower and lateral part of the
dorsum sellae, curves round the lateral side of the internal
carotid artery, and then passes forwards more directly within
the cavernous sinus than the others (Fig. 85).

The oculo-motor, trochlear, and abducent nerves, during

their course *n the cavernous sinus, receive communica-
tions from the carotid plexus and from the ophthalmic
nerve ; and they all enter the orbit by passing through
the superior orbital fissure. Before doing so, the oculo-
motor nerve divides into an upper and a lower division.
As they pass through the superior orbital fissure the various
nerves undergo a change in their relative positions. That,
however, will be studied in the dissection of the orbit.

Arteria Carotis Interna. The intracranial portion of the

internal carotid artery may now be examined (Figs. 39, 85,

240

HEAD AND NECK

86, 92). It lies upon the lateral aspect of the body of the
sphenoid, and, for the greater part of its course, it'traverses the
cavernous sinus. It emerges from the carotid canal into the
foramen lacerum at the apex of the petrous hone ; then it passes
through the upper part of the foramen lacerum, pierces the outer
layer of dura mater, and enters the middle cranial fossa, at the
Infundibulum

Abducens nerve
Trigeminal nerve

Trochlear ner

Acoustic and
facial nerves

Glosso-pharyn-
geal nerve

Accessory nerve

Section throu
the medulla
oblongata

Transverse sinus

Optic nerve

nternal carotid
artery

|A Posterior
J*.V- communicating
B\ artery

' *' Oculo-motor nerve

Posterior cerebra

artery
Superior
cerebellar arter
Tentorium

Basilar
artery

Vertebral
artery

Superior petro.-
sinus
Transverse sir

Occipital sinus

Superior sagittal sinus

Straight sinus (divided)

FlG. 88. Floor of the Cranium after the removal of the Brain and the
Tentorium Cerebelli. The blood vessels forming the circulus arteriosus
have been left in place.

root of the posterior clinoid process ; there it bends, at right

angles, and passes forwards to the lower root of the small wing
of the sphenoid, where it turns abruptly upwards and pierces
the inner layer of the dura mater, immediately posterior to
the entrance of the optic nerve into the optic foramen and
on the medial side of the anterior clinoid process. It was
severed at that point during the removal of the brain ; but it
will be afterwards seen to end, on the basal aspect of the

LATERAL PART OF MIDDLE CRANIAL FOSSA 241

brain, at the commencement of the lateral fissure (O.T. Sylvian

fissure), by dividing into the anterior and middle cerebral
arteries. Throughout its whole course it is surrounded by
sympathetic filaments, and soon after its entrance into the
cranium the abducent nerve crosses its lateral side.

The intracranial portion of the internal carotid artery gives

off the following branches :

1. Branches to the hypophysis, \ These are minute twigs

2. Branches to the semilunar ganglion, which arise in the

3. Branches to the dura mater, - J cavernous sinus.

4. Ophthalmic, ~\

5. Posterior communicating, These win be studied at a Uter

6. Anterior cerebral, \ terminal V st

7. Middle cerebral, / branches, j

8. Chorioidal. J

Plexus Caroticus Interims. The sympathetic filaments

which form the internal carotid plexus can be satisfactorily
dissected only in a subject which has not been injected ; and
even then, the dissection is an exceedingly difficult one. The
internal carotid plexus is placed in the cavernous sinus and is
massed chiefly upon the lower and medial aspect of the internal
carotid artery, at the point where it makes its bend upwards.
It supplies filaments to the hypophysis, to the third and fourth
nerves, to the ophthalmic division of the trigeminal nerve and
to the semilunar ganglion, and gives the sympathetic root to
the ciliary ganglion (O.T. lenticular ganglion).

Nervus Petrosus Superficialis Major. The greater super-

ficial petrosal nerve, along with a small arterial twig from the
middle meningeal artery, can readily be exposed in the groove,
on the anterior face of the petrous bone, which leads from the
hiatus canalis facialis to the foramen lacerum. It is placed under
the semilunar ganglion, which must therefore be turned for-
wards and laterally. In the canalis facialis it joins the ganglion
geniculi of the facial nerve. When traced in the opposite
direction, it will be found to enter the foramen lacerum, where
it joins the deep petrosal nerve from the carotid plexus. The
trunk formed by the union of these two filaments is the nerve
of the pterygoid canal (O.T. Vidian nerve).

. Nervus Petrosus Superficialis Minor. The lesser superficial petrosal

nerve appears upon the anterior face of the petrous bone, through an
aperture which is placed immediately lateral to the hiatus canalis facialis.
It leaves the cranial cavity by passing downwards between the great wing
of the sphenoid and the petrous part of the temporal bone, or through the
canaliculus innominatus or through the foramen ovale, to reach the otic
VOL. Ill 16

242 HEAD AND NECK

ganglion. It, as has been mentioned already (p. 220), is formed by the
union of the tympanic branch of the glosso-pharyngeal with a branch
from the ganglion geniculi of the facial.

External Superficial Petrosal Nerve. It is convenient at this stage to

take note of a fourth petrosal nerve the external superficial petrosal. It
takes origin from the sympathetic plexus which accompanies the middle
meningeal artery, and, entering the petrous bone, is conducted to the
ganglion geniculi of the facial nerve.

Middle and Accessory Meningeal Arteries. The entrance

of the middle meningeal artery through the foramen spinosum
should now be examined. It gives minute twigs to the
semilunar ganglion, and one the superficial petrosal artery
which accompanies the greater superficial petrosal nerve
into the hiatus canalis facialis. The further course of the
middle meningeal artery has been described already (p. 118).
The nervus spinosus, from the mandibular nerve, also enters
the cranium through the foramen spinosum (p. 179).

The accessory meningeal artery enters the cranium through

the foramen ovale, and is distributed chiefly to the semilunar
ganglion.
THE ORBIT.

Within the orbital cavity the following structures are

grouped around the eyeball and the optic nerve :

'Rectus superior.

Rectus inferior.

Rectus lateralis.
Muscles, . ,\ Rectus medialis.

Obliquus superior.

Obliquus inferior.
^Levator palpebrse superioris.

Ophthalmic artery and its branches.

Vessels, . . \ Ophthalmic veins (superior and inferior), with their tribu-

taries.

Oculo-motor (3rd cerebral).

Trochlear (4th cerebral).

Abducent (6th cerebral).

Nerves, . A T I from ophthalmic division of the trigeminal

Naso^ry, J or fifth cerebral nerve.

Zygomatic branch of the maxillary division of the tri-
geminal nerve.
Ciliary ganglion.
Lacrimal gland.
Fascia Bulbi.

Dissection. The roof of the orbit must be removed with

the aid of the saw, the chisel, and the bone forceps. Begin by

Frontal sinus

PLATE VIII

, Frontal sinus

Supra-orbital
" margin
.Ethmoidal cell

Coronoid proces
of mandibl

Middle concha
Inferior concha

_jTip of mastoid
I process

Maxillary sinus

FIG. 89. Antero-posterior radiograph of Living Skull. (Gouldesbrough. )

PLATE IX

Frontal sinus

Ethmoidal cells

Frontal sinu?

Petrous part of
temporal bone

-Mastoid cells

Inferior concha
FIG. 90. Antero-pdsterior radiograph of Skull, showing large frontal sinuses.

THE ORBIT 243

removing the thick cranial wall above the orbital opening,

leaving only a thin portion corresponding to the superior orbital
arch.

Strip the soft structures including the periosteum downwards

from the cut margin of the skull to the superior orbital margin.
Then take the saw and make two incisions through the frontal
bone to the floor of the anterior fossa. One, vertically down-
wards, opposite the anterior end of the cribriform plate of the
ethmoid, and the second downwards and forwards immediately
anterior to the lateral end of the small wing of the sphenoid.
After the saw cuts are made take the bone forceps and chip
away the frontal bone between the saw cuts, to the level of the
floor of the anterior fossa. As the bone is removed the frontal
air sinus may be opened and its extent should be noted (Figs.
89, 90). Next take the chisel and cut through the floor of
the anterior fossa immediately in front of the posterior border
of the small wing of the sphenoid. Carry the cut medially
to 2 mm. in front of the optic foramen ; then turn it forwards
along the medial border of the orbital plate of the frontal bone
and lateral to the depression in the region of the cribriform
plate of the ethmoid ; then, with the aid of the chisel and bone
forceps, gradually chip away the whole of the bony roof of the
orbit, but do not injure the subjacent periosteum. Next remove
the remains of the small wing of the sphenoid with the exception
of the margin of the optic foramen, which must be left intact.
The superior orbital fissure is now fully opened up, and no
difficulty will be met with as the nerves in the wall of the
cavernous sinus are traced forwards into the orbit, but the
anterior clinoid process may be chipped away to gain additional
freedom for further dissection. After the bony roof of the orbit
has been removed examine the exposed periosteum.

Periosteum. If the dissection has been successfully

carried out, the periosteum clothing the under surface of the
orbital roof will be exposed uninjured. The periosteum of
the orbit forms a funnel-shaped sheath, which encloses all the
contents of the cavity except the zygomatic and infra-orbital
nerves and the infra-orbital artery. It is but loosely attached
to its bony walls. Posteriorly, it is directly continuous,
through the superior orbital fissure, with the dura mater.
Expanding with the cavity, it becomes continuous anteriorly,
around the orbital opening, with fhe periosteum which
clothes the exterior of 'the skull. There it presents im-
portant connections with the palpebral fascia also.

Dissection. Open the eyelids and draw the eyeball forwards

with the forceps ; then, with \ fi.ne needle, carry a piece of
thread through the ocular conjunctiva, being careful not to
penetrate the eyeball, for that would render its subsequent
inflation impossible. Finally, stitch the thread to the nose, and
the eyeball will be securely held forwards. Turn now to the
periosteum of the roof of the orbit, divide it transversely, close
in 16 a

244

HEAD AND NECK

to the anterior margin of the orbit, and then, from before

backwards, along the middle line of the orbit. Turn the
two flaps so marked out laterally and medially respectively.
As the region of the superior orbital fissure is approached be
careful not to injure the nerves which pass through the fissure ;
the one most likely to be injured is the small trochlear nerve
which lies near the medial end of the fissure. Secure it at once,
and trace it forwards through the fat to the superior oblique
muscle which lies along the upper part of the medial walljyTthe

Lacrimal gland

Frontal nerve
Short ciliary nerves ^-

Lacrimal nerve

Ophthalmic nerve

Infra-trochlear nerve

-Supra-trochlear nerve
Supra-orbital nerve

- Anterior ethmoidal nerve

Long ciliary nerves

Naso-ciliary nerve
Ciliary ganglion

Optic nerve

Maxillary nerve
Motor root of trigemina
'Mandibular nerve

x Semilunar ganglion (thrown laterally)

FlG. 91. The Ophthalmic Nerve of the Left Side. The semilunar ganglion
and the nerves have been everted and turned over to show the motor root.

orbit. In the middle line of the orbit the large frontal nerve
wiir be found lying in the fat on the surface of the levator pal-
pebrae superioris. Trace the nerve forwards to its division into
, its two terminal branches : a large supra-orbital branch accom-
panied by a corresponding artery, and a medial and smaller
supra-trochlear branch. Follow the supra-trochlear branch to
the superior medial angle of the orbit, where it passes above
the pulley of the superior oblique muscle. Return to the
trochlear nerve and the superior oblique muscle ; clean the
muscle from behind forwards. It ends in a tendon which passes
through the fibrous pulley, situated at the upper and medial
angle of the orbit, then turns backwards and laterally, and dis-

THE ORBIT 245

appears below the levator palpebrae superioris and the superior

rectus. Define both the tendon and the pulley. Return to the
frontal nerve, pull it aside and clean the levator palpebrae
superioris, upon which the nerve lies. Define the margins of
the levator palpebras and note that it lies upon the superior
rectus muscle of the eyeball. Raise the levator palpebrae,
carefully, and note a small twig of the superior division of the
ocular motor nerve which pierces the superior rectus and enters
the levator palpebrae. Now find the lacrimal nerve and the
accompanying lacrimal artery, which lie in the fat at the junction
of the roof with the lateral wall of the orbit, and trace them
forwards to the lacrimal gland. The gland lies under cover of
the lateral end of the superior orbital margin. When all the
structures which have been mentioned have been found and
cleaned study them in detail.

Nervus Frontalis. The frontal jie^v^ is thp continuation

of the stem of the ophthalmic division of the trigeminal
nerve, after it has given off its lacrimal and naso-ciliarv
Branches. It enters the orbit through the superior orbital
fissure, above the muscles, and runs forwards, upon the upper
surface of the levator palpebrae superioris, immediately sub-
jacent to the periosteal lining of the orbital cavity. It ends,
at a variable distance from the orbital opening, by dividing
into the supra-orbital and supra-trochlear branches.

The supra-trochlear nerve is the medial and smaller of the

two terminal branches of the frontal. It runs towards the
trochlea of the superior oblique muscle, above which it pierces
the palpebral fascia, leaves the orbit, and turns round the
orbital arch to reach the forehead. Its further course has
been described already (p. 47). In the orbit it gives off
one small twig close to the pulley of the superior oblique
muscle ; the twig passes downwards to join the infra-trochlear
branch of the naso-ciliary nerve.
The supra-orbital nerve is continued onwards, in the line
of the parent stem, and, .passing through the supra-orbital
notch or foramen, it turns upwards on the forehead (p.
47). The division of the supra-orbital nerve into a lateral
and a medial branch was seen during the dissection of the
scalp (p. 47). Sometimes the separation takes place within
the orbit, and in that case the larger lateral part occupies
the supra-orbital notch.

Nervus Lacrimalis. The lacrimal nerve is the smallest

of the terminal branches of the ophthalmic division of the
trigeminal. It enters the orbit through the superior orbital
fissure, above the level of the muscles, and runs forwards,

in 16 &

246

HEAD AND NECK

PLATE X

p IG> Q 2 . _ Dissection of the Orbit and the Middle Fossa of the

Cranium. On the right side the trochlear nerve has been
removed, and in the left orbit portions of the structures
above the ophthalmic artery have been taken away. (Dr.
E. B. Jamieson.)

Superior sagittal sinus.

Cut anterior part of falx cerebri.

Muco - periosteum of anterior

ethmoidal air cell.

Anterior ethmoidal artery and
nerve and posterior ethmoidal
artery.
Muco - periosteum of a middle

ethmoidal air cell.

Muco-periosteum of a posterior

ethmoidal air cell.

Optic nerve.
Ophthalmic artery.
Internal carotid artery.
Wall of right cavernous sinus.
Oculo-motor nerve.
. Basilar plexus.

Abducens nerve.
. Inferior petrosal sinus.
. Semilunar ganglion.
. Middle meningeal artery.

17. Mandibular nerve.

1 8. Maxillary nerve.

19. Oculo-motor nerve.

20. Trochlear nerve.

21. Frontal nerve.

22. Superior ophthalmic vein.

23. Orbital branch of middle menin-

geal artery.

24. Posterior ciliary arteries and

short ciliary nerves.

25. Lacrimal artery and nerve.

26. Superior rectus.

27. Levator palpebrae superioris.

28. Supra-orbital nerve.

29. Supra-trochlear nerve.

30. Supra-orbital artery.

31. Terminal part of ophthalmic

artery.

32. Muco-periostemn of infundibu-

lum.

PLATE X

30
2 9

26

FIG. 92.

\ '.-.

v,# tk> . -

; :~V

THE ORBIT 247

along the lateral wall of the cavity, above the upper margin
of the lateral rectus muscle. At the anterior part of the
orbit it continues its course, under cover of the lacrimal gland,
until it reaches the lateral part of the upper eyelid, in which
it ends (p. 27). Within the orbital cavity it gives numerous
twigs to the deep surface of the lacrimal gland, and sends
downwards a filament which connects it with the zygomatic
branch of the maxillary nerve.

Nervus Trochlearis. The small troqhlear nerve is destined

entirely for the supply of the superior oblique muscle. Having
entered the orbit through the superior orbital fissure, above the
muscles, it passes forwards and medially, under the periosteum,
and finally sinks into the posterior part of the upper or orbital
surface of the superior oblique muscle.

GlandulaLacrimalis. The lacrimal gland is a small, flattened

and distinctly lobular structure, of oval form, which is placed
in the antero-lateral part of the orbit, its long axis lying
parallel with the anterior margin of the orbit (Figs. 92, 97). It
consists of two parts or groups of lobules a superior and an
inferior imperfectly separated from each other. Tbeglattdttla
lacrimalis superior, which constitutes the main mass of the gland,
lies in the orbital cavity. Its lateral convex surface is lodged
in a hollow upon the medial aspect of the zygomatic process
of the frontal bone, and it is bound to the lateral part of the
orbital arch by short fibrous bands which proceed from the
periosteum. The deep or medial surface is slightly concave,
and rests upon the levator palpebrae superioris and lateral
rectus, which intervene between it and the eyeball. The
glandula lacrimalis inferior lies below and anterior to the
superior part, from which it is partially separated by the ex-
panded tendon of the levator palpebrse superioris. It projects
into the base of the. upper eyelid, and rests upon the con-
junctiva which lines the deep aspect of the lid. That portion
of the gland has been already examined in the dissection of
the eyelids (p. 27). Even in the undissected subject it can
be seen, through the conjunctiva, when the upper eyelid is
fully everted.

The lacrimal gland secretes the tears, and its ducts

(three to five from the superior part and three to nine from
the inferior part) open upon the deep surface of the upper
eyelid in the neighbourhood of the fornix (Fig. 9).

Musculus Levator Palpebrse Superioris. The elevator

248 HEAD AND NECK

muscle of the upper eyelid rests upon the upper surface of

the rectus superior. Posteriorly, it is narrow and pointed,
but it expands as it passes forwards, above the eyeball, to
the upper eyelid. It arises from the under surface of the
roof of the orbit, immediately anterior to the optic foramen
and, therefore, from the inferior surface of the small wing of
the sphenoid bone. In the anterior part of the orbital
cavity it widens out into a broad membranous expansion,
which splits into three lamellae. The most anterior lamella
is attached to the palpebral fascia of the upper eyelid and
by it to the upper tarsus. The middle lamella is attached
directly to the upper border of the upper tarsus. The
posterior lamella is attached to the upper margin of the
conjunctiva. The lateral and medial margins of the ex-
pansion are fixed to the rim of the orbital opening, in close
proximity to the medial palpebral ligament and the lateral
palpebrae raphe. By those attachments, excessive action of
the muscle upon the upper eyelid is checked. The levator
palpebrae superioris is supplied by the upper division of the
oculo-motor nerve, and it is the elevator not only of the
upper eyelid but also of the upper fornix of the conjunctiva.

Dissection. Divide the frontal nerve and throw the ends

forwards and backwards. The levator palpebrae superioris also
may be cut midway between its origin and insertion. When
the posterior portion is raised a minute nerve twig will be seen
entering its deep or ocular surface ; it is a branch of the superior
division of the third or oculo-motor nerve.

The eyeball should now be inflated. That may be done from

the front or from behind. If the latter method is selected, gently
separate the fat under cover of the superior rectus muscle, and
push the ciliary vessels and nerves away from the optic nerve.
Next, make a small incision through the sheath of the nerve.
Pass a ligature round the nerve, anterior to the opening, and
then pass a blowpipe, provided with a stylet, through the incision
and along the nerve, into the interior of the eyeball. When the
globe of the eye is fully inflated, the ligature may be tightened
as the blowpipe is withdrawn. A very much better plan, how-
ever, is to inflate the eyeball from the front. For that purpose
make an oblique valvular aperture in the sclero-corneal junction,
with the point of a sharp narrow-bladed knife. Insert a blow-
pipe through the aperture, and on its withdrawal, after the
inflation of the eyeball, the valvular character of the opening
is sufficient to prevent the escape of the air.

Posterior to the eyeball, at the sides of the superior rectus,

the dissector will notice a quantity of loose bursal-like tissue.
It is the fascia bulbi (O.T. capsule of Tenon}. Seize the upper
part of it with the forceps, and remove a small portion with a
pair of scissors. An aperture is thus made in the fascia, and the

THE ORBIT

249

handle of the knife can be introduced into the space between it

and the eyeball. In favourable cases the extent of the fascia
can be gauged, and perhaps even the prolongations or sheaths
which it gives to the tendons of the ocular muscles may be
made out. The description of the fascia bulbi is given on p. 259.

Musculus Rectus Superior. The superior rectus, which lies

under cover of the levator palpebrse superioris, is now fully
exposed. It is the thinnest of the recti muscles, and it arises
from the upper margin of the optic foramen, passes forwards
above the optic nerve, and ends, upon the upper aspect of
the eyeball, in a thin, delicate
and somewhat expanded
tendon, which is inserted
into the sclera, about 8 mm.
posterior to the sclero-cor-
neal junction. It is supplied
by a branch from the sup-
erior division of the oculo-
motor nerve ; when it con-
tracts it turns the eyeball so
that the centre of the cornea
moves up wards and medially.

Musculus Obliquus Sup-

erior. The Superior oblique
muscle is the longest and

narrowest of the muscles

attached to the eyeball.
It arises from the roof of the orbit, immediately anterior
to the upper and medial part of the optic foramen between
the rectus superior and the rectus medialis. It passes
forwards along the upper part of the medial wall of the
cavity, above the medial rectus. At the anterior part of
the orbit it ends in a slender tendon, which enters the trochlea
and at once changes its direction, proceeding backwards and
laterally, upon the upper surface of the eyeball, under cover
of the superior rectus. Beyond the lateral edge of the
superior rectus the tendon expands somewhat, and is inserted
into the sclera, midway between the entrance of the optic
nerve and the cornea (Fig. 93).

The trochlea or pulley through which the tendon passes is

a small fibre-cartilaginous ring, which is attached by fibrous
tissue to the trochlear fossa of the frontal bone. The pulley

G. 93- Diagram of the Superior

bli i u< : Muscle " < From

Meyer.

_, ,. .

a. Trochlea and synovia! sheath.

250 HEAD AND NECK

is lined with a synovial sheath which facilitates the movement

of the tendon ; and from its lateral margin it gives a fibrous
investment to the tendon.

The superior oblique is supplied by the trochlear nerve

and moves the eyeball so that the centre of the cornea is
turned downwards and laterally.

Dissection. Divide the superior rectus midway between its

origin and its insertion, and reflect the cut ends. When the
posterior part of the muscle is raised, the superior division of the
oculo-motor nerve is brought into view, as it sinks into the deep
or ocular surface of the muscle. It sends a twig to the levator
palpebrae superioris. The removal of some fat will bring the
optic nerve more fully into view. At the posterior part of the
orbit three structures will be seen crossing the optic nerve viz.,
(i) the naso-ciliary nerve ; (2) the ophthalmic artery ; and (3)
the superior ophthalmic vein. All three must be carefully
cleaned and their branches followed out. From the naso-
ciliary nerve one or two delicate thread-like branches the long
ciliary nerves will be found passing along the optic nerve
to reach the eyeball. The short ciliary nerves, much more
numerous, accompany the long ciliary branches, and can readily
be disengaged from the fat which surrounds the optic nerve. A
strong member of the short ciliary group should be selected and
followed backwards ; it will lead the dissector to the ciliary
ganglion. That is a minute body which is situated upon the
lateral side of the optic nerve in the posterior part of the orbit.
With a little patience and care the roots which the naso-ciliary
nerve and inferior division of the oculo-motor nerve give to
the ciliary ganglion can be isolated, and perhaps even the
sympathetic root from the internal carotid plexus will be found.
After the ciliary ganglion and its roots and branches have been
defined, clear away the fat which lies lateral to the ganglion, and
secure the abducens nerve, which enters the ocular surface of the
lateral rectus. Then clean the optic nerve (Fig. 92) .

Nervus Opticus. The optic nerve enters the orbit through

the optic foramen. It carries with it a strong, loose sheath
of dura mater, and also more delicate investments from
the arachnoid and pia mater. The ophthalmic artery, which
accompanies it, lies on its infero-lateral aspect. Within the
orbit the nerve inclines forwards and laterally, and at the same
time somewhat downwards, to the back of the eyeball, where
it pierces the sclera a short distance to the medial side of
the centre of its posterior surface. The dissector has noted
already that the ophthalmic artery and vein and the naso-
ciliary nerve cross above the optic nerve, and that it is
closely accompanied by the delicate ciliary nerves and
vessels. The optic nerve is slightly longer than the distance

THE ORBIT 251

which it has to run from the optic foramen to the globe of

the eye, so that the movements of the eyeball may not be
interfered with. Within the eyeball the optic nerve spreads
out in the retina.

Nervus Naso-ciliaris. The naso-ciliary nerve (O.T. nasal)

arises from the ophthalmic division of the trigeminal in the
anterior part_of the cavernous sinus. It passes through the
superior orbital fissure and~enters the orbital cavity, between
the two heads of the lateral rectus muscle and between the
two divisions of the third nerve. It then runs forwards and
medially, and, crossing obliquely above the optic nerve, it runs
between the medial rectus and superior oblique muscles to
the medial wall of the orbit, where it divides into two ter-
minal branches viz., the infra=trochlear and the anterior
ethmoidal nerves. In addition to those, it gives off in the
orbit the following branches: (i) long root to the ciliary
ganglion; (2) long ciliary nerves; (3) posterior ethmoidal
nerve.

Radix Longa Ganglii Ciliaris. The long root of the

ciliary ganglion is a very slender filament which springs from
the naso-ciliary as it enters the orbit between the heads of
the lateral rectus. It runs along the lateral side of the optic
nerve, and enters the upper and posterior part of the ciliary
ganglion.

Nervi Ciliares Longi. The two long ciliary branches

spring from the naso-ciliary as it crosses the optic nerve.
They pass forwards, upon the medial side of the optic
nerve, to reach the globe of the eye, where they pierce the
sclera. One of the long ciliary nerves very constantly
unites with one of the short ciliary filaments.

Nervus Ethmoidalis Posterior. The posterior ethmoidal

nerve passes through the posterior ethmoidal foramen to the
ethmoidal cells and the sphenoidal air sinus.

Nervus Infratrochlearis. The infra-trochlear branch runs

along the medial wall of the orbit below the superior oblique
muscle. After passing under the trochlea of that muscle, it
emerges from the orbit and appears upon the face above
the medial commissure of the eyelids, where it has been
dissected already (p. 27). Near the pulley it receives a
communicating twig from the supra-trochlear nerve.

Nervus Ethmoidalis Anterior. The anterior ethmoidal

nerve is the larger of the two terminal branches of the naso-

252 HEAD AND NECK

ciliary nerve. It leaves the orbit by the anterior ethmoidal

canal, and is conducted to the interior of the cranium, in which
it appears at the lateral margin of the cribriform plate of the
ethmoid. The canal in which it runs can readily be opened
up with the bone-forceps to expose the nerve. Upon the
cribriform plate it turns forwards, under the dura mater, and
almost immediately disappears, through a slit-like aperture at
the side of the crista galli, into the nasal cavity. There it
gives internal nasal branches to the mucous membrane, and is
continued downwards upon the posterior aspect of the nasal
bone. Finally, it emerges upon the face, as the external
nasal nerve^ by passing between the lower margin of the
nasal bone and the lateral cartilage of the nose. Its terminal
filaments have been described already (p. 30).

Ganglion Ciliare (Fig. 97). The ciliary ganglion is a

small quadrangular body, not much larger than the head
of a large pin. It is placed in the posterior part of the orbit,
between the optic nerve and the lateral rectus muscle, and
very commonly on the lateral side of the ophthalmic artery.
At its posterior border it receives its three roots \ whilst from
its anterior border the short ciliary nerves are given off.

The sensory root is given off by the naso-ciliary, and is called

the long root. The short or motor root is a short, stout trunk ;
it springs from the branch of the oculo-motor nerve which
goes to the inferior oblique muscle. The sympathetic root is
derived from the internal carotid plexus ; it joins the ganglion,
close to the entrance of the long root from the naso-ciliary
nerve. In some cases it joins the long root before it reaches
the ganglion.

Nervi Ciliares Breves. The short ciliary nerves are from

five to seven in number. As they pass along the optic nerve
they divide and thus increase in number ; at the back of
the eyeball from twelve to eighteen may be counted. They
form two groups, superior and inferior, and the lower nerves
are generally more numerous than the upper. Finally, they
pierce the sclera by a series of apertures which are placed
around the entrance of the optic nerve.

Arteria Ophthalmica. The ophthalmic artery is a branch

of the internal carotid. It accompanies the optic nerve
into the orbit through the optic foramen. At first it lies
below the optic nerve, but soon winds round its lateral side,
and, crossing above it, passes forwards along the medial

THE ORBIT

253

wall of the orbit, below the superior oblique muscle. At the

medial margin of the front of the orbit it ends by dividing
into two terminal branches viz., the frontal and the dorsal
nasal (Fig. 95).

The branches of the ophthalmic artery are very numerous,

but it is seldom that they can all be satisfactorily displayed,
unless a special injection has been made. They are :

7. Palpebral.

8. Dorsal nasal.

9. Frontal.

Arteria Lacrimalis. The lacrimal branch accompanies

the lacrimal nerve; it supplies the lacrimal gland and the

1. Lacrimal.

2. Muscular.

3. Arteria centralis retinae.

4. Ciliary.

5. Supra-orbital.

6. Ethmoidal.

Sinus venosus sclerae

Anterior ciliary
artery

Sclera

Vena vorticosa

Long posterior
ciliary artery

Anterior ciliary
artery

Ciliary muscle

Long posterior
ciliary artery

Vena vorticosa

Long posterior
ciliary artery

FIG. 94. Dissection of the Eyeball showing the Arrangement

of the Ciliary Nerves and Vessels.

conjunctiva. In each eyelid an arterial arch, the areas

tarseus, is formed by the anastomoses of the two lateral
palpebral branches of the lacrimal with the two medial
palpebral branches of the ophthalmic.

Muscular branches come off at variable points, not only

from the main artery, but also from certain of its branches.
They supply the muscles contained in the orbital cavity.

Arteria Centralis Retina. The arteria centralis retinae is

a minute but important artery. It pierces the infero-medial
surface of the optic nerve, 1 2 mm. (about half an inch) posterior
to the eyeball, and passes, in the substance of the nerve,
to the interior of the globe of the eye.
254

HEAD AND NECK

Arteria Ciliares. The ciliary arteries are very numerous.

Two groups are recognised viz., a posterior and an anterior.
Two sets of posterior ciliary arteries are described. They
are known as the short and the long posterior ciliary arteries
respectively. The short ciliary arteries are several in number ;
they spring partly from the ophthalmic trunk and partly from
its lacrimal and muscular branches. They accompany the
short ciliary nerves and, after piercing the posterior part of

1 Medial palpebral

Frontal v

Dorsal nasal

Infra-trochlear nerve

, Anterior ethnioidal
\J artery and nerve

Posterior ciliary
Posterior ethmoidal
Ophthalmic

Lateral
palpebral

Supra-orbital \

Arteria centralist
retina?

Posterior ciliary
Muscular .
Lacrimal ;

Ophthalmic

Naso-ciliary nerve
^Internal carotid

FIG. 95. Diagram of the Ophthalmic Artery and its Branches.

(After Quain and Meyer, modified. )

the sclera, around the optic nerve, they enter the chorio-
apillary layer of the chorioid. The long posterior ciliary
arteries (Fig. 94) are two in number. They spring from the
ophthalmic trunk and run forwards, one on each side of the
optic nerve. After they have pierced the sclera they run
forward, one on each side, in the horizontal plane, anct
between the sclera and the chorioid to the iris. The anterior
ciliary arteries come off, in the anterior part of the orbit,
from the lacrimal and muscular branches. They vary in
number from six to eight, and run to the anterior part of

THE ORBIT 255

the eyeball, where they form an arterial circle under the con-
junctiva. Finally, they pierce the sclera immediately posterior
to the cornea.

Arteria Supraorbitalis. The supra-orbital artery accom-

panies the supra-orbital nerve to the forehead, where it was
dissected at a previous stage (p. 47).

Artericz Ethmoidaks. There are two ethmoidal branches,

an anterior and a posterior ; they pass through the anterior
and posterior ethmoidal foramina in the medial wall of the
orbit. The posterior ethmoidal artery supplies the mucous
lining of the posterior ethmoidal cells, and sends twigs to the
upper part of the nose. The anterior ethmoidal artery is
a larger branch. It runs in company with the anterior
ethmoidal nerve, and gives off minute twigs at each stage of
its course. Thus, in the anterior ethmoidal foramen, it gives
branches to the mucous lining of the anterior ethmoidal cells
and the frontal sinus during its short sojourn in the cranial
cavity it gives off a small anterior meningeal artery ; in the
nasal cavity, it gives twigs to the mucous membrane. Its
terminal branch appears on the face and supplies the side of
the nose.

Arteria Dorsalis Nasi. The dorsal artery of the nose is

distributed at the root of the nose, and anastomoses with
the angular branch of the external maxillary artery.

Arteria Frontalis. The frontal artery accompanies the

supra -trochlear nerve to the forehead, where it has been
dissected already (p. 47).
Venae Ophthalmicse. As a general rule there are two
ophthalmic veins, superior and inferior. The superior
ophthalmic vein is the larger of the two and it accompanies
the artery. It takes origin at the root of the nose, where
it communicates with the angular vein. The inferior
ophthalmic vein lies below the level of the optic nerve, and
it is brought into communication with the pterygoid venous
plexus by an offset which passes through the inferior orbital
fissure. The two ophthalmic veins receive numerous tribu-
taries during their course through the orbit ; finally they
pass between the two heads of the lateral rectus muscle, and
through the superior orbital fissure, to open into the cavernous
sinus, either separately or by a common trunk.

Musculi Recti et Obliqui Oculi. Associated with the

origins of the recti muscles of the eyeball are two tendinous

256 HEAD AND NECK

arches, a superior and an inferior. Both are attached later-

ally to a projection on the great wing of the sphenoid bone
at the lateral margin of the superior orbital fissure. The two
bands diverge from one another as they pass medially across
the superior orbital fissure, the upper band extending to the
superior margin, and the lower to the inferior margin of the
optic foramen. The superior rectus, which is the thinnest of
the four recti, springs from the medial part of the upper
band ; the inferior rectus, which is thicker but smaller than
the superior, springs from the middle part of the lower band.
The lateral and longest rectus, which is thicker than either the
superior or inferior, arises by two heads, one from the lateral part
of the upper band, and one from the lateral part of the lower
band. The interval between the two heads is traversed by the
two divisions of the oculo-motor nerve, the naso-ciliary nerve,
the abducens nerve, and the ophthalmic veins. The medial
rectus, which is the shortest and thickest of all the recti,
springs from the medial part of the lower band. The superior
oblique springs from the body of the sphenoid, between the
superior and medial recti. The origin of the inferior oblique
lies near the anterior margin of the orbital cavity, entirely
away from the other muscles which move the eyeball. It
arises from the orbital plate of the maxilla close to the lower
and medial angle of the orbital cavity.

Dissection. To display the attachments of the ocular muscles

which arise at the apex of the orbital cavity divide the optic
nerve close to the optic foramen, and turn the eyeball forwards.
Then define the origin of each muscle, but take care not to
injure the structures which pass between the upper and lower
heads of the lateral rectus. Next, replace the eyeball in position
and display the inferior oblique which lies in the anterior part
of the orbital cavity and is best dissected from the front. Evert
the lower eyelid and make an incision through the conjunctiva,
along the level of its reflection from the eyelid to the eyeball.
A little dissection in the floor of the anterior part of the orbit
and the removal of some fat will expose the inferior oblique
muscle, as it passes laterally and backwards to gain the lateral
surface of the sclera.

After the origins of the muscles have been satisfactorily

displayed study first the arrangement of the nerves which pass
through the superior orbital fissure, next the insertions of the
muscles which move the eyeball, and finally the remaining
structures which lie in the orbital cavity.

Arrangement of the Nerves in the Superior Orbital

Fissure. The various nerves met with in the dissection of

THE ORBIT

257

the cavernous sinus can now be traced into the orbital cavity,
and the dissector will note that the arrangement of the nerves
in the superior orbital fissure is somewhat different from that
in the sinus.

The lacrimal, frontal, and trochlear nerves enter the orbit

above the upper head of the lateral rectus muscle, on very
much the same plane (Fig. 96). The other nerves enter
between the heads of the lateral rectus the superior division
of the oculo-motor nerve occupying the highest place ; next
comes the naso-ciliary nerve ; then the inferior division of
the oculo-motor nerve ; and the abducent nerve is the lowest.

Frontal nerve

Superior rectus
M. levator palpebrse

Lacrimal nerve

Trochlear nerve

Naso-ciliary j
nerve

M. rectus
lateralis
Abducens nerve
Inferior orbital fissure

Superior division of
third nerve

M. obliquus superior

I [Optic foramen

M. rectus inferior

Inferior division of
oculo-motor nerve

FIG. 96. Diagram of the Orbital Cavity, and of the origin of the ocular
muscles in relation to the optic foramen and the superior orbital fissure,
and the nerves that traverse the fissure.

Insertions of the Muscles which move the Eyeball. The

recti are inserted into the sclera, 6 to 8 mm. (about quarter of
an inch) behind the cornea. The medial rectus has the
most anterior insertion, and both the medial and lateral recti
are attached a little further forwards than the superior and
inferior recti. The insertions of the superior and inferior
oblique muscles are both much further back than the inser-
tions of the recti, behind the transverse vertical plane which
divides the eyeball into equal anterior and posterior parts,
and mainly lateral to an antero-posterior vertical plane which
divides the eyeball into equal lateral and medial halves.

VOL. in 17

258

HEAD AND NECK

Nervus Oculomotorius. The two divisions of the oculo-

motor nerve enter the orbit through the superior orbital
fissure, between the two heads of the lateral rectus. The
superior division has been traced to the rectus superior and
the levator palpebrae superioris. The inferior division is
larger. It almost immediately divides into three branches,

M. levator palpebrae superior

M. rectus superior

M. obliquus superior
Lacrimal gland

M. rectus lateralis

Abducens nerve

Ciliary ganglion
Naso-ciliary nerve

Ophthalmic division
of trigeminal nerve r
Maxillary division
of trigeminal nerve

Motor root of
trigeminal nerve

Semilunar ganglion ' /

Mandibular division of fifth nerve

Trochlea

M. rectus inferior

Trochlear nerve
Abducens nerve

Optic nerve

1 \ Oculo-motor

| \nerve
Abducens nerve
Trochlear nerve

FIG. 97. Dissection of the Orbit and the Middle Cranial Fossa. Both
roots of the fifth nerve, with the semilunar ganglion, are turned laterally.

for the supply of the rectus medialis, the rectus inferior, and
the obliquus inferior. The nerves to the two recti enter the
ocular surfaces of the muscles ; the nerve to the inferior
oblique is prolonged forwards, in the interval between the
rectus inferior and rectus lateralis, and enters the posterior
border of the inferior oblique muscle. Soon after its origin
this branch gives the short motor root to the ciliary ganglion.

Nervus Abducens. The abducens nerve will be found

closely applied to the ocular surface of the lateral rectus. It

THE ORBIT 259

enters the orbit through the interval between the heads of

lateral rectus muscle, and it supplies the lateral rectus only.

Musculus Obliquus Inferior. The inferior oblique muscle

arises from a small depression on the orbital surface of the
maxilla, immediately lateral to the opening of the naso-
lacrimal duct. It passes laterally, below the inferior rectus
muscle, and, inclining slightly backwards, ends in a thin
membranous tendon, which gains insertion into the lateral
aspect of the sclera of the eyeball under cover of the rectus
lateralis. The insertion is not far from that of the superior
oblique. The inferior oblique is supplied by the inferior
division of the oculo-motor nerve. It turns the eyeball so that
the centre of the cornea is directed upwards and laterally.

Fascia Bulbi (O.T. Capsule of Tenon). The connections

of the fibrous sheath of the eyeball are somewhat com-
plicated, and they cannot be satisfactorily displayed, in every
detail, in an ordinary dissection. The fascia may be studied
from a threefold point of view (i) in its connection with
the eyeball; (2) in its connections with the muscles inserted
into the globe of the eye \ and (3) in its connections with
the walls of the orbit.

The relation which the fascia bulbi bears to the eyeball

is very simple. The membrane is spread over the posterior
five-sixths of the globe the cornea alone being free from it.
Anteriorly, it lies in relation with the ocular conjunctiva, with
which it is intimately connected, and it ends by blending
with the conjunctiva close to the margin of the cornea.
Posteriorly, it fuses with the sheath of the optic nerve where
the nerve pierces the sclera. The internal surface of the
membrane (i.e. the surface towards the globe of the eye) is
smooth, and is connected to the eyeball by some soft, yielding,
and humid areolar tissue, the interval between them con-
stituting, in fact, an extensive lymph space. Its external
surface is in contact posteriorly with the orbital fat, to which
it is loosely adherent ; and it is firmly attached to the ocular
conjunctiva more anteriorly. It obviously, therefore, forms
a membranous socket in which the eyeball can rotate with
the greatest freedom.

The tendons of the various ocular muscles are inserted

into the eyeball within the fascia bulbi, and they gain its

interior by piercing the fascia opposite the equator of the

globe (Fig. 98). The lips of the openings through which

in 17 a

260 HEAD AND NECK

the four recti muscles pass are prolonged backwards upon the
muscles, in the form of sheaths, much in the same manner
that the internal spermatic fascia is prolonged upon the
spermatic cord from the abdominal inguinal ring. The
sheaths gradually become more and more attenuated, until at
last they blend with the perimysium of the muscular bellies.
In the case of the superior oblique muscle the corresponding
prolongation is related only to the reflected portion of the
tendon ; and it ends by becoming attached to the fibrous
pulley through which the tendon passes. The sheath of the
inferior oblique may be traced upon the muscle as far as the
floor of the orbit. The ocular edge of each of the four
apertures through which the recti muscles pass is strengthened
by a slip of fibrous tissue (Lockwood), and as the fascia bulbi
is firmly bound to the bony wall of the orbit at various
points these slips act as pulleys, and protect the globe of the
eye from pressure during contraction of the muscles. .The
aperture for the superior oblique is not furnished with such
a slip, and it is doubtful if the opening for the inferior oblique
muscle possesses one.

Dissection. An admirable view of the relations which the

fascia bulbi presents to the eyeball and the tendons of the ocular
muscles can be obtained by the following dissection : Divide
the lateral commissure of the eyelid up to the margin of the
orbital opening. Pull the eyelids widely apart, so as to expose
as much as possible of the anterior face of the eyeball. Next,
divide the conjunctiva, by a circular incision, just beyond the
cornea. Along that line the fascia bulbi is so intimately con-
nected with the conjunctiva that it is divided at the same time.
Now raise carefully both conjunctiva and fascia bulbi from the
surface of the eyeball, and spread them out round the orbital
opening, as is depicted in Fig. 98. The openings in the fascia
bulbi for the tendons of the ocular muscles and the thickened
margins of the apertures are well seen. Note also the sheaths
which are given to the muscles.

Check and Suspensory Ligaments. The connections of

the fascia bulbi to the walls of the orbital cavity are
somewhat complicated. The suspensory ligament (Lockwood)
plays an important part in supporting the eyeball. It
stretches across the anterior part of the orbit, after the
fashion of a hammock ; its two extremities are narrow,
and are attached respectively to the zygomatic and lacrimal
bones. Below the eyeball it widens out and blends with
the fascia bulbi. The lateral and medial check ligaments

THE ORBIT

261

also constitute bonds of union between the fascia bulbi and

the orbital wall. They are strong bands which pass from
the sheaths around the lateral and medial recti muscles
to obtain attachment to the zygomatic and lacrimal bones
respectively, where they are brought into association with
the extremities of the suspensory ligament. The function
of the check ligaments is to limit the contraction of the
medial and lateral recti muscles, and thus prevent excessive
rotation of the eyeball in a lateral or medial direction.
There is a similar but less direct" provision by means of which
the actions of the superior and inferior recti muscles are limited.

Tendon of superior oblique

Tendon of superior rectus

Tendon of lateral rectus

Cut edge of fascia bulbi

and conjunctiva

Tendon of inferior rectus

Fascia bulbi thrown

back from eyeball

Tendon of medial rectu

FIG. 08. Dissection of the Fascia Bulbi from the front.

The action of the superior rectus is checked through an
intimate connection with the levator palpebrae superioris in
the anterior part of the orbit ; the action of the inferior rectus
is checked through a connection with the suspensory ligament.

Dissection. In order that the zygomatic branch of the

maxillary division of the trigeminal nerve may be displayed in
its course through the orbit, the orbital contents must be removed.
The nerve will then be found in the midst of a little soft fat in
the angle between the floor and lateral wall of the orbit.

Nervus Zygomaticus (O.T. Temporo-Malar). The zygo-

matic nerve is small. It arises, in the infra-temporal fossa,
from the maxillary division of the trigeminal nerve. It enters
the orbit through the inferior orbital fissure, and almost

in 17 6

262 HEAD AND NECK

immediately divides into two terminal branches the

zygomatico- temporal and the zygomatico-facial.

Ramus Zygomaticotemporalis. The zygomatico -temporal

branch runs forwards and upwards upon the lateral wall of the
orbit, under cover of the periosteum, and, after receiving a
communicating twig from the lacrimal nerve, it enters the
zygomatico-orbital canal of the zygomatic bone. That canal
conducts it to the anterior part of the temporal region, where
it has been examined already (pp. 19 and 170).

Ramus Zygomaticofacialis. The zygomatico-facial branch

also enters a zygomatico-orbital canal, and is finally con-
ducted to the face by the zygomatico - facial canal which
traverses the zygomatic bone (p. 19).

PREVERTEBRAL REGION.

The following are the structures to be displayed in the

prevertebral area :

Vertebral vein.

Vertebral and cranio-vertebral

articulations.

Prevertebral muscles.
Intertransverse muscles.
Cervical nerves.
Vertebral artery.
Dissection. To separate the anterior part of the head, with
the pharynx, from the posterior part and the vertebral column
a somewhat complicated dissection is necessary. Place the
head upside down, so that the cut margin of the skull rests upon
the table ; divide the common carotid artery, the internal
jugular vein, the vagus nerve, and the sympathetic trunk, on
each side, at the level of the neck of the first rib ; pull the
trachea and oesophagus, together with the great blood-vessels
and nerves, away from the anterior surface of the vertebral
column. The separation must be effected right up to the base
of the skull. At that point great caution must be observed ;
otherwise, the pharyngeal wall or the insertions of the pre-
vertebral muscles will be damaged. The base of the skull
having been reached, the point of the knife should be carried
across the basilar portion of the occipital bone, between the
pharynx and the prevertebral muscles, to divide the thick in-
vesting periosteum.

The basilar portion of the occipital bone must now be divided

by means of a chisel. Still retaining the part upside down,
place the skull so that its floor rests upon the end of a wooden
block. Then apply the edge of the chisel to the under surface
of the basilar portion of the occipital bone, adjust it accurately
in the interval between the pharyngeal wall and the prevertebral
muscles, and with a wooden mallet drive it through the base of
the skull, inclining it, at the same time, slightly backwards.

PREVERTEBRAL REGION 263

The next step in the dissection consists in making two saw-

cuts through the cranial wall. The head having been placed
upon its side, the saw must be applied to the lateral aspect of
the skull, half an inch posterior to the mastoid process, and be
carried obliquely forwards and medially to reach a point immedi-
ately posterior to the jugular foramen. A similar saw-cut must
be made upon the opposite side of the head.

To complete the dissection the dissector must again use

the chisel. Placing the preparation so that the floor of
the cranial cavity looks upwards, divide the base of the skull,
on each side, in the interval between the petrous portion of the
temporal bone and the basilar portion of the occipital bone.
Anteriorly, this cut should reach the lateral extremity of the
incision already made through the basilar portion ; whilst
posteriorly, it should be carried to the medial side of the jugular
foramen to reach the medial end of the corresponding saw-cut.
When that has been done upon both sides of the basilar portion,
the anterior part of the skull, carrying the pharynx and the great
blood-vessels and nerves, can be separated from the posterior
part of the skull and cervical portion of the vertebral column.
The only large nerve which will be divided is the hypoglossal,
but, as it is cut close to the basis cranii, and above its connection
with the ganglion nodosum of the vagus, it retains its position.

The pharynx and anterior portion of the skull should now

be covered with a piece of cloth soaked in preservative solution,
and the whole enveloped in an oil-cloth wrapper. It can then
be laid aside until the dissection of the prevertebral region and
the ligaments of the cervical vertebrae and the occiput has been
completed.

Returning to the posterior part of the skull and the cervical

portion of the vertebral column, the dissector should proceed
to define the attachments of the muscles which lie anterior
to the transverse processes and the bodies of the vertebrae.
They are three in number on each side, viz. :

1. The longus colli.

2. The longus capitis (O.T. rectus capitis anticus major).

3. The rectus capitis anterior (O.T. anticus minor).

Musculus Longus Colli. The longus colli is the most

powerful of the prevertebral muscles of the neck, and it lies
nearest to the median plane. Its connections are somewhat
intricate, but when it has been thoroughly cleaned it will be
seen to consist of three portions viz., upper and lower
oblique parts, and a middle vertical part.

The lower oblique division arises from the lateral aspect of

the bodies of the upper two or three thoracic vertebrae. It
extends upwards, and slightly laterally, and ends in two
tendinous slips which are inserted into the anterior tubercles
of the transverse processes of the fifth and sixth cervical
vertebrae. In the interval between that portion of the longus
colli and the scalenus anterior, the vertebral artery will be
in 17 c

26 4

HEAD AND NECK

seen. The upper oblique part arises by three tendinous

slips from the anterior tubercles of the transverse processes
of the third, fourth, and fifth cervical vertebrae ; it tapers
somewhat as it proceeds upwards and medially to obtain a
pointed and tendinous insertion into the anterior tubercle of

Scalenus anterior
Scalenus medius
Scalenus posterior

FIG. 99. Prevertebral Muscles of the Neck. On the right side the longus
capitis has been removed. (Paterson.)
the atlas. The vertical part of the muscle is much the largest
of the three divisions. It lies along the medial side of the
oblique portions, and is intimately connected with both of
them. It arises, in common with the inferior oblique part,
by two or three slips from the sides of the bodies of the

PREVERTEBRAL REGION 265

upper two or three thoracic vertebrae ; and it derives addi-

tional slips of origin from the bodies of the lower two cervical
vertebras ; lastly, its lateral border is reinforced by slips from
the transverse processes of the lower three or four cervical
vertebrae. It passes vertically upwards, and is inserted upon
the medial side of the upper oblique part of the muscle by
three tendinous processes, which obtain attachment to the
bodies of the second, third, and fourth cervical vertebrae. It
is supplied by the anterior rami of the cervical nerves. It
bends the neck forwards.

Longus Capitis (O.T. Rectus Capitis Anticus Major).

The longus capitis is an elongated muscle which arises by
four tendinous slips from the anterior tubercles of the trans-
verse processes of the third, fourth, fifth, and sixth cervical
vertebrae. It is inserted, anterior to the foramen magnum,
upon the under aspect of the basilar portion of the occipital
bone. To reach its insertion the muscle inclines slightly
medially as it ascends upon the anterior aspect of the
vertebral column (Fig. 99). It is supplied by twigs from the
first loop of the cervical plexus. It bends the head forwards.

Eectus Capitis Anterior (O.T. Anticus Minor). The

rectus capitis anterior is a small muscle. It is partly con-
cealed by the upper portion of the longus capitis, which
should be detached from its insertion, and turned downwards
so as to bring the capitis anterior fully into view. It arises
from the anterior aspect of the lateral mass of the atlas and,
proceeding upwards and medially, is inserted into the under
surface of the basilar portion of the occipital bone, postero-
lateral to the longus capitis (Fig. 99). It is supplied by a
filament from the first loop of the cervical plexus. It bends
the head forwards.

Before proceeding farther, the dissector should again

examine the attachments of the scalene muscles (v. p. 233).

Musculi Intertransversarii. To obtain a proper display

of the intertransverse muscles the prevertebral and scalene
muscles must be removed. The intertransverse muscles, on
each side, consist of seven pairs of small fleshy slips which
connect the bifid extremities of the cervical transverse pro-
cesses ; they are the anterior and posterior intertransverse
muscles. Each anterior muscle is attached to the anterior
tubercles of two adjacent transverse processes; whilst the
posterior extends between the posterior tubercles. The
266 HEAD AND NECK

highest pair of muscular slips lies between the atlas and the
epistropheus ; the lowest pair connects the transverse process
of the seventh cervical vertebra with the transverse process
of the first thoracic vertebra.

Nervi Cervicales. The cervical spinal nerves have a

very definite relation to the intertransverse muscles. The
anterior rami of the lower seven nerves make their appearance,
by passing laterally, between the two corresponding muscles.
The posterior divisions of the same nerves turn backwards,
medial to the posterior muscles.

The upper two cervical nerves emerge from the vertebral

canal differently from the others. They pass laterally over
the posterior arch of the atlas and the vertebral arch of the epi-
stropheus, respectively, behind the articular processes, whilst
the lower nerves are situated in front of the articular processes.

The anterior ramus of the first cervical nerve passes for-

wards medial to the rectus capitis lateralis, and then turns
downwards to join the anterior ramus of the second cervical
nerve, with which it forms the first loop of the cervical plexus.
The posterior ramus passes backwards into the sub-occipital
triangle. The anterior ramus of the second cervical nerve
passes laterally between the first pair of intertransverse
muscles, and the posterior ramus runs backwards medial
to the first posterior intertransverse muscle.

Dissection. The vertebral artery as it traverses the succession

of foramina in the transverse processes of the cervical vertebrae
should now be exposed. Remove the intertransverse muscles
as well as the muscles still attached to the transverse process
of the atlas viz., the rectus lateralis, the inferior oblique, and
the superior oblique. The anterior tubercles and the costal
portions of the transverse processes of the third, fourth, fifth,
and sixth cervical vertebras should then be snipped off with the
bone forceps.

Arteria Vertebralis. The vertebral artery is a vessel of

great importance, for, together with its fellow of the opposite
side and the basilar artery, which is formed by their union, it
supplies the hind-brain, the mid-brain, and the posterior parts
of the cerebral hemispheres, and it helps to supply the spinal
medulla. It commences at the root of the neck, as a branch
of the first part of the subclavian artery, and it runs upwards,
through the transverse processes of the upper six cervical
vertebrae, to the base of the skull. It enters the skull through
the foramen magnum and unites, in the posterior fossa of the

PREVERTEBRAL REGION

267
cranium, at the lower border of the pons, with its fellow of
the opposite side to form the basilar artery. On account of
its varying relations it is divided into four parts. The^rc/
part, which extends from the subclavian artery to the trans-
verse process of the sixth cervical vertebra, has been seen
already (p. 154). It lies between the longus colli medially,
the scalenus anterior laterally, the transverse process of the
seventh cervical vertebra and the inferior cervical ganglion of

Posterior atlanto-

occipital membrane'

Posterior ramus of

sub-occipital nerve

Greater occipital nerve

Vertebral artery

Anterior ramus of a
spinal nerve

Posterior arch of atlas

v : '-^/-Ligamentum nuchae

Posterior rami of spinal

nerves

Seventh cervical verteora

FIG. 100. Dissection of the Ligamentum Nuchas and of the Vertebral

. Artery in the Neck.

the sympathetic posteriorly, and the vertebral vein and the

common carotid artery anteriorly (Figs. 53, 54).
The second part, now exposed, commences where the
artery enters the transverse process of the sixth cervical
vertebra. It passes vertically upwards, through the series
of foramina transversaria, till it reaches the foramen in the
transverse process of the epistropheus. In that it runs
laterally, as well as upwards, to gain the foramen in the
more laterally placed transverse process of the atlas ; and, as
it emerges upon the upper aspect of the atlas (Figs. 56, TOO),
the third part commences and curves round the lateral and

268 HEAD AND NECK

posterior aspects of the corresponding upper articular process

of the atlas, in a groove upon the upper surface of its posterior
arch (Figs. 20, 38). As soon as it has passed under cover
of the lateral margin of the posterior atlanto-occipital mem-
brane it becomes the fourth part. The fourth part turns
upwards, pierces the dura mater, and passes into the skull
through the foramen magnum, anterior to the uppermost
digitation of the ligamentum denticulatum ; then, turning
antero-medially, between the hypoglossal nerve above and
the first cervical nerve below, it passes to the anterior surface
of the medulla oblongata, and, as already stated, joins its
fellow of the opposite side at the lower border of the pons
(Figs. 37, 144).

Relations. The relations of the first part have already

been sufficiently considered. The second part lies in and
between the transverse processes of the cervical vertebrae,
medial to the intertransverse muscles, lateral to the bodies
of the vertebrae, and anterior to the anterior rami of the
cervical nerves as they pass laterally. It is surrounded not
only by the sympathetic nerve plexus derived from the
inferior cervical ganglion, which accompanies all parts of
the artery, but also by a venous plexus which terminates, below,
as the vertebral vein or veins. The third part of the artery
lies on the posterior arch of the atlas in the anterior boundary
of the sub-occipital triangle. As it turns backwards, from the
foramen in the transverse process of the atlas, the anterior
ramus of the first cervical nerve lies to its medial side,
between it and the lateral mass of the atlas ; and, as it turns
medially, posterior to the upper articular facet of the atlas,
the trunk of the first cervical nerve lies below it, on the
posterior arch of the atlas, and the posterior ramus enters
the triangle from beneath its lower border. For the relations
of the fourth part see the preceding paragraph and pp.
117, 382.

Branches. No branch of importance is given off from

the first part. The second part gives off lateral spinal
(p. 90) and muscular branches. The branches from the
third part are muscular twigs, and branches to anastomose
with twigs from the occipital and the deep cervical arteries.
The fourth part gives off a meningeal branch before it
perforates the dura mater and, afterwards, a series of branches
to the central nervous system (see pp. 382, 383).
PREVERTEBRAL REGION 269

Vena Vertebralis. Only the first part of the vertebral

artery is accompanied by a definite vertebral vein. There
are no accompanying veins with the fourth part of the artery,
but a plexus is formed round the commencement of the
third part, by the union of tributaries from the venous plexus
in the vertebral canal and from the plexus of veins in the
sub-occipital triangle. The plexus accompanies the second
part of the artery through the transverse processes of the
cervical vertebrae ; it anastomoses with the venous plexuses in
the vertebral canal ; and it terminates, below, as one or two
vertebral veins. The vertebral veins accompany the first
part of the artery and end in the posterior aspect of the
commencement of the innominate vein.

Dissection. The muscles must now be completely removed,

.in order that the vertebral and cranio- vertebral joints, and the
ligaments in connection with the cervical portion of the verte-
bral column, may be examined.

THE JOINTS OF THE NECK.

The epistropheus, atlas, and occipital bone present a series

of articulations in which the uniting apparatus is very different
from that of the vertebras below.

Articulations of the Lower Five Cervical Vertebrae. The

lower five cervical vertebrae are united together very much
upon the same plan as the vertebrae in other regions of the
vertebral column. The bodies and the vertebral arches are
connected by distinct articulations and special ligaments.

Three separate joints may be said to exist between the

opposed surfaces of the bodies of two adjacent cervical
vertebrae viz., a central synchondrosis and two small col-
lateral diarthrodial joints.

The synchondrosis occupies by far the greatest part of

the interval between the vertebral bodies, and it presents
the usual characters of such an articulation. The opposed
bony surfaces are coated with a thin layer of hyaline or
encrusting cartilage, and are connected together by an inter-
posed disc of fibro- cartilage. The intervertebral fibro-
cartilages are distinctly deeper anteriorly than posteriorly,
and upon that circumstance the cervical curvature of the
column in great measure depends.

The two diarthrodial joints are placed, one on each side,

2 7
HEAD AND NECK

where the disc of fibro-cartilage is absent. They are of small

extent, and are confined entirely to the intervals between the
projecting lateral lips of the upper surface of the body
and the bevelled-off lateral margins of the lower surface of
the vertebral body immediately above. The bony surfaces
are coated with encrusting cartilage, and are separated by
a synovial cavity enclosed by a feeble articular capsule.

The ligaments which bind the bodies of the lower five

cervical vertebrae together are the direct continuation upwards
of the anterior and the posterior longitudinal ligaments of
the vertebrae. When the medulla spinalis was removed,
the laminae of the vertebrae, below the epistropheus, were

Synovial part of
joint between bodies
of vertebrae

Joint betwe
articular processes

Capsule around
joint between two
articular processes

Intervertebral fibro-
cartilage

FIG. 101. Frontal section through bodies of certain of the

Cervical Vertebrae.

taken away, so that very little dissection will be required to

make out the connections of both of the ligaments mentioned.
The anterior longitudinal ligament is a strong band placed on
the anterior faces of the vertebral bodies. It is more firmly
fixed to the intervening intervertebral fibre-cartilages than to
the bones, ^ht posterior longitudinq^ ligament^ which lies on
the posterior aspects of the vertebral bodies, constitutes the
anterior boundary of the vertebral canal. In the cervical
region it completely covers the bodies and does not present
the denticulated appearance which is" so characteristic lower
down. It is attached chiefly to the fibro-cartilages and the
adjacent margins of the bones.
The vertebral arches of the lower five cervical vertebrae are
bound together by (a) the articulations between the articular
processes; (b) ligamenta flava ; (c) interspinous ligaments,
and (d) intertransverse ligaments ; (e) ligamentum nuchae.

JOINTS OF THE NECK

271

The joints between the opposing articular processes are of

the diarthrodial variety. The surfaces of bone are coated
with cartilage ; there is a joint cavity surrounded by a
distinct articular capsule, lined with a synovial stratum. The
capsule is more laxly arranged in the neck than in the lower
regions of the vertebral column.

The ligamenta flava may be examined on the laminae which were

removed for the display of the spinal medulla, and which the dissector was
directed to retain. They fill up the gaps between the laminae of the
vertebrae, and can be seen best when the anterior aspect of the specimen
is viewed.

Ligamenta Flava. The ligamenta flava are composed of

Root of vertebral
arch, divided

FIG. 102. The Ligamenta Flava in the Lumbar Region.

yellow elastic tissue. E^h is attached superiorly to the

anterior surface and inferior margin of the lamina of the
vertebra above, whilst inferiorly it is fixed to the posterior
surface and superior margin of the lamina of the vertebra
next below. The laminae and the ligaments form, together,
a smooth, even, posterior wall for the vertebral canal. Each
ligament extends from the posterior part of the articular
processes to the median plane, where its free thickened
median border is in contact with its fellow of the opposite
side. The median slit between them, in the space between
each pair of vertebral arches, is filled with some lax connective

272 HEAD AND NECK

tissue, which allows the egress from the vertebral canal of

some small veins. The width of the ligaments in the different
regions of the vertebral column depends upon the size of
the vertebral canal. Therefore, they are widest in the neck
and in the lumbar part of the column. The ligamenta flava,
by virtue of their great strength and elasticity, are powerful
agents in maintaining the curvatures of the vertebral column ;
they also give valuable aid to the muscles in restoring the
vertebral column to its original position after it has been bent
in a ventral direction.

The inter spinous ligaments are most strongly developed in

the lumbar region, where they fill up the intervals between
the adjacent margins of contiguous spinous processes. In
the thoracic region, and more so in the neck, they are very
weak.

The supraspinous ligaments are thickened bands which

connect the summits of the spinous processes. In the neck
they are replaced by the ligamentum nuchse (p. 67).

The inter transverse ligaments are feebly marked in the

cervical region and extend chiefly between the anterior bars
of the transverse processes.

Articulations of the Epistropheus, Atlas, and Occipital

Bone. The articulations which exist between the atlas and
the occipital bone and the atlas and the epistropheus all
belong to the diarthrodial -class. Between the atlas and
epistropheus (O.T. axis) there are three such joints viz.,
a pair between the opposed articular processes, and a third
between the anterior face of the dens and the posterior face
of the anterior arch of the atlas. Between the atlas and
occipital bone there is a pair of joints viz., between the
occipital condyles and the elliptical cavities upon the
upper aspects of the lateral masses of the atlas. In ad-
dition, the epistropheus is attached to the occipital bone by
ligaments.

The ligaments connecting the three bones together may

be divided into three main groups, as follows :

Ligaments connecting atlas^

with epistropheus, . .

Anterior longitudinal.

Ligamenta flava.

Capsular.

Transverse . portion of cruciate ligament

with inferior crus.

Accessory ligaments of the atlanto-epi-

stropheal joints.
JOINTS OF THE NECK 273

Ligaments connecting occi-

pital bone with atlas, .

Anterior longitudinal ligament.

Anterior atlanto-occipital membrane.
Posterior atlanto-occipital membrane.
Transverse part of cruciate ligament with

superior crus.
Capsular.

{Membrana tectoria.
Superior and inferior crus of the cruciate
ligament.
Alar.
Apical.

Ligamentum Longitudinal e Anterius (Fig. 103). The

anterior longitudinal ligament is a continuation upwards of
the common anterior longitudinal ligament. Below, it is
attached to the anterior aspect of the body of the epi-
stropheus, whilst above, it is fixed to the anterior arch of the
atlas. It is thick and strong in the middle, but thins off
towards the sides.

Ligamenta Flava. The yellow ligaments fill the interval

between the laminae of the epistropheus and the posterior
arch of the atlas, to the contiguous margins of which they
are attached. They are broader and more membranous than
the ligamenta flava at lower levels.

Capsulse Articulares. The articular capsules are somewhat

lax, and are attached to the margins of the articular processes.

Membrana Atlanto-Occipitalis Anterior (Fig. 103). The

anterior occipito-atlantal membrane extends from the upper
border of the anterior arch of the atlas to the under surface
of the basilar portion of the occipital bone, anterior to the
foramen magnum. On each side of the median plane it is
thin and membranous, and stretches laterally so as to abut
against the atlanto-occipital articular capsule. In the median
plane it is strengthened by the upper part of the anterior
longitudinal ligament.

Membrana Atlanto-Occipitalis Posterior. The thin and

weak posterior occipito-atlantal membrane occupies the gap
between the posterior arch of the atlas and the posterior
border of the foramen magnum, to both of which it is
attached. It is very firmly connected with the dura mater,
and on each side it reaches the atlanto-occipital articular
capsule. Each of its lateral borders forms an arch over the
groove, posterior to the upper articular facet of the atlas, in
which the vertebral artery and the first cervical nerve are
lodged. It is not uncommon to find the borders ossified.

VOL. in 18

274

HEAD AND NECK

Atlanto - Occipital Articular Capsules. The atlanto-

occipital capsules connect the occipital condyles with the
lateral masses of the atlas. They completely surround the
joints, and are connected anteriorly with the anterior atlanto-
occipital membrane, and posteriorly with the posterior atlanto-
occipital membrane.

The occipital bone, therefore, around the foramen magnum

is attached by special ligaments to each of the four portions

Basilar portion of
occipital bone

Dura mater

Vertebral artery and

first cervical nerve

Second cervical
nerve

Anteiior atlanto-
occipital membrane
Two parts of the apical
ligament

Crus superius

Anterior arch of atlas

Transverse ligament
Anterior longitudinal
ligament
Crus inferius

Lenticular disc of cartilage

between the body of the epi-
stropheus and the dens

FIG. 103. Median section through the Basilar Portion of Occipital Bone,
the Atlas and the Epistropheus. (From Luschka, slightly modified.)

Between the membrana tectoria and the transverse ligament a small synovial bursa
may be seen.

of the atlas viz., to the anterior arch, to the two lateral

masses, and to the posterior arch.

Dissection. The remaining ligaments are placed within

the vertebral canal, in connection with its anterior wall. For
their proper display it is necessary therefore to remove, with
the bone forceps, the laminae of the epistropheus and the posterior
arch of the atlas. The squamous part of the occipital bone also
must be taken away, by sawing it through, on each side, immedi-
ately posterior to the jugular process and the condyle, carrying
the saw cut into the foramen magnum. The upper part of the
tube of dura mater, which still remains in the vertebral canal,
must next be carefully detached. When that has been done,

JOINTS OF THE NECK 275

a broad membranous band stretching upwards over the posterior

aspect of the body and dens of the epistropheus is displayed.
This is the membrana tectoria.

The Membrana Tectoria (O.T. Posterior Occipito- axial

Ligament). The tectorial membrane is a broad ligamentous
sheet which is attached, below, to the posterior aspect of the
body of the epistropheus, where it is continuous with the
posterior longitudinal ligament of the vertebrae. It extends
upwards, covering the dens and the anterior margin of the
foramen magnum, and is attached, above, to the superior
grooved surface of the basilar portion of the occipital bone.

Dissection. Detach the tectorial membrane from the epi-

stropheus and throw it upwards upon the basilar portion of the
occipital bone. By that proceeding the accessory ligaments of
the atlanto-epistropheal joints and the cruciate ligament will be
brought into view, and very little further dissection is required
to define them.
Accessory Atlanto-epistropheal Ligaments (Fig. 104).
The accessory atlanto-epistropheal ligaments are two strong
bands which take origin from the posterior aspect of the
body of the epistropheus, close to the base of the dens.
Each band passes upwards and laterally, and is attached to
the medial and posterior part of the corresponding lateral
mass of the atlas. To a certain extent they assist the alar
ligaments in limiting the rotary movements of the atlas
upon the epistropheus.

Ligamentum Cruciatum (Fig. 104). The cruciate ligament

is composed of a transverse and a vertical part. The trans-
verse part is by far the most important constituent. It is a
strong band which stretches from the tubercle on the medial
aspect of the lateral mass of the atlas on one side to the
corresponding tubercle on the opposite side. With the
anterior arch of the atlas, it forms a ring which encloses the
dens the pivot around which the atlas, bearing the head,
turns. It is separated from the posterior aspect of the dens
by a loose synovial membrane which extends forwards, on
each side, until it almost reaches the synovial membrane in
connection with the median joint between the dens and the
anterior arch of the atlas. Indeed, in some cases a com-
munication exists between the two synovial cavities.

The vertical part of the cruciate ligament consists of an

upper and a lower limb, whicti are termed the crura. Both

276

HEAD AND NECK

are attached to the dorsal surface of the transverse ligament.

The crus superius is the longer and flatter of the two, and
extends upwards on the posterior aspect of the dens to be
attached to the upper aspect of the basilar part of the
occipital bone, immediately beyond the anterior margin of
the foramen magnum. The crus inferiiis, much shorter,
extends downwards, and is fixed to the posterior aspect of
the body of the epistropheus.

Membrana tectoria
Crus superius

Apical
ligament
***

Lateral

mass of

atlas

Atlanto
pistropheal joint

Body of epistro-
pheus

Accessory atlan

epistropheal

ligament

Crus inferius

Membrana tectoria

FlG. 104. Dissection showing the posterior aspects of the Ligaments con-
necting the Occipital Bone, the Atlas and the Epistropheus with each
other.

Dissection. Detach the superior crus from the occipital

bone, and throw it downwards. The apical ligament is thus
displayed, and a better view of the alar ligaments is obtained.

Ligamentum Apicis Dentis. The apical ligament of the

dens consists of two parts an anterior and a posterior. The
posterior part is a rounded cord-like ligament which is attached,
below, to the summit of the dens, and, above, to the anterior
margin of the foramen magnum. Inasmuch as it is developed
around the continuation of the notochord, from the dens
to the basis cranii, it is a structure of considerable morpho-
logical interest. The anterior part of the apical ligament is a
flat and weak band which is attached, above, to the anterior

JOINTS OF THE NECK 277

margin of the foramen magnum at the same point as the

posterior portion. Below, the two portions are separated by
an interval filled with areolar tissue, and the anterior part is
attached to the dens immediately above its articular facet for
the anterior arch of the atlas.

Ligamenta Alaria (Fig. 104). The alar ligaments are very

powerful bands which spring, one from each side of the
summit of the dens. Each passes laterally and slightly up-
wards to be attached to the medial aspect of the corre-
sponding condyloid eminence' of the occipital bone. The
alar ligaments limit rotation of the head, and in this they are
aided by the accessory atlanto-epistropheal ligaments.

Movements. Nodding movements of the head are permitted at the

atlanto-occipital articulations. Rotatory movements of the head and atlas
around the dens, which acts as a pivot, take place at the atlanto-
epistropheal joints. Excessive rotation is checked by the alar ligaments.

MOUTH AND PHARYNX.

The dissectors must now return to the anterior part of the

skull, which had been laid aside while the dissection of the
prevertebral region was being carried on. The mouth and
pharynx should engage their attention in the first instance.

Mouth. The mouth is the expanded upper part of the

alimentary canal which is placed in the lower part of the
face, below the nasal cavities. Its cavity is controlled by
muscles which are under the influence of the will, and it
is separable into two parts : a smaller external part, termed
the vestibule, which is bounded externally by the lips and
cheeks, and internally by the teeth and gums; and a large
part, the mouth proper, which is placed within the teeth.

The mucous lining of the mouth should be thoroughly cleansed, and

the two subdivisions of the cavity examined through the oral fissure.

Vestibulum Oris. The vestibule of the mouth, which

lies outside the teeth and gums, is a mere fissure-like space,
except when the cheeks are inflated with air. It is into the
vestibule of the mouth that the parotid ducts open (p. 164).
Above and below, it is bounded by the reflection of the
mucous membrane from the lips and cheeks on to the
alveolar margins of the maxillae and mandible. Anteriorly,
it opens upon the face by means of the oral fissure ; whilst

278 HEAD AND NECK

posteriorly, it communicates, on each side, with the cavity

of the mouth proper through the interval between the last
molar tooth and the anterior border of the ramus of the
mandible. The existence of that communicating aperture is
of importance in cases of spasmodic closure of the jaws, when
all the teeth are in place, because through it fluids may be
introduced into the posterior part of the mouth proper.

In paralysis of the facial muscles the lips and cheeks fall away from the
dental arches and food is apt to lodge in the vestibule.

Cavum Oris Proprium. The mouth proper is bounded, an-

teriorly and laterally, by the gums and teeth, whilst, posteriorly,
it communicates, by means of the isthmus of the fauces, with
the pharynx. The floor is formed by the tongue and the
mucous membrane which connects it with the inner aspect
of the mandible ; the roof is vaulted, and is formed by the
hard and the soft palates. It is into the mouth proper
that the ducts of the submaxillary glands and the ducts of
the sublingual glands open (p. 194). When the mouth is
closed the dorsum of the tongue is usually applied more or
less closely to the palate and the cavity is almost completely
obliterated.

The various parts which bound the oral cavity may now
be examined in turn.

Labia Oris. The structure of the lips has, in a great

measure, been examined already in the dissection of the face
(p. 10). Each lip is composed of four layers: (i) Cuta-
neous; (2) muscular; (3) glandular; and (4) mucous. The
skin and mucous membrane become continuous with each
other at the free margin of the lip. The mucous membrane
is reflected from the inner aspect of the upper lip to the
alveolar margin of the maxillae, and from the inner aspect of the
lower lip to the mandible. In each case it is raised in the
median plane in the form of a free fold termed the frenulum.
The muscular layer constitutes the chief bulk of the lips. It
is formed by the orbicularis oris and the various muscles
which converge upon the oral fissure. Numerous labial
glands lie in the submucous tissue which intervenes between
the mucous membrane and the muscular fibres. The ducts
of those glands pierce the mucous membrane and open into
the vestibule. In each lip there is an arterial arch formed
by the corresponding labial arteries (p. 16).

MOUTH 279

The lymph vessels of both lips join the submaxillary

lymph glands, but some of the lymph vessels of the upper
lip pass to the superficial parotid glands.

Buccse. Six layers can be distinguished in the cheeks,

four of which were examined in the dissection of the face.
They are (i) Skin; (2) a fatty layer, traversed by some of
the facial muscles and by the external maxillary artery; (3)
the bucco-pharyngeal fascia ; (4) the buccinator muscle ;
(5) the submucous tissue, in which lie numerous buccal glands
similar in character to the labial glands; (6) the mucous
membrane. Four or five mucous glands of larger size,
termed the molar glands, occupy a more superficial position.
They lie either external or internal to the bucco-pharyngeal
fascia, close to the point where it is pierced by the parotid
duct, and their ducts open into the vestibule of the mouth.
The bucco-pharyngeal fascia is a dense membrane which covers
the buccinator muscle. Above and below, it is attached to
the alveolar portions of the maxilla and mandible respectively,
whilst posteriorly it is continued over the pharynx. The
muscles which traverse the fatty layer are chiefly the zygo-
maticus, the risorius, and the posterior fibres of the platysma.
The parotid duct pierces the inner four layers of the cheek,
and opens into the vestibule of the mouth, opposite the second
molar tooth of the maxilla,

Gingivse et Dentes. The gums are covered with a smooth

and vascular mucous membrane, which is firmly bound down
to the subjacent periosteum of the alveolar portions of the
jaws by a stratum of dense connective tissue. It is continuous,
on the one hand, with the mucous membrane of the lips and
cheeks, and, on the other, with the mucous membrane of the
mouth proper. The gums closely embrace the necks of the
teeth.

In the adult, the teeth in each jaw number sixteen. From

the median line backwards, on each side, they are the two
incisors, the canine, the two praemolars, the three molars.

Floor of the Mouth. The mucous membrane is reflected

from the inner aspect of the mandible to the side of the
tongue ; but in the anterior part of the mouth the tongue lies
more or less free in the oral cavity, and there the mucous
membrane stretches across the floor from one half of the
mandible to the other. On each side, in the anterior region,
the projection formed by the sublingual gland, the plica sub-

280 HEAD AND NECK

lingualis, can be distinguished. Further, if the tongue is

pulled upwards, a median fold of mucous membrane will be
seen to connect its under surface to the floor. It is the frenulum
lingua. At the sides of the frenulum the dissector must
look for the openings of the submaxillary ducts. Each
terminates on a papilla placed close to the side of the
frenulum. More posteriorly, between the side of the tongue
and the mandible and on the summit of the plica sub-
lingualis, are the openings of the sublingual ducts.

Roof of the Mouth. The hard and the soft palates form

Frenulum linguae.

Tip of tongue

turned up' , _. ^ ., _

Deep lingual vein nVtaST^T A L '^&M31 \

"Plica sublingu.ilis
Orifice of
submaxillary duct

FIG. 105. The Sublingual Region in the Interior of the Mouth.

the continuous concave and vaulted roof of the mouth (Fig.

1 06). Projecting from the middle of the posterior free margin
of the soft palate, and resting upon the dorsum of the tongue,
the uvula will be seen (Fig. 106). Running along the median
line of both the hard and the soft palates is a raphe
which terminates anteriorly, opposite the incisive foramen
of the hard palate, in a slight elevation or papilla termed
the incisive papilla. In the anterior part of the hard palate
the mucous membrane, on each side of the raphe, is thrown
into three or 'four transverse hard corrugations or ridges;
more posteriorly it is comparatively smooth. By carefully
palpating the postero-lateral angles of the palate the dissector

MOUTH 281

will be able to feel the hamuli of the medial pterygoid

laminae.

Isthmus Faucium. The isthmus of the fauces is the name

given to the communication between the mouth proper and
the pharynx (Fig. 106). To obtain a good view of it the
mouth must be well opened and the tongue depressed. The
isthmus faucium and the parts which bound it can be
examined best in the living subject, and the dissector should
study his own isthmus faucium with the aid of a looking-glass

Uvula

Pharyngo-
palatine arch

Palatine tonsil

Glosso-palatine
arch

Posterior wall of

oral part of

pharynx

Tongue
FIG. 1 06. Isthmus of the Fauces as seen through the widely opened Mouth,
The palatine tonsils, in the subject from which this drawing was made,
were somewhat enlarged.

(Fig. 1 06). It is bounded above by the soft palate, below by

the dorsum of the tongue, and on each side by a curved
fold of mucous membrane, termed the arcus glossopalatinus
(O.T. anterior pillar of the fauces).

Each glosso-palatine arch descends from the posterior part

of the inferior surface of the soft palate and, inclining forwards
as it descends, it ends upon the side of the posterior part of
the tongue. It encloses the glosso-palatinus muscle. .

The pharyn go-palatine arches which are also described as

boundaries of the isthmus of the fauces lie, in reality, on the
side wall of the oral part of the pharynx. They pass down-

282 HEAD AND NECK

wards and backwards from the sides of the lower margin of

the soft palate, and each encloses a pharyngo-palatine muscle.
In the triangular interval which is formed by the divergence
of the glosso- and pharyngo-palatine arches, on each side, lies
a palatine tonsil.

Strictly speaking, the term isthmus faiicium should be confined to the

interval between the two glosso-palatine arches, as the palatine tonsil and
the pharyngo-palatine arches belong to the side wall of the pharynx.

Pharynx. The pharynx is a wide musculo-aponeurotic

canal, about 12.5 cm. (5 inches) long. It extends from the
base of the cranium to the level of the body of the sixth
cervical vertebra (Fig. 1 10). There, at the lower border of the
cricoid cartilage, it becomes continuous with the oesophagus.
It is placed posterior to the nasal cavities, the mouth and the
larynx, and it serves as the passage which conducts air to
and from the larynx, as well as the food from the mouth to
the oesophagus.

Under ordinary conditions it is expanded from side to

side and compressed antero-posteriorly, so that it possesses
anterior and posterior walls and two borders. Above the
level of the orifice of the larynx there is always sufficient
space for the passage of air to the lungs, but below the
orifice of the larynx the anterior and posterior walls are in
contact, except when separated by the passage of food
(Fig. 112).

It is widest above, at the base of the cranium, posterior

to the orifices of the auditory tubes (O.T. Eustachian).
Thence it narrows to the level of the hyoid bone. It widens
again at the level of the upper part of the larynx and then
rapidly narrows to its termination.

To obtain a proper idea of the connections of the pharynx, the dissector

should distend its walls moderately by stuffing it with tow. This may be
introduced either from above, through the mouth, or from below, through
the oesophagus.

When the pharynx is distended it has a somewhat ovoid

form. Posteriorly, its wall is complete, and, when in position,
it lies anterior to the upper six cervical vertebrae, the pre-
vertebral muscles, and the prevertebral fascia. It is bound
to the prevertebral fascia by some lax connective tissue which
offers no impediment to the movements of the canal during
the process of deglutition. On each side, the pharynx is
related to the great vessels and nerves of the neck, as well

PHARYNX 283

as to the styloid process and the muscles which take origin

from it ; and the pharyngeal plexus of nerves ramifies over
its margin, extends on to its surfaces, and supplies it with
motor and sensory twigs. Anteriorly, the pharyngeal wall is
interrupted by the openings of the nasal cavities, mouth, and
larynx ; and it is from the structures which lie in proximity to
those apertures that it derives its principal attachments. From
above downwards it is attached, on each side (a) to the
medial pterygoid lamina ; (b) to the pterygo-mandibular
raphe; (c) to the side of the tongue; (d) to the medial
aspect of the mandible ; (e) to the hyoid bone ; (/) to the
thyreoid cartilage ; (g) to the cricoid cartilage. Above, it is
attached to the basis cranii. The various attachments will
be studied more fully when the constituent parts of its walls
are dissected.

It should be recognised that an altogether false idea of

the natural form of the pharynx is obtained when it is
removed from the vertebral column and is stuffed with tow
or other substances. In transverse sections of the frozen
body it will be noted that the cavity of the nasal part of the
pharynx remains patent under all conditions, whilst at lower
levels the anterior wall is more or less nearly approximated
to the posterior wall, and below the opening of the larynx the
cavity of the pharynx presents the appearance of a simple
transverse slit.

Pharyngeal Wall. The wall of the pharynx consists of

four well-marked strata. From without inwards they are :
(i) bucco-pharyngeal fascia; (2) pharyngeal muscles; (3)
pharyngeal aponeurosis ; (4) mucous membrane. The
muscular layer, which is composed of the three constrictor
muscles, with the stylo-pharyngeus and pharyngo-palatinus,
on each side, must now be dissected.

Bucco-pharyngeal Fascia. The bucco-pharyngeal fascia

is a coating of fibrous tissue which covers both the buccinator
and the pharyngeal muscles.
Dissection. Remove the bucco-pharyngeal fascia and clean
the pharyngeal muscles, sweeping the knife in the direction of
their fibres. Note the veins which lie between the fascia and
the muscles, forming the pharyngeal plexus, and the pharyngeal
plexus of nerves to which the pharyngeal branches of the vagug
nerve, the glosso-pharyngeal nerve, and the superior cervical
sympathetic ganglion have already been traced. The veins
and nerves must be removed for the proper display of the muscles.

284

HEAD AND NECK

Venae Pharyngese. The pharyngeal veins lie mostly upon

the posterior wall and the borders of the pharynx, where they
anastomose together in a plexiform manner. They constitute,
collectively, the pharyngeal venous plexus, which receives
blood from the pharynx, soft palate, and prevertebral region.
It communicates with the pterygoid plexus and the cavernous

I'uccinator.
Tensor veli palatini.
Levator veli palatini.
Superior constrictor.
Middle constrictor.
Inferior constrictor.
Thyreo-hyoid.
Hyoglossus.
Stylo-hyoid.
Mylo-hyoid.
'. Crico-thyreoid.
Stylo-pharyngeus.
Stylo-glossus.
Stylo-hyoid ligament.
Pterygo-mandibular raphe.
Glosso-pharyngeal nerve.
Superior laryngeal artery.
Superior laryngea! nerve.
External laryngeal nerve.
Inferior laryngeal nerve and
artery.

FIG. 107. Profile view of the Pharynx to show the Constrictor Muscles.
(From Turner.)

sinus. Two or more channels carry the blood from it to the

internal jugular vein.
Constrictor Muscles. The constrictor muscles are three
pairs of curved sheets of muscular fibres which are so arranged
that they overlap each other from below upwards ; thus, the
inferior constrictor overlaps the lower part of the middle
constrictor, whilst the middle constrictor, in turn, overlaps the

PHARYNX 285

lower part of the superior constrictor. The three muscles are

inserted, in the median plane, into the median raphe which
descends from the basilar portion of the occipital bone along
the posterior aspect of the pharynx.

Musculus Constrictor Pharyngis Inferior (Fig. 107, /).

The inferior constrictor muscle is relatively short, anteriorly,
at its origin, and relatively long, posteriorly, where it blends with
the fellow of the opposite side in the median raphe of the
posterior wall of the pharynx. It arises from the posterior
part of the side of the cricoid cartilage, and from the
inferior cornu, the oblique line, and the upper border of
the thyreoid cartilage. The muscle curves backwards and
medially, in the pharyngeal wall, to meet its fellow of the
opposite side in the median raphe. The lower fibres take
a horizontal direction, but the remainder ascend, with increas-
ing degrees of obliquity, until the highest fibres reach the raphe
at a point a short distance below the base of the skull. The
lower margin of the inferior constrictor overlaps the com-
mencement of the oesophagus, and the inferior laryngeal
nerve and the laryngeal branch of the inferior thyreoid artery
pass upwards, ^nder cover of it, to reach the larynx. It is
supplied by twigs from the. pharyngeal plexus and the recur-
rent nerve.

Musculus Constrictor Pharyngis Medius. The middle con-

strictor is a fan-shaped muscle (Fig. 107, e). It arises from
the greater and lesser cornua of the hyoid bone and from
the lower part of the stylo-hyoid ligament. From those origins
its fibres pass round the pharyngeal wall, to be inserted with
the corresponding fibres of the opposite side into the median
raphe. As they curve backwards and medially, the lowest
fibres descend, the highest ascend, and the intermediate fibres
run horizontally. The lower portion of the muscle is over-
lapped by the inferior constrictor, and in the interval which
separates the margins of the muscles anteriorly, opposite the
thyreo-hyoid interval, the internal laryngeal nerve and the
laryngeal branch of the superior thyreoid artery will be seen
piercing the thyreo-hyoid membrane to gain the interior
of the pharynx. It is supplied by twigs from the pharyngeal
plexus.

Dissection. To bring the extensive origin of the superior

constrictor fully into view the internal pterygoid muscle must
be cut through about its middle, if that has not been done already

286 HEAD AND NECK

(p. 199), and then the upper and lower portions must be turned
aside.

Musculus Constrictor Pharyngis Superior (Fig. 107, d\

The superior constrictor has a weak but continuous line
of origin from the following parts : (a) the lower third of
the posterior border of the medial pterygoid lamina and its
hamulus ; (fr) the pterygo-mandibular raphe, which is common
to it and the buccinator muscle; (c) the posterior end of the
mylo-hyoid line on the medial aspect of the mandible ; (d) the
mucous membrane of the mouth and side of the tongue. From
their origins, the fibres curve backwards and medially to reach
the median raphe, whilst, as a rule, some of the highest gain
a distinct insertion into the pharyngeal tubercle on the under
surface of the basilar portion of the occipital bone.

The lower part of the superior constrictor is overlapped

by the middle constrictor; and the stylo-pharyngeus passes
into the interval between the two as it descends to its inser-
tion (Fig. 107, n). The upper border of the muscle, which is
free and crescentic, falls short of the base of the skull.

Raphe Pterygo-mandibularis (Fig. 107, q\ The pterygo-

mandibular raphe is a strong, narrow, tendinous band, which
extends from the hamulus of the medial pterygoid lamina to
the posterior part of the mylo-hyoid line of the mandible. It
acts as a tendinous bond of union between the buccinator
and superior constrictor muscles. Its connections can be
appreciated best by introducing the finger into the mouth
and pressing laterally along the course of the raphe.

Sinus of Morgagni. The term sinus of Morgagni is ap-

plied to the semilunar interval which intervenes between
the basis cranii and the upper crescentic margin of the
superior constrictor. The deficiency in the muscular wall of
the pharynx in that region is compensated for by the increased
strength of the pharyngeal aponeurosis, which, in that situa-
tion, is called the pharyngo-basilar fascia. In contact with the
outer surface of the aponeurosis are two muscles belonging
to the soft palate viz. the levator veli palatini and the tensor
veli palatini (Fig. 107, c and b\ The levator, which is rounded
and fleshy, lies posterior to the tensor, which is flat and more
tendinous. The tensor can readily be recognised from its
position in relation to the deep surface of the internal
pterygoid muscle, and because its tendon turns medially under
the hamulus of the medial pterygoid lamina. In the upper

PLATE XI

Angle of
mandible
Epiglottis

Thyreoid
cartilage

Cricoid cartilage

FIG. 1 08. Radiograph of " Neck, lateral view, showing the position of the
pharynx and oesophagus in which a bougie with a metal core had been
inserted. (Gouldesbrough. )

PLATE XII

Air in trachea r^

Sternal end of
clavicle

First rib

I Arch of aort

tie. 109. Radiograph of Neck, anterior view, showing the position of

the oesophagus in which a bougie with a metal core had been inserted.
(Gouldesbrough. )

. PHARYNX 287

part of the space, close to the base of the skull and between
the origin of the two muscles, the auditory tube (O.T.
Eustachian tube] can be defined.

Pharyngeal Aponeurosis. The upper part of the pharyn-

geal aponeurosis is strong, and it maintains the integrity of
the wall of the pharynx where the muscular fibres of the
superior constrictor are absent. As it passes downwards it
gradually becomes weaker, until it is ultimately lost as a
distinct layer. It lies between the muscles and mucous
membrane and is visible, from the outside of the pharynx,
only where the muscles are absent. It is the principal means
by which the pharynx is attached to the base of the skull,
and it is united also to the auditory tubes and the bony
margins of the choancz.

Dissection. The pharynx must now be opened by a vertical

median incision through the entire length of its posterior wall.
At the upper extremity of the cut, the knife should be carried
transversely, close to the base of the skull. The stuffing must
then be removed and the mucous surface of the pharynx cleansed.

Interior of the Pharynx. The mucous membrane is now

exposed, and it should be noted that it is continuous,
through the various apertures which open into the pharynx,
with the mucous membrane of the nasal cavities, the auditory
tubes and tympanic cavities, the mouth proper, the larynx, and
the o&sophagus.

Racemose glands, which lie immediately subjacent to the

mucous membrane and secrete mucus, are present in great
numbers. There are also numerous lymph follicles, and
in certain localities they are aggregated together into large
masses (the palatine tonsils and the pharyngeal tonsil),
which will be studied with the regions of the pharynx in
which they are placed.

The soft palate projects into the pharynx, posterior to

the isthmus faucium, and divides the cavity of the pharynx
into an upper and a lower part. -The upper part, called
the naso - pharynx, communicates with the nasal cavities
and the tympanic cavities by four apertures, viz. the two
choanae (O.T. posterior nares) -and the two auditory tubes
(O.T. Eustachian tubes).

The lower portion of the pharynx may be regarded as

consisting of an oral part, which lies posterior to the
mouth and tongue, and a laryngeal part, placed posterior

HEAD AND NECK

to the larynx. Below the soft palate there are three

openings into the pharynx, viz. the opening of the mouth or
isthmus faucium, the opening of the larynx, and the opening of
the oesophagus.

Middle nasal concha

Middle meatus
Atrium

Inferior
nasal cond
Inferior meatus

Vestibule of
nasal cavity

M. genioglossu
M. geniohyoideu

M. mylohyoideus

Hyoid bone
Cartilage of epiglottis

Thyreoid cartilage

Superior meatus

Recessus spheno-ethmoidalis
/Sphenoidal sinus
Hypophysis

/Pharyngeal recess
Pharyngeal tonsil

---Orifice of auditory tube

Upper surface

of soft palate

Salpingo-pharyngeal

fold

Pharyngo-palatine

arch

Palatine tonsil

Pharyngeal surface
of tongue
Epiglottis

Cuneiform tubercle

Corniculate cartilage
Laryngeal ventricle
Cricoid cartilage

FIG. no. Sagittal section, a little to the right of the median plane,
through the Nasal Cavity, the Mouth, Pharynx, and Larynx.

Pars Nasalis. The naso-pharynx is situated immediately

posterior to the nasal cavities and below the body of the
sphenoid and the basilar part of the occipital bone. It is the
widest part of the pharynx. Its walls, except the soft palate,
are not capable of movement, and, consequently, its cavity

PHARYNX 289

always remains patent, and presents under all conditions very

much the same form.

In its anterior boundary are the choanae, through which it

opens into the nasal cavities. The choantz are two oblong
orifices which slope from the base of the cranium downwards
and forwards to the posterior border of the hard palate.
Each is about 25 mm. (one inch) long and 12.5 mm. (half an
inch) wide, and it is separated from its fellow by the posterior
part of the septum nasi, which is formed by the posterior
border of the vomer. By looking through the choanse the
dissector will obtain a partial view of the lower two meatuses
of the nose and of the posterior ends of the middle and
inferior conchse.

On each side wall of the naso-pharynx is seen the orifice

of the corresponding auditory tube, and posterior to it the
pharyngeal recess. The pharyngeal orifice of the auditory
tube lies immediately posterior to the lower part of the
corresponding choana, on a level with the posterior end of
the inferior concha of the same side. It is bounded above
and posteriorly by a prominent and rounded margin termed
the torus tubarius, which is altogether deficient below and
anteriorly. A fold of mucous membrane, termed the salpingo-
pharyngeal fold, descends, upon the side wall of the pharynx,
from the posterior lip of the orifice of the auditory tube. As
the fold is traced downwards it gradually disappears.

The dissector should pass a Eustachian catheter through the nose into
the auditory tube. Hold the catheter with the point downwards. Pass it
backwards through the right nasal cavity, along the septum of the nose, to
the posterior wall of the pharynx. Pull it towards the palate till the bent end
of the catheter catches against the back of the hard palate. Turn the point
through a quarter of a circle to the right side of the head and it will enter
the right auditory tube. If it is desired to catheterise the left auditory tube
pass the catheter through the left nasal cavity, and in the final stage turn the
point to the left side.

In the natural condition of parts there is a deep recess

on the side wall of the naso-pharynx immediately posterior
to the prominent posterior lip of the orifice of the auditory
tube. It is termed the pharyngeal recess.

The roof and posterior wall of the naso-pharynx are not

marked off from one another. They form together a continuous
curved surface. The upper portion of the surface looks
downwards and may be regarded as the roof ; the lower portion,
which looks forwards, constitutes the posterior wall The roof

VOL. Ill 19

2 9 o HEAD AND NECK

is formed by the basilar part of the occipital bone, and

also by a small part of the under surface of the basi-sphenoid,
both of which are covered with a dense periosteum and a
thick coating of mucous membrane. The posterior wall is
supported, posteriorly, by the anterior arch of the atlas and
the anterior surface of the epistropheus. In that part of the
roof which lies between the two pharyngeal recesses there
is a marked collection of lymphoid tissue, called the pharyngeal
tonsil. Over its surface the mucous membrane is thickened
and wrinkled, and in its lower part a small median pit,
termed the pharyngeal bursa, may sometimes be found ; the
bursa is just large enough to admit the point of a fine probe.

The floor of the naso-pharynx is formed by the curved,

sloping upper surface of the soft palate. Between the posterior
border of the soft palate and the posterior wall of the pharynx
there is an interval, termed the naso-pharyngeal isthmus, through
which the naso-pharynx communicates with the oral pharynx.

It is important to note that the posterior wall and roof of

the naso-pharynx can be explored by the finger introduced
through, the mouth and the naso-pharyngeal isthmus.

When the naso-pharynx is illuminated, by light reflected

from a mirror introduced through the mouth, a view of the
four orifices which open into the nasal part of the pharynx
may be obtained. Owing to the mirror being placed
obliquely, and below the level of the hard palate, only the
posterior parts of the inferior conchse are visible through the
choanae, and the inferior meatuses of the nose are altogether
out of sight. The middle and superior meatuses of the nose
and the middle and superior conchse, however, can be brought
into view and their condition ascertained. The lateral walls
of the naso-pharynx and the orifices of the auditory tubes
also can be fully inspected.

Pars Oralis. The oral pharynx lies posterior to the mouth

and tongue. The anterior wall of its lower part is formed
by the base or pharyngeal part of the tongue, which looks
more or less directly backwards. Above the tongue is the
isthmus of the fauces, or the opening into the mouth, limited
on each side by the glosso-palatine arch. The glosso-pala-
tine arches may be regarded, therefore, as the lateral boundary
lines between the mouth and the pharynx. On the side wall
of the oral pharynx the pharyngo-palatine arch forms a
prominent fold which gradually disappears as it passes back-

PHARYNX 291

wards and downwards. Within the fold is the pharyngo-

palatine muscle, which is of importance because the posterior
palatine arches form the boundaries of the naso-pharyngeal
isthmus, on each side, and by the contraction of the pharyngo-
palatine muscles the two pharyngo- palatine arches can be
approximated until the opening of the isthmus is obliterated ;
the passage of food and fluids from the oral pharynx into
the naso-pharynx is thus prevented.

The glosso-palatine arch and the pharyngo-palatine arch

form, on each side-wall of the oral pharynx, the anterior and
posterior limits of a triangular interval in which is lodged the
palatine tonsil. The upper part of the interval, above the
level of the tonsil, forms a small depression termed the supra-
tonsillar fossa.

In the child, and not uncommonly in the adult, a triangular

fold of mucous membrane, called the plica triangularis, ex-
tends backwards from the lower part of the glosso-palatine
arch and the base of the tongue across the surface of the
palatine tonsil. The upper border of the fold may be free
or it may become attached to a greater or less extent to the
surface of the tonsil.

Pars Laryngea. The laryngeal portion of the pharyngeal

cavity diminishes rapidly in width to the level at which it be-
comes continuous with the oesophagus. In its anterior wall, from
above downwards, may be seen: (i) the epiglottis; (2) the
superior aperture of the larynx, with a recessus piriformis on
each side ; and (3) the posterior surfaces of the arytsenoid
and cricoid cartilages, covered with muscles and mucous
membrane.

Aditus Laryngis. The superior aperture of the larynx,

situated below the pharyngeal part of the tongue, is a
large, obliquely placed opening which slopes rapidly from
above downwards and backwards. It is somewhat triangular
in outline. The basal part of the opening, placed above and
anteriorly, is formed by the free border of the epiglottis.
Posteriorly, the opening rapidly narrows, and it ends in the
interval between the two arytaenoid cartilages. The sides of
the aperture are formed by two sharp and prominent folds
of mucous membrane, termed the ary-epiglottic folds, which
connect the right and left margins of the epiglottis with the
corresponding arytsenoid cartilages. Two small nodules of
cartilage, in the posterior part of each ary-epiglottic fold,
2 9 2

HEAD AND NECK

produce two rounded eminences, of which the anterior is the

cuneiform tubercle, and the posterior is the corniculate tubercle.

On each side of the lower part of the laryngeal opening

there is a small three-sided or pyramidal depression, called the
recessus piriformis. On the lateral side each piriform recess is
bounded by the posterior part of the corresponding lamina
of the thyreoid cartilage and the corresponding part of the
thyreo-hyoid membrane ; on the medial side, by the arytaenoid

Tongue

Rima glotti

Recessus piriform

Superior cornu
of thyreoid

Pharyngeal wall
(cut)

Glosso-epiglottic
fold

Vallecula

Pharyngo-
epiglottic fold

Epiglottis

Tubercle of
epiglottis

Ary-epiglottic

fold
Laryngeal ventricle

Plica ventricularis
Cuneiform tubercle

Corniculate
cubercle

Mucous membrane
covering posterior
aspect of cricoid
cartilage

FIG. in.

-Superior Aperture of Larynx exposed by cutting through

the posterior wall of the pharynx.

cartilage and the ary-epiglottic fold ; whilst its posterior wall

is formed by the posterior wall of the pharynx, when that is
in place. The piriform recess has a wide entrance, which
looks upwards ; but it rapidly narrows towards the bottom
(Figs, in and 112). It is of practical importance because
sharp-pointed bodies introduced into the pharynx are liable
to be caught in the walls of the sinus.

Below the level of the opening of the larynx, the anterior

PHARYNX

293

and posterior walls of the pharynx are always closely applied

to each other, except during the passage of food.

The otsophageal opening is placed opposite the lower border

of the cricoid cartilage, at the narrowest part of the
pharynx.

Velum Palatinum. The soft palate is a movable curtain,

which projects downwards and backwards into the pharynx.
During deglutition it is raised, and helps to shut off the
nasal part of the pharynx from the portion below. Anteriorly,
it is attached to the posterior margin of the hard palate ; on
each side it is connected with the side wall of the pharynx ;
whilst posteriorly it presents a free border. From the centre
Thyreo-hyoid ligament

Plica vocalis
Processus vocalis
Arytaenoid cartilage

Platysma
Posterior wa

of pharynx
Retropharyn-
geal space

Carotid sheath

M. sternohyoideus

M. thyreohyoideus

Thyreoid cartilage
M. omohyoideus
Recessus piriformis
Superior thyreoid
Descendens
hypoglossi
Common carotid
Internal jugular

Vagus

Scalenus anterior

M. longus colli Vertebral artery

Sympathetic trunk

FIG. 112. Transverse section through the Neck at the level of upper
part of the Thyreoid Cartilage.

of the free margin the conical process, termed the uvula,

projects ; whilst the sharp concave part of the border, on each
side of the uvula, becomes continuous with the pharyngo-
palatine arch, which descends on the side-wall of the pharynx.
The upper surface of the soft palate is convex and continuous
with the floor of the nasal cavities. The inferior surface is
concave and forms part of the vaulted roof of the mouth
and the roofs of the supra-tonsillar recesses. From the
posterior part of the inferior surface, on each side, a glosso-
palatine arch curves downwards ; and along its median plane
may be seen a slightly marked median ridge or raphe.

The soft palate is composed of a fold of mucous membrane,

between the two layers of which are interposed muscular,

in 19 a

294 HEAD AND NECK

aponeurotic, and glandular structures, together with blood

vessels and nerves.

The two levatores veli palatini.

The two tensores veli palatini.
Palatal muscles, . -( The two glosso-palatini.

The two pharyngo-palatini.

The musculi uvulae.
Palatal aponeurosis.
Palatal glands.

C Ascending palatine, from external maxillary.

A t I Palatine branch from ascending pharyngeal.

| Twigs from the descending palatine branch of the internal

^ maxillary.
( M
Nerves,

Branches from pharyngeal plexus.

The racemose mucous glands in the soft palate form a very

thick layer, immediately subjacent to the mucous membrane
which clothes its inferior surface. Close to the posterior
border of the hard palate the soft palate contains very few
muscular fibres ; and in that situation it is composed chiefly
of the two layers of mucous membrane enclosing the glands
and the palatal aponeurosis.

Dissection. The dissection of the soft palate is difficult,

and it is only in a fresh part that the precise relations of the
different muscular layers can be made out. Begin by rendering-
it tense by means of a hook, and then carefully remove the
mucous membrane from its upper and lower surfaces, and also
from the glosso- and pharyngo - palatine arches. The latter
proceeding will expose the glosso-palatine and the pharyngo-
palatine muscles, on each side.

Musculi Glosso-palatini. The glosso-palatini are delicate

muscular slips, each of which arises from the side of the
posterior part of the tongue, whence it curves upwards and
medially to reach the under surface of the soft palate, above
the glandular layer. There its fibres spread out and become
continuous with the corresponding muscular fasciculi of the
opposite side. It forms the lowest muscular stratum of the
soft palate. The nerve supply is derived from the accessory
nerve. When the glosso-palatini muscles contract the
glosso-palatine arches are approximated in the median plane,
and the cavity of the mouth is shut off from the cavity of
the pharynx.

Musculi Pharyngo-palatini. In the soft palate each

pharyngo-palatine muscle consists of two strata, an upper

PHARYNX 295

and a lower, between which are enclosed the corresponding

muscle of the uvula and the levator of the soft palate.

The upper layer is very weak and confined to the posterior

part of the velum. It constitutes the most superficial muscular
stratum on the upper aspect of the soft palate, and becomes
continuous with the corresponding portion of the muscle of
the opposite side. The deeper layer takes origin from the
posterior margin of the palate bone and from the palatal
aponeurosis, and some of its fibres mingle with those of the
corresponding muscle of the' opposite side. Lateral to the
soft palate the two strata blend, and are joined by one or two
delicate muscular slips which spring from the lower border of
the cartilage of the auditory tube. Those slips are some-
times described as the salpingo-pharyngeus muscle. The three
parts blend at the postero-lateral border of the soft palate,
and from there the pharyngo-palatinus passes downwards and
backwards in the pharyngo-palatine arch, and spreads out
into a thin sheet of fibres in the wall of the pharynx. The
pharyngo-palatinus blends, to some extent, with the stylo-
pharyngeus, and is inserted, with the stylo-pharyngeus, into the
posterior border of the thyreoid cartilage. Some of its fibres,
however, incline backwards and are inserted into the pharyngeal
aponeurosis. It helps to close the isthmus of the pharynx and
to elevate the larynx; it is supplied by the accessory nerve.

Musculi Uvulae. The two small muscles of the uvula,

right and left, lie in the upper part of the soft palate, covered
on their upper surfaces by the upper parts of the pharyngo-
palatine muscles, which must be removed before the muscles
of the uvula can be seen. Each muscle of the uvula is a
minute slip which springs from the posterior nasal spine.
As they pass backwards the two slips blend, and their fibres
are inserted into the mucous membrane of the uvula. They
are supplied by the accessory nerve, and when they contract
they elevate the uvula.

Dissection. The levator veli palatini muscle has been seen

already, on the outer aspect of the pharynx, in the sinus of
Morgagni (Fig. 1 07) . To display it from the inside it is necessary to
remove the mucous membrane, the submucous tissue, and the
membranous part of the wall of the pharynx between the auditory
tube, above, and the upper border of the superior constrictor,
below ; afterwards the fibres of the muscle must be followed
into the -soft palate where it lies between the two layers of the
pharyngo -palatine muscle. In a well-injected subject the dissector
in 19 6

296 HEAD AND NECK

will note the terminal part of the ascending palatine branch of

the external maxillary artery descending along the levator
palati into the soft palate.

Musculi Levatores Veil Palatini. Each elevator muscle

of the soft palate is a rounded, fleshy muscle which arises from
the lower and medial border of the cartilage of the corre-
sponding auditory tube, and from the rough surface on the
under aspect of the apex of the petrous part of the adjacent
temporal bone. It passes downwards and forwards, crosses
the upper border of the superior constrictor, pierces the
pharyngeal aponeurosis, passes below the orifice of the auditory
tube, and enters the soft palate. There its fibres spread out
below the uvular muscle and above the anterior or deep
portion of the pharyngo-palatinus. Anteriorly, some of the
fibres are inserted into the palatal aponeurosis ; but more
posteriorly, the majority of the fibres become continuous
with the corresponding fasciculi of the opposite side. The
nerve supply is derived from the accessory nerve. The name
of the muscle indicates its action.

Musculi Tensores Veil Palatini. The origin of each

tensor muscle of the soft palate and the relations of its
muscular belly were noted on p. 200. The muscle descends
from the scaphoid fossa of the base of the skull along the
lateral surface of the medial pterygoid lamina, and it ends
in a tendon which turns horizontally towards the median
plane, below the hamulus, where a bursa mucosa facilitates
the play of the tendon on the bone. In the soft palate the
tendon expands below the lower layer of the pharyngo-
palatinus, and some of its fibres blend with the palatal
aponeurosis, whilst others gain attachment to the horizontal
part of the palate bone. It is supplied by the mandibular
division of the trigeminal nerve. Its name indicates its
action.

Palatal Aponeurosis. The palatal aponeurosis extends

backwards from the posterior margin of the hard palate, to
give strength and support to the soft palate. At first it
is strongly marked, but it weakens rapidly as it passes
posteriorly. The small portion of the soft palate which it
supports contains few muscular fibres, and remains always
more or less horizontal in position. The much more extensive
posterior muscular part of the soft palate constitutes the
movable sloping portion, The tensor gf the soft palate

PHARYNX 297
operates upon the anterior aponeurotic portion of the soft
palate.

Vessels and Nerves of the Soft Palate. The ascending

palatine branch of the external maxillary artery is, as a rule,
the principal artery of supply to the soft palate. It has
already been traced on the wall of the pharynx (pp. 205 and
210), where it lies in the sinus of Morgagni, in relation to the
levator veli patatini muscle, which it accompanies into the soft
palate. The palatine branch of the ascending pharyngeal
artery may also be traced into the soft palate ; in cases
where the ascending palatine artery is small, this twig becomes
enlarged and takes its place (p. 210). The descending palatine
branch of the internal maxillary artery also sends small twigs
to the soft palate and palatine tonsil.

Two nerves enter the soft palate from the spheno-palatine

ganglion viz., the posterior palatine and the middle palatine
nerve. It would appear, however, that they do not supply
the muscles, but are distributed to the mucous membrane.
The levator veli palatini, the musculus uvulae, the glosso-
palatinus, and the pharyngo-palatinus are supplied by twigs
from the pharyngeal branches of the vagus, which convey to
the muscles fibres which are originally derived from the cerebral
part of the accessory nerve (v. p. 223) (W. Aldren Turner).
The tensor veli palatini is probably supplied by the branch
which it receives from the otic ganglion, which conveys to
it. fibres originally derived from the motor part of the mandi-
bular division of the trigeminal nerve.

Tonsillse Palatinse. The palatine tonsils are two prominent

masses of lymphoid tissue, placed one in each side wall
of the pharynx, in the .triangular interval between the two
palatine arches and immediately above the pharyngeal part
of the tongue. The pharyngeal or medial surface of the
tonsil is covered with mucous membrane and presents a
number of orifices which lead into crypts or recesses in its
substance. The deep or lateral surface is embedded in the
pharyngeal wall and is supported by the superior constrictor
muscle of the pharynx (see p. 205). It is covered by a layer
of fibrous tissue which forms an incomplete capsule for the
organ. It is important to note that between the palatine
tonsil and the superior constrictor there is some lax connective
tissue, so that the tonsil can be pulled forwards by the vol-
sellum without dragging the wall of the pharynx with it.

298 HEAD AND NECK

Each palatine tonsil has a rich blood-supply. It derives

arterial twigs from the tonsillar and ascending palatine
branches of the external maxillary, the descending palatine
branch of the internal maxillary, the ascending pharyngeal,
and the dorsalis linguae of the corresponding side.

The dissectors should note that the tonsil lies at about

the level of the angle of the mandible, and that the wall of
the pharynx separates it from the external maxillary artery.
The internal and external carotid arteries also lie lateral to
the region of the tonsil, but they are further away than the
external maxillary.

Tuba Auditiva (O.T. Eustachian Tube). The auditory

tube is the canal which conveys air from the pharynx to the
tympanic cavity. It is about 25 mm. long and is divided
into two portions, according to the parts which enter into
the construction of its wall. In the lateral part of its course,
as it nears the tympanic cavity, its walls are bony, and it runs
in the interval between fhp fympanic and petrous portions
pQhe temporal bone. The medial part consists mainly of
cartilage! It is^placed on the base of the skull, and is
lodged in the gutter or groove between the petrous part of
the temporal bone and the great wing of the sphenoid. The
cartilaginous part of the tube comes under the notice of the
dissector at the present stage, and he should first note its
direction and then study its relations and the construction of
its wall.

The dissector can readily ascertain the direction of the

canal by passing a probe into it through its pharyngeal orifice.
It runs backwards and laterally, with a slight inclination up-
wards, and passes first alcove and then to the lateral side of
the elevator muscle of the soft palate, and along the medial
side of the upper part of the tensor of the soft palate. It
lies, therefore, in a considerable part of its extent, between
the two muscles (Fig. 218).

Before removing the mucous membrane from the

pharyngeal part of the tube, the dissector should note that at
the lower margin of the orifice there is a prominent rounded
eminence, the levator cushion, due to the subjacent elevator
muscle of the soft palate. The removal of the mucous
membrane will reveal the fact that the wall of the tube is
formed, in great part, by a triangular plate of cartilage, which
is folded upon itself so as to protect the tube on its upper and.

PHARYNX 299

medial aspects. The cartilage is deficient below and later-

ally, its place being taken by dense fibrous tissue, which con-
nects the margins of the cartilage and completes the wall of
the canal. The projecting free base of the cartilage gives
rise to the torus tubarius, already examined, on the side
wall of the naso-pharynx (p. 289). A muscular slip, which
descends from the lateral margin of the cartilage, in relation
to the lateral, unprotected side of the tube, has been termed
the dilatator tuba (Rudinger). It joins the tensor of the soft
palate. The interior of the tube is lined with mucous
membrane continuous with that of the pharynx and the
tympanic cavity; and its calibre varies considerably in
different parts of its course. It is narrowest at a point
termed the isthmus^ situated at the junction nf tbp nsspnns
and cartilaginous parts. As the tube is ^flc^d fmm thp>
rsthmuTtO the pharyjlXL it gradually inrrpasps in ralifrrf, anrl it
attains its greatest width at its pharyngeal aperture.
CAROTID CANAL.

The carotid canal, which traverses the petrous part

of the temporal bone, contains the internal carotid artery,
the internal carotid continuation of the cervical part of the
sympathetic trunk, and a plexus of veins.

Dissection. To open up the carotid canal, remove its inferior

wall with the bone forceps ; but do not interfere with the auditory
tube, which lies in close proximity. The dissection must be
made on one side only.

Arteria Carotis Interna. The portion of the internal

carotid artery which passes through the carotid canal in the
petrous part of the temporal bone is about 18 mm. (three-
quarters of an inch) long. At first it ascends vertically;
then, bending suddenly, it runs horizontally and forwards.
It emerges from the canal at the apex of the petrous
bone and enters the foramen lacerum, where it turns upwards,
pierces the external layer of the dura mater, and enters
the middle fossa of the skull. The remainder of the course
of the internal carotid artery has been examined already
(p. 239). Within the carotid canal it lies below and anterior
to the cochlea and the tympanic cavity. The greater super-
ficial petrosal nerve and r the. dteinilunar ganglion are placed

'. ; I

v .V-V\ wi!

mcuibAL OUIUUL

300 HEAD AND NECK

above it, but are separated from it by a thin plate of bone,

which, however, may be replaced by fibrous tissue.

Nervus Caroticus Interims. The dissector has already

noted that the internal carotid nerve is a large branch which
proceeds from the upper end of the superior cervical ganglion,
and enters the carotid canal, with the internal carotid artery.
It divides almost immediately into two parts, which are placed
one on each side of the artery. Each part soon divides into
a number of branches which communicate together, around
the internal carotid artery, forming the internal carotid plexus.
The dissection of the branches is a matter of some difficulty,
and can be satisfactorily effected only under specially favour-
able circumstances.

At the posterior end of the cavernous sinus a ganglion is

sometimes found in the plexus, and where the sixth nerve
crosses the internal carotid artery the plexus is very dense.
That part is known as the cavernous plexus. At the anterior
end of the cavernous sinus the carotid plexus breaks up into
branches which accompany the anterior and middle cerebral
arteries.
The internal carotid plexus communicates with the
tympanic plexus by means of superior and inferior carotico-
tympanic branches given off in the carotid canal, and with
the spheno-palatine ganglion by the great deep petrosal
branch, which unites with the greater superficial petrosal of
the facial nerve to form the nerve of the pterygoid canal
(O.T. Vidian). It gives branches also to the semilunar
ganglion, the third, fourth, sixth and the ophthalmic branch
of the fifth nerve, and a branch which accompanies the naso-
ciliary nerve into the orbit, where it joins the ciliary
ganglion.

NERVUS MAXILLARIS.

As the maxillary nerve passes forwards, from the semilunar

ganglion to the face, it traverses the foramen rotundum, the
upper part^f the pterygo-palatine^fossa/the pterygo-maxillary
fissure, the nifra-temporal fossa, the inferior orbital fissure, and
the infra-orbital canal. The dissector should therefore proceed
to expose the nerve in those localities.

Dissection. Remove the temporal muscle and the upper

head of the external pterygoid muscle, and, placing the saw

NERVUS MAXILLARIS

301

upon the cut margin of the skull at a point immediately above

the external meatus, carry it obliquely downwards and forwards,
through the squamous part of the temporal bone and the great
wing of the sphenoid, towards the medial end of the superior
orbital fissure. This saw-cut should enter the superior orbital
fissure immediately to the lateral side of the foramen rotundum.
A second saw-cut should then be made from the cut margin of
the cranial wall, immediately above the anterior margin of the
great wing of the sphenoid bone, downwards into the superior
orbital fissure to meet the first saw-cut. The wedge-shaped
piece of bone included between the cuts can now be removed.
To obtain additional space, and to open up the pterygp-palatine
fossa more fully, remove what remains of the great wing of the

Maxillary nerve
Ophthalmic nerve
ingeal branch of maxillary nerve - '
Sensory root

lotorroot ol v /-^~j
trigemina! // ^j7r~T
Semilunar ganglion '
Mandibular nerve

Spheno-palatine ganglio

Post, palatine ''

Middle palatine

Ant. palatine

Zygomatic nerve - Posterior superior alveolar

Infra-orbital

Zygomatico-temporal
] Zygomatico-facial

Middle superior alveolai

Anterior superior
r eolar

FIG. 113. Diagram of the Maxillary Nerve.

sphenoid upon the lateral side of the foramen rotundum, but

the circumference of that aperture must be carefully preserved.
Proceed, in the next place, to open up the infra-orbital canal.
In its posterior part its upper wall is usually so thin that it can
easily be removed by a pair of dissecting forceps, but more
anteriorly the canal sinks deeply under the lower part of the
rim of the orbital openingj and there the chisel must be employed.
The maxillary nerve can now be defined and its branches dis-
played. The infra-orbital artery and vein, which accompany
the nerve in the infra-orbital canal, will be exposed at the same
time.

Nervus Maxillaris. The maxillary nerve springs from the

semilunar ganglion, within the cranial cavity (Fig. 113). It is
composed entirely of sensory fibres, and passes forwards,
outside the dura mater and in relation to the lower part of the

302 HEAD AND NECK

cavernous sinus, to the foramen rotundum, through which it

enters the pterygo-palatine fossa. It crosses the upper part
of that fossa, curves laterally through the pterygo-maxillary
fissure into the infra-temporal fossa, and, near the middle
of the inferior orbital fissure, enters the infra-orbital canal,
where it receives the name of infra-orbital. The infra -
orbital canal traverses the floor of the orbit, which, it should
be remembered, forms the roof of the maxillary sinus
also. Finally, leaving the infra-orbital canal, the nerve
emerges upon the face through the infra-orbital foramen, and
breaks up, under cover of the quadratus labii superioris,
into numerous branches which unite with twigs from the
facial nerve to form a dense plexus. Its terminal filaments
are distributed to the lower eyelid, the nose, and the upper
lip. The course of the maxillary nerve may be separated
into five stages, in each of which branches are given off.
These are :

1. Within the cranium, . Meningeal (p. 238).

2. In the pterygo-pala- ^ _ ,

tine fossa, . . / Spheno-palatme.

3. In the infra-temporal fZygomatic (already described, p. 261).

fossa, . . . \ Posterior superior alveolar.

4. In the infra-orbital /Middle superior alveolar.

canal, . . . \Anterior superior alveolar.

( Palpebral, ^

5. In the face, . . \ Nasal, J- already described : (p. 15).

{ Labial, J

The spheno-palatine branches are two stout twigs which arise

from the inferior aspect of the maxillary nerve, and proceed
vertically downwards, in the pterygo-palatine fossa, to the
spheno-palatine ganglion, of which they constitute the sensory
roots.

The zygomatic nerve, which has already been dissected

in the orbit, can now be traced to its origin from the
maxillary nerve in the infra-temporal fossa.

Nervi Alveolares Superiores. There are usually three

superior alveolar nerves which are distinguished as posterior,
middle, and anterior. The middle superior alveolar nerve is
sometimes absent as a separate trunk, in which case its fibres
arise in common with the anterior superior alveolar branch.

The posterior superior alveolar nerve takes origin in the

infra-temporal fossa, and almost immediately divides into
two branches, which proceed downwards upon the posterior

NERVUS MAXILLARIS 303

aspect of the body of the maxilla. They contribute a few

fine filaments to the mucous membrane of the cheek and
to the gum, and then disappear* into the minute" posterior
alveolar foramina to supply the three molar teeth and the lining
membrane of the maxillary sinus.

The middle superior alveolar nerve supplies the two

premolar teeth. It arises from the infra-orbital nerve, and
can be easily detected (if present as a separate branch) when
the parent trunk is gently raised from the floor of the infra-
orbital canal. It descends in a minute canal which traverses
the lateral wall of the maxillary sinus.

The anterior superior alveolar nerve, much the largest of

the three alveolar branches, springs from the infra-orbital as it
approaches the anterior part of the canal. To bring it into
view raise the parent trunk from the floor of the canal, and
the branch will then be seen to enter a special bony tunnel
which traverses the maxilla in the anterior wall of the
maxillary sinus. The dissector should endeavour to open
up that canal with the chisel. After supplying a branch to
the mucous membrane of the lower and anterior part of
the nasal cavity, the anterior superior alveolar nerve divides
into branches for the incisor and the canine teeth.

While traversing the maxilla, the three superior alveolar

branches communicate with one another, and form two
nerve loops (Fig. 113). Numerous twigs proceed from both
loops, and they communicate with one another to form a
fine plexus. It is from that plexus that the terminal fila-
ments to the teeth and gums take origin.

Arteria Infraorbitalis. The infra - orbital artery is a

branch of the internal maxillary. It arises in the pterygo-
palatine fossa and accompanies the infra-orbital nerve. In
the face its terminal twigs anastomose with branches of the
external maxillary, transverse facial, and buccinator arteries ;
in the infra-orbital canal it gives some fine branches to the
contents of the orbital cavity, and also the anterior superior
alveolar artery which accompanies the nerve of that name,
and supplies the incisor and canine teeth, and the lining
membrane of the maxillary sinus.

The infra-orbital vein joins the pterygoid plexus.

304 HEAD AND NECK

NASAL CAVITIES.

Dissection. The portion of the mandible which still remains,

together with the tongue and larynx, must now be removed from
the upper part of the skull. From the angle of the mouth, on
each side, carry the knife backwards, through the buccinator
and the mucous membrane of the cheek, and through the pterygo-
mandibular raphe and the side wall of the pharynx. The
internal pterygoid muscle has been divided already, but it will
be necessary to cut the internal carotid artery, the smaller
vessels which are still undivided and the nerves which still
connect the pharynx with the skull. The larynx and tongue
must be laid aside for future dissection.

The anterior part of the skull should next be divided into two
parts by sawing through it, in the sagittal direction, close to
one side of the nasal septum. As a general rule the nasal
septum is not vertical, but deviates more or less to one or other
side of the median plane. The deviation is more frequently
to the right than to the left side. Endeavour to determine the
direction which it takes in the skull under observation by
passing a probe into the nasal cavity through the choanae. The
section through the skull should be made close to the concave
side of the septum. Begin anteriorly by introducing a knife
into the nostril of that side, and carry it upwards through the
cartilaginous part of the nose to the nasal bone. Then place the
specimen so that the face rests upon the table, and divide the
soft palate in the median plane. The section may now be
completed by sawing through the hard palate and bony roof of
the nasal cavity at the side of the median plane. The dissector
should make every effort to preserve the septum of the nose
intact. As a general rule the upper concha is partially injured.
That is not a very serious matter, as the lateral aspect of the
nasal cavity can be studied upon the opposite side when the
septum of the nose has been removed.

Septum Nasi. The nasal septum divides the cavity of

the nose into two narrow chambers the right and left nasal
cavities. It is not placed accurately in the median plane,
but almost invariably shows a bulging or deviation to one
or other side (more frequently to the right side). Imme-
diately above the orifice of the nostril or anterior aperture
of the nasal cavity, the septum shows a slight depression
which corresponds to the vestibule of the nose, and forms
the medial wall of that subdivision of the nasal cavity.
The vestibular part of the partition is clothed with skin,
continuous with the external integument ; a number of stiff
hairs, termed vibrissa, project from the skin into the cavity.
Over the rest of its extent the septum nasi is covered with
mucous membrane, which is closely adherent to the subjacent
periosteum forming with it a muco- periosteum and it is

NASAL CAVITIES

305

separable into two districts, viz., a lower or respiratory

area, and a much smaller upper or olfactory area, comprising
not more than the upper third of the septum, in which
branches of the olfactory nerve spread out. The respiratory
mucous membrane is very thick and spongy. It is highly
vascular and contains numerous mucous glands. The minute
orifices of the gland ducts can be detected by the naked
eye. Over the olfactory district of the septum the mucous

FrontrtTsibos

Vestibule oi
nasal cavity

Opening of
vomero-nasal organ

Sublingual gland
Mandibl

Septal^artilage

rpendicular lamina of ethmoid

Vomer

Sphenoidal air sinus

Torus tubarius

Opening of auditory
tube

Pharyngeal recess
-Pharyngeal tonsil

Anterior arch of atlas

Soft palate
Transverse ligament

Epistropheus
Epiglottis

Hyoid bone

FIG. 114. Antero-posterior section through the Nose, Mouth, and

Pharynx, a little to the left of the median plane.

membrane is softer and more delicate, and not so thick. In

the fresh state it presents a yellowish colour, and the glands
are smaller.

In favourable cases a minute orifice may be detected in the mucous

membrane on the lower and anterior part of the nasal septum, immediately
posterior to the vestibular area. It is placed above the anterior end of a
well-marked elongated projection which passes obliquely backwards and
upwards, and corresponds to the thickened lower margin of the septal
cartilage. The aperture varies in diameter from | mm. to i^ mm.
(Schwalbe). It leads into a narrow canal, which passes backwards for
a short distance, and then ends blindly. It is of interest because it
tepresents in the human subject the rudiment of the vomero-nasal organ
VOL. Ill 20

306 HEAD AND NECK

(O.T. organ of Jacob son), a tubular structure which is highly developed in

some of the lower animals.

Construction of the Nasal Septum. Strip the muco-

periosteum from the exposed surface of the septum nasi, and
the parts forming the septum will be rendered visible. The
bulk of the partition is composed of the vomer and the per-
pendicular lamina of the ethmoid posteriorly, and of the
septal cartilage anteriorly. Small portions of other bones take
a minor part in its construction. Thus, above and posteriorly
there are the crest and rostrum of the sphenoid ; above and
anteriorly are the nasal spine of the frontal bone and the crest
of the nasal bones ; whilst below there is the crest of bone
formed by the apposition of the palatal processes of the
palate and maxillary bones of opposite sides.

Cartilago Septi Nasi. The septal cartilage fills up the

wide angular gap which intervenes between the vomer and the
perpendicular lamina of the ethmoid, and it projects forwards
towards the point of the nose. It is a broad irregularly
quadrilateral plate. Its upper and posterior border is in ap-
position with the anterior border of the perpendicular lamina
of the ethmoid ; its lower and posterior border, much thickened,
is received into the groove in the anterior border of the vomer
and the nasal crest of the maxillae. The angle between the
two borders mentioned is prolonged backwards, for a varying
distance, in the form of a tongue-shaped cartilaginous process,
which occupies the interval between the two plates of the
vomer. The upper and anterior border of the septal cartilage
is in contact, above, with the suture between the two nasal
bones ; below that, it is related to the two lateral cartilages
of the nose, whilst still lower down it occupies the interval
between the medial parts of the two larger alar cartilages.

Its connection with the lateral cartilage on each side is a very intimate
one ; indeed, below the nasal bones, the three cartilages are directly
continuous, but lower down they are separated by a fissure which runs
upwards for some distance on each side. The lower and anterior border is
very short ; it is free, and extends backwards to the anterior nasal spine.
The anterior angle of the septal cartilage is blunt and rounded, and does not
reach to the point of the nose, which is formed by the alar cartilages.

The deviation of the septum nasi from the median plane will now (in all
probability) be seen to be due to a bulging of the vomer and perpendicular
lamina of the ethmoid to one side, along their line of union. It is not
developed until after the seventh year.

Dissection. The septal cartilage and thin bony part of the

septum must now be removed piecemeal. The removal must

NASAL CAVITIES 307

be done very carefully, in order to preserve intact the muco-

periosteum which clothes the opposite side of the septum. It
is in that muco-periosteum that the nerves and blood-vessels
must be examined.

Vessels and Nerves of the Septum Nasi. The following

is a list of the nerves :

Nerves of Smell, . Olfactory.

!i. Naso-palatine.
2. Medial nasal branch of the anterior eth-
moidal nerve.
3. Nasa 1 branches from spheno- palatine
ganglion and from the nerve of the
_ pterygoid canal (O.T. Vidian).

The Medial Group of Olfactory Nerves. The medial group

of olfactory nerves is associated with the muco-periosteum
of the upper part of the nasal septum and the various nerve
filaments are barely distinguishable, except in a fresh part ;
further, they are so soft that it is hardly possible to isolate
them. They proceed upwards in grooves on the surface of
the perpendicular lamina of the ethmoid, and leave the nasal
cavity through the medial series of apertures in the cribriform
plate of the same bone.

Neruus Naso-palatinus. The naso-palatine nerve is a

long slender twig which can easily be detected upon the deep
surface of the muco-periosteum of the septum. It springs from
spheno-palatine ganglion, and enters the nasal cavity through
the spheno-palatine foramen. In the first part of its course
it runs medially, upon the inferior surface of the body of the
sphenoid. Having gained the nasal septum, it changes its
direction and passes downwards and forwards, in a shallow
groove on the surface of the vomer, under cover of the muco-
periosteum. Finally, it enters the foramen of Scarpa, and,
where the two foramina of Scarpa open into the common
incisive foramen, the nerves of opposite sides unite in a plexus
from which branches are given to the mucous membrane
covering the anterior part of the hard palate. The naso-
palatine nerve is accompanied by the posterior nasal septal
artery ; and, as it lies on the surface of the vomer, it supplies
some small twigs to the muco-periosteum of the septum nasi.

A few nasal branches from the spheno-palatine ganglion, and

also from the nerve of the pterygoid canal, reach the muco-
periosteum over the superior and posterior part of the septum.
They are very minute, and it is questionable if the dissector
308 HEAD AND NECK

will be able to discover any trace of them in an ordinary

part.

The medial nasal branches of the anterior ethmoidal nerve

will be found descending over the anterior part of the nasal
septum. They may be traced as far as the vestibule.

The arteries which convey blood to the septum nasi are :

(i) the posterior nasal septal branch of the spheno-palatine
artery, which accompanies the naso-palatine nerve; (2) a
branch of the anterior ethmoidal, accompanying the medial
branches of the anterior ethmoidal nerve; (3) some minute
twigs, to the upper part of the septum, from the posterior
ethmoidal artery ; (4) the septal branch of the superior labial
artery, which is distributed to the lower and front part of the
septum.

Dissection. Disengage the naso-palatine nerve and the

medial branches of the anterior ethmoidal nerve from the surface
of the muco-periosteum of the septum, in order that, afterwards,
they may be traced to their origins. Then, with scissors, divide
the muco-periosteum along the roof ot the nasal cavity and
turn it down. When that is done, the opposite nasal cavity
will be exposed.

Cava Nasi. The nasal cavities are two chambers placed

one on each side of the septum nasi. They are narrow, but
the vertical depth and antero-posterior length of each cavity
is very considerable. The width increases somewhat from
above downwards ; thus, in the upper part, the superior
concha is separated from the septum by an interval of only
2 mm., whilst lower down a space of 4 or 5 mm. intervenes
between the inferior concha and the septum. Each nasal
cavity presents a medial wall formed by the septum, a lateral
wall, a roof, a floor, and an anterior and a posterior aperture.

The anterior apertures of the nasal cavities, or nostrils, are

two oval orifices which open upon the face and look down-
wards. The posterior apertures, or choancz, open into the naso-
pharynx and look backwards and downwards.

The narrow roof of the nasal cavity consists of a

middle, horizontal portion, formed by the cribriform plate of
the ethmoid bone, and of an anterior and a posterior sloping
part. The anterior part is formed by the narrow grooved
nasal surface of the frontal spine of the frontal bone, by the
nasal bone, and by the angle between the lateral cartilage and
the septal cartilage. The posterior part of the roof is com-
posed of the anterior and inferior surfaces of the body of the

NASAL CAVITIES
309

sphenoid, and also of the ala of the vomer, the sphenoidal

process of the palate bone, and the vaginal process of the
medial pterygoid lamina, all of which are applied to the inferior
surface of the body of the sphenoid.

The floor of the nasal cavity is of considerable width. It is

formed by the palatal processes of the maxilla and the palate
bones, and is concave from side to side. Further, it presents

Anterior
ethmoidal cell

Infuudibulum

Posterior angle of

septal cartilage

between vomer.

and perpendicular

lamina of ethmoid

Middle meatu
Middle conch

Maxillary
sinus

Inferior meatus

Inferior concha

FIG. 115. Posterior aspect of Frontal section through the Nasal

Cavities opposite the Crista Galli of the Ethmoid Bone.

The upper arrow shows the opening of an anterior ethmoidal cell into the hiatus
semilunaris. The lower arrow passes from the maxillary sinus into the hiatus
semilunaris.
a gentle antero-posterior slope, being slightly higher anteriorly
than posteriorly. On the anterior part of the floor, and close
to the septum nasi, the dissector may see a minute funnel-
shaped depression of the muco-periosteum leading into the
incisive foramen. The depression is of interest from a
developmental point of view ; for it is a vestige of the
extensive communication which existed in the embryo between
the cavities of the nose and the mouth.

3 io HEAD AND NECK

Lateral Wall of the Nasal Cavity. The lateral wall of

each nasal cavity is rendered uneven by the projection of
the three conchae (O.T. turbinal bones).

The part which the different bones take in the formation of the lateral
wall of the cavity of the nose must in the first place be studied in a
sagittal section through the macerated skull, and the dissector should
constantly refer to such a preparation during the dissection. Anteriorly, it
is formed by the lateral cartilage, the alar cartilage, the nasal bone, and the
frontal process of the maxilla. More posteriorly the lacrimal, the ethmoid,
and the inferior concha, and a portion of the body of the maxilla,
enter into its construction ; whilst still more posteriorly are the perpen-
dicular part of the palate bone and the medial pterygoid lamina of the
sphenoid. Placed in relation to the lateral aspect of the lateral wall are
the ethmoidal air-cells, which intervene between the upper part of the
nasal cavity and the orbit, whilst, at a lower level, the great air sinus
of the maxilla, the maxillary sinus, is situated immediately to the lateral
side of the nasal cavity (Fig. 115).

Turning now to the dissection, the dissector will see that

the lateral wall is separable into three areas or districts.
They are (i) the vestibule; (2) the atrium meatus medii ;
(3) the region of the conchse and the intervening meatuses.

Vestibulum Nasi. The vestibular part (Fig. 116, e, e')

of the lateral wall is a depression of a somewhat oval form
placed immediately above the aperture of the nostril. It is
partially divided into an upper and lower portion by a short
ridge, which projects forwards from its posterior boundary ;
and in the whole of its extent it is clothed by ordinary integu-
ment. From the skin a number of stout, stiff hairs, termed
vibrisscz, project (Fig. 1 1 6, 5 ). The vibrissae which spring
from the anterior part of the region incline backwards, whilst
those which are implanted into the posterior part are directed
forwards ; in that manner a sieve-like arrangement is provided
at the anterior aperture of the nose. The vestibular part of
the lateral wall is placed opposite the corresponding area on
the septum nasi, and the two together constitute an ampullated
entrance to the nasal cavity. The capacity and shape of the
vestibule are influenced to a certain extent by the contraction
of the nasal muscles.

Atrium Meatus Medii. The atrium of the middle meatus

of the nasal cavity (Fig. 116, s) is placed above, and slightly
posterior to, the vestibular district, and it receives its name from
the fact that it lies immediately anterior to the middle meatus.
It is slightly hollowed out and concave, and at its upper part,
near the nasal bone, a feeble elevation termed the agger nasi

NASAL CAVITIES

may be noticed ; the agger nasi begins close to the anterior

part of the attached margin of the middle concha, and runs
obliquely downwards and forwards. It represents an addi-
tional concha which is present in some mammals. A slight
depression above the agger nasi, which leads posteriorly to

FIG. 116. Lateral wall of the Left Nasal Cavity. (From Schwalbe.

1. Frontal air sinus.

2. Free border of the nasal bone.

3. Cribriform plate of ethmoid.

4. Sphenoidal air sinus,

5. Vibrissae.

6', 6. The two parts of the vestibular area.

7. Elevation intervening between the

vestibular district and the atrium.

8. Atrium meatus medii.

9. Agger nasi, or rudiment of an anterior

concha.
10. Concha suprema.

ir. Recessus spheno-ethmoidalis.

12. Superior concha.

13. Superior meatus.

14. Middle concha.

15. Inferior concha.

1 6. Plica naso-pharyngea.
17. Meatus naso-pharyngeus.

1 8. Orifice of auditory tube.

19. Posterior lip of auditory tube.

20. Pharyngeal recess.

21. Incisive foramen.

, l>, c. Free border of the middle concha.

the olfactory district of the lateral wall of the nasal cavity,

is the sulcus olfadorius.

Conchae (O.T. turbinal bones). Posterior to the vestibule

and the atrium are the conchae, with the intervening meatuses.
The superior concha (Fig. 116, 12), which projects from the
labyrinth of the ethmoid bone, is very short, and is placed

3 i2 HEAD AND NECK

on the upper and posterior part of the lateral wall of the

cavity. Its free border begins a little below the centre
of the cribriform plate, and passes obliquely downwards
and backwards, to a point immediately below the body
of the sphenoid, where it ends. The middle concha (Fig.
1 1 6, i 4 ) also is a part of the ethmoid. Its free border begins
a short distance below the anterior end of the cribriform
plate, and at first takes a vertical course downwards ; then,
bending suddenly, it passes backwards, and it ends midway
between the body of the sphenoid and the posterior border
of the hard palate. The inferior concha (Fig. 1 1 6, 15) is an
independent bone ; it extends backwards, upon the lateral
wall of the nasal cavity, midway between the middle concha
and the floor of the nose. Its lower free margin is some-
what convex downwards.

Meatus Nasi. The superior meatus (Fig. 1 16, i 3 ) is a short

narrow fissure between the superior and middle conchae.
The posterior ethmoidal cells open into its upper and anterior
part, by one, or, in some cases, by several apertures.

To bring the apertures into view, turn the superior concha aside,
introduce the blade of a pair of forceps under its entire length, and force
it upwards. Care should be taken not to injure the mucous membrane
more than is necessary.

The middle meatus is a much more roomy passage than

the superior meatus ; it extends backwards from the atrium,
between the middle and inferior conchae. To expose it tilt
the middle concha forcibly upwards and backwards.

The upper and anterior part of the middle meatus leads into
a funnel-shaped passage which runs upwards into the corre-
sponding frontal sinus. The passage is called the infundi-
bulum, and it constitutes the channel of communication
between the frontal sinus and the nasal cavity.

Upon the lateral wall of the middle meatus a deep curved

groove or gutter, which commences at the infundibulum and
runs from above downwards and backwards, will be seen.
The groove is termed the hiatus semilunaris (Fig. 117), and
in it are the openings of the anterior ethmoidal cells and
the maxillary sinus. The slit-like opening of the maxillary
sinus lies in the posterior part of the hiatus semilunaris.
The upper boundary of the hiatus semilunaris is prominent
and bulging. It is termed the bulla ethmoidalis. On or

NASAL CAVITIES

above the bulla is the aperture of the middle ethmoidal

cells (Fig. 117).

Dissection. Open the maxillary sinus from the lateral side,

by sawing upwards through the zygomatic process of the maxilla.
Then examine the interior of the sinus.

The orifice by means of which the great maxillary air sinus

communicates with the middle meatus lies in the medial wall
of the sinus, much nearer the roof than the floor a position
highly unfavourable for the escape of fluids which may
collect in the cavity. Sometimes, however, a second orifice,

, Frontal air sinus

- Bulla ethmoidalis '

/Orifice of middle ethmoidal cells

/Orifices of posterior ethmoidal cells

Recessus spheno-ethmoidalis
/Sphenoidal sinus

Orifice of anterior
ethmoidal cells

Hiatus semilunar

Atriun
Orifice of maxil-
lary sinus

Vestibul

Orifice of naso-lacrimal duct

Cut edge of
middle concha

Middle meatus
Pharyngeal

Orifice of
auditory tube
Salpingo-
phary ngeal fold

Soft palate

Inferior meatus

Cut edge of inferior

concha

FIG. 117. Lateral wall of Nasal Cavity and Naso-pharynx.

The three conchas have been removed.

circular in outline, will be found. If it is present it is situated

lower down, and it opens into the middle meatus, immediately
above the middle point of the attached margin of the inferior
concha.

The dissector should note that, on account of the relation-

ship of the infundibulum to the hiatus semilunaris and of the
latter to the opening of the maxillary sinus, there is a
tendency, in some cases, for the secretion of the frontal
sinuses to flow into the maxillary sinus.

The inferior meatus is the horizontal passage which lies

between the inferior concha and the floor and lateral wall

3 i4 HEAD AND NECK

of the nasal cavity. It is placed posterior to the vestibule,

and the free border of the inferior concha turns downwards
and limits it anteriorly (Fig. 117). On that account, and
because its floor slopes downwards and backwards, the in-
ferior meatus is more accessible to the current of expired
air than to the current of inspired air. In the anterior part
of the inferior meatus will be found the opening of the naso-
lacrimal duct, which conveys the tears to the nasal cavity
(Fig. 117).

Dissection. To bring the aperture of the naso-lacrimal

canal into view, remove a small portion of the anterior part of
the inferior concha with the scissors (Fig. 117).

The orifice of the naso-lacrimal duct varies in form,

according to the manner in which the mucous membrane is
arranged around it. Sometimes it is wide, patent, and circular ;
at other times the mucous membrane is prolonged over
the opening, reducing its size and acting as a flap valve to
the orifice. In some cases, indeed, the orifice may be so
minute that it is difficult to find. Its continuity with
the lacrimal sac should in all cases be established by passing
a probe, from above downwards, through the naso-lacrimal
canal (Fig. 9).

The space above and behind the superior concha is termed

the recessus spheno-ethmoidalis^ and in its posterior part is the
aperture of the sphenoidal air sinus (Fig. 117). The orifice
of the sphenoidal air sinus may be circular or slit-like, accord-
ing to the manner in which the mucous membrane is disposed
around it.

The term meatus communis is applied to the narrow cleft-

like portion of the nasal cavity which extends from the roof
to the floor between the septum medially and the conchse
laterally ; and the part of the cavity which lies posterior
to the conchal region, and between it and the choanae,
is the naso-pharyngeal meatus (Fig. 1 1 6, i 7 ).

Muco - periosteum of the Lateral Walls of the Nasal

Cavities. It has been noted that the vestibule is lined with
integument. The remainder of each lateral wall of the nasal
cavity is covered with mucous membrane which is so closely
blended with the subjacent periosteum that the two are
inseparable and form a muco-periosteum. A similar membrane
covers the roof and the floor. The muco-periosteum is
continuous, through the naso-lacrimal duct, with the ocular

NASAL CAVITIES 315

conjunctiva ; through the various apertures, with the delicate

lining membrane of the air-cells which open into the nasal
cavity, and, through the choanse, with the pharyngeal mucous
membrane. On the lateral wall, as on the septum, the
muco- periosteum is separable into an upper, olfactory, and
a lower, respiratory portion ; but the subdivision cannot be
appreciated by the naked eye, for the one district passes
into the other without any sharp line of demarcation. The
olfactory region comprises merely the region of the upper
concha ; the respiratory region includes the middle and inferior
conchae, the middle meatus, the inferior meatus, and the atrium.
On the lower part of the lateral wall the muco-periosteum
is thick and spongy, more particularly over the lower borders
and posterior extremities of the middle and inferior conchae,
where the membrane presents an irregular surface and forms
soft, bulging cushions. The spongy condition is due to the
presence of a rich venous plexus, the vessels of which run,
for the most part, in an antero-posterior direction. In the
region of the inferior concha, the veins are so numerous
that the muco-periosteum assumes the character of cavernous
tissue, and is sometimes spoken of as the "erectile body."
When turgid with blood it swells out and obliterates the
interval between the concha and the septum. The muco-
periosteum of the floor, meatuses and atrium, is smoother
than, and not so thick as, that over the conchae. Every-
where, numerous mucous glands are embedded in it, and
the minute punctiform orifices of the ducts are visible to
the naked eye. In the olfactory region the lining membrane
of the nose, in the fresh state, is of a yellowish colour, and
it is softer and more delicate than in the respiratory part.

The great vascularity of the mucous membrane of the nose

is, doubtless, for the purpose of moistening and raising the
temperature of the inspired air.

Nerves and Vessels on the Lateral Wall of the Nasal

Cavity :

Nerves of Smell, . Olfactory nerves.

Lateral nasal branches of anterior ethmoidal.

!I.
2. Nasal branch of anterior superior alveolar.
:

Nerves of Common f 3. Posterior superior nasal branches from spheno-

Sensation, . .^ palatine ganglion and from the nerve of the

pterygoid canal.

[.. Two posterior inferior nasal branches from the

anterior palatine nerve.
3 i6 HEAD AND NECK

The olfactory nerves are from twelve to twenty in number.

They are formed by numerous fine nerve filaments, which
spring from the olfactory cells of the olfactory mucous mem-
brane, and they are arranged in two groups ; a medial or septal
group, from the upper part of the septum (p. 307), and a lateral
group, from the upper third of the lateral wall of the nasal
cavity. The nerve filaments lie in the muco-periosteum, but
the nerves which they form are lodged in shallow bony
grooves and small bony canals in the walls of the nasal cavity.
At the roof of the nose the nerves pass through the foramina
in the cribriform plate of the ethmoid ; then they pierce the
meninges, from which they derive sheaths, and they end in
the lower part of the olfactory bulb of the same side.

Dissection. Follow the naso-palatine nerve, which was

exposed on the nasal septum, across the roof of the nasal cavity
to the spheno-palatine foramen in the lateral wall of the nose.
By dissecting carefully in the muco-periosteum in the neigh-
bourhood of the foramen, in a good part, the dissector may be
able to display one or more of the posterior superior nasal nerves.
At the same time he should display the spheno-palatine branch
of the internal maxillary artery which enters the nose through
the spheno-palatine foramen.

The posterior superior nasal nerves arise from the spheno-

palatine ganglion and from the nerve of the pterygoid canal.
In spite of the fact that they are minute filaments, the
dissector should endeavour to trace them to their distribution
upon the lateral wall. They enter the nose through the
spheno-palatine foramen, which is situated at the posterior
end of the superior meatus ; and are distributed to the muco-
periosteum over the upper and middle conchae, and the
posterior part of the septum.

Dissection. Make a vertical incision through the muco-

periosteum over the posterior part of the medial pterygoid
lamina, then carefully raise the membrane, reflect it forwards
and seek for the inferior nasal nerves. They both pierce the
perpendicular plate of the palate bone ; the upper one at a
point on a level with the interval between the posterior ends of
the middle and inferior conchae, and the lower at the level of
the posterior end of the inferior concha.

The inferior nasal nerves are two in number ; they both

arise from the anterior palatine nerve.

The upper of the two inferior nasal nerves emerges through

a small aperture in the perpendicular part of the palate bone,
at a point between the posterior extremities of the middle and

NASAL CAVITIES 317

inferior conchae. It divides into an ascending and descending

branch. Both run forwards ; the former on the middle
concha, the latter on the inferior concha. The lower of the
two inferior nasal nerves appears through a foramen in the
perpendicular part of the palate bone, immediately posterior
to the inferior concha, upon which it is distributed.

The anterior ethmoidal nerve (O.T. nasal] should be ex-

posed as it descends in the groove upon the deep surface of
the nasal bone (p. 252). It gives medial branches to the
septum, and lateral branches to the muco-periosteum over the
anterior part of the lateral wall, and to the anterior parts of
the middle and inferior conchse.

The main artery of supply to the nasal muco-periosteum

is the spheno-palatine, a branch of the internal maxillary. It
gains entrance to the nasal cavity through the spheno-palatine
foramen, in company with the posterior superior nasal nerves.
Its septal branch accompanies the naso-palatine nerve, whilst
others are distributed upon the lateral wall of the cavity.
Several twigs are given also by the descending palatine branch
of the internal maxillary and the two ethmoidal arteries, but
these are small and will be seen only in cases where the
injection of the subject has been unusually successful.

SPHENO-PALATINE GANGLION AND INTERNAL

MAXILLARY ARTERY.

The spheno-palatine ganglion is situated in the pterygo-

palatine fossa, on the lateral side of the spheno-palatine fora-
men ; and at this stage it can be exposed best by a dissection
from the medial or nasal side.

Dissection. The muco-periosteum has already been re-

moved from the posterior part of the lateral wall of the nasal
cavity, and the inferior nasal branches of the anterior palatine
nerve have been found piercing the perpendicular part of the
palate bone. The dissector cannot fail to notice the course
taken by the trunk from which those filaments arise. The
lamina of bone which forms the medial wall of the pterygo-
palatine canal is so thin that the nerve can be distinctly seen
through it. By carefully opening up the canal with a small
chisel, and following the anterior palatine nerve upwards, the
dissector will be led to the ganglion in the pterygo-palatine
fossa. The naso-palatine nerve should at the same time be
traced to its origin. The ganglion is so hemmed in by the bony
walls of the fossa that it is very difficult to display it thoroughly ;

318 HEAD AND NECK

but by removing the orbital process of the palate bone, and a

portion of the body of the sphenoid, with the bone forceps, the
dissector may expose it more or less satisfactorily. In the same
restricted space will be found the terminal portion of the internal
maxillary artery, from which numerous branches are given off.

Ganglion Sphenopalatinum. The spheno-palatine gang-

lion is a small, triangular flattened body, which is lodged in
the pterygo-palatine fossa. It is embedded in fat, and is
surrounded by the terminal branches of the internal maxil-
lary artery. Two stout spheno - palatine branches descend
to it from the maxillary nerve, but only some of their fibres
end in the ganglion ; the remainder are continued directly
into the nasal and palatine nerves which proceed from the
ganglion. The spheno-palatine branches may be regarded
as constituting the sensory roots of the ganglion.

From the spheno-palatine ganglion branches are given off

which radiate in four directions viz., medially, to the nose ;
downwards, to the palate ; backwards, to establish connections
with the facial nerve and carotid plexus, as well as to supply
the mucous membrane of the pharynx ; and, forwards, to the
orbit.

Medial branches, . Posterior superior nasal nerves.

( Anterior palatine.
Descending branches, -j Middle palatine.

{ Posterior palatine.

( Nerve of pterygoid canal.

Posterior branches, . -j Some lateral posterior superior nasal

{ branches.
Anterior branches, . Orbital.

From the internal maxillary artery twigs are given off

which accompany the above-mentioned nerves.

Posterior Superior Nasal Nerves. There are two groups of

the posterior superior nasal nerves, a medial and a lateral.
The medial branches pass through the spheno-palatine
foramen and across the roof of the nasal cavity to the posterior
part of the septum. The largest of them, the naso-palatine
nerve, runs downwards and forwards in a groove on the
surface of the vomer (p. 307). Some of the branches of the
lateral posterior group also pass through the spheno-palatine
foramen and are distributed to the superior meatus, to the
superior and middle conchae, and to the posterior ethmoidal
air cells. Other branches of the lateral group pass backwards,
some in the muco-periosteum of the upper and posterior part

SPHENO- PALATINE GANGLION 319

of the nasal cavity, and one in the pharyngeal canal (O.T.

pterygo-palatine or pharyngeal nerve). They are distributed
to the muco-periosteum of the posterior part of the roof of
the nasal cavity, to the adjacent parts of the wall of the
pharynx, to the sphenoidal air sinus, and to the pharyngeal
part of the auditory tube.

The descending branches are the palatine nerves, and with

them are incorporated the posterior inferior nasal nerves.
The palatine nerves are three in number, anterior (O.T. great
or posterior palatine), middle, ?.nd posterior. As a rule the
three spring, by a common trunk, from the lower aspect of
the ganglion. The trunk descends in the pterygo-palatine
canal, which has been opened up already, but to expose the
nerves a dense fibrous investment must also be removed.
The nerve-trunk will then be seen breaking up into its con-
stituent parts.

Dissection. Trace, in the first instance, the two smaller

nerves viz., the middle and posterior palatine branches. They
leave the main canal and enter the lesser palatine canals, which
conduct them through the pyramidal process of the palate bone.
It is well to secure the nerves as they emerge from the lower
openings of the canals, before opening the canals. The dissector
can readily find them by dissecting posterior to the hamulus of
the medial pterygoid lamina and gently separating the soft parts
from the under aspect of the pyramid of the palate bone. As
the dissection is being made from the medial side, the middle
palatine nerve will be first encountered, and it will be seen to
pass backwards into the soft palate, under cover of the tendinous
expansion of the tensor veli palatini. 1 The tensor must be
divided, in order that the nerve may be followed to its distribu-
tion. The posterior palatine nerve will be found issuing from
its canal a short distance to the lateral side of the preceding
nerve. It is distributed to the soft palate in the neighbourhood
of the palatine tonsil. It is smaller than the middle palatine
nerve, and is sometimes absent. The large anterior palatine
nerve should now be followed onwards to the hard palate. To
do that, open up the lower part of the pterygo-palatine canal by
removing a small portion of the posterior and lateral part of the
horizontal plate of the palate bone.

The anterior palatine nerve is the largest branch of the

spheno-palatine ganglion. It descends through the pterygo-
palatine canal, accompanied by the great palatine branch of
the internal maxillary artery ; it enters the palate through the
greater palatine foramen and runs forwards, in a groove on the

1 The present is a good opportunity to observe the corrugated or wrinkled

appearance of the tendon of the tensor, as it passes under the hamulus.

320 HEAD AND NECK

lower aspect of the hard palate, towards the incisive foramen.

It supplies the gum, the mucous membrane, and the glands
of the vault of the mouth ; and, in the neighbourhood of the
incisive foramen, it communicates with the naso-palatine
nerve. As it passes down the pterygo- palatine canal the
posterior inferior nasal branches, which were enclosed in
its sheath, leave it and enter the nasal cavity (p. 316).

Whilst tracing the anterior palatine nerve in the palate,

the dissector should note the numerous glands which are
placed under the mucous membrane of the vault of the
mouth, and the manner in which they indent the bone. 1

Dissection. The dissector will experience some difficulty

in exposing the nerves in the pharyngeal and pterygoid canals,
which are very inaccessible.

To open up the pharyngeal canal the sphenoidal process of

the palate bone must be cautiously removed with the bone forceps,
and then the dissector should proceed to open up the pterygoid
canal (O.T. Vidian), which traverses the root of the pterygoid
process. As the bone is very hard and brittle in this region, the
dissection must be effected very carefully.

The nerve of the pharyngeal canal belongs to the posterior

superior nasal group (p. 318).

Nervus Canalis Pterygoidei (O.T. Vidian}. The nerve

of the pterygoid canal is formed by a junction between the
greater superficial petrosal branch of the facial and the great
deep petrosal branch of the carotid plexus. It traverses the
pterygoid canal, and joins the posterior aspect of the spheno-
palatine ganglion, of which it may be considered to repre-
sent both the motor and sympathetic root. In the canal it
is invested by a strong fibrous envelope, and when that is
removed the nerve may sometimes be noticed to break up
into a fine plexus which surrounds the accompanying artery.
It has already been seen to give some fine filaments to the
muco-periosteum of the nose.

Rami Orbitales. The orbital branches of the ganglion

are exceedingly minute ; they pass forwards, through the
inferior orbital fissure, to supply the periosteum of the orbit.

Termination of Internal Maxillary Artery. The internal

1 An equally good method of tracing the anterior palatine nerve is to

remove the palatal processes of the palate and maxilla with the bone
forceps, and then to display the nerve and artery on the upper surface of
the mucous membrane and glands.

SPHENO-PALATINE GANGLION 321

maxillary artery breaks up into its terminal branches in the

pterygo-palatine fossa. They are

1. Posterior superior alveolar (p. 174).

2. The infra-orbital (p. 303).

3. The descending palatine.

4. The spheno-palatine.

Arteria Palatina Descendens. The descending palatine

artery is a terminal branch of the internal maxillary artery.
As it descends, in the pterygo-palatine fossa, it gives off, usually,
the artery of the pterygoid canal, and, as it enters the pterygo-
palatine canal, several small palatine arteries spring from it ;
then it becomes the great palatine artery. The great palatine
artery descends through the great palatine foramen into the
hard palate ; there it runs forwards to reach the incisive
foramen, through which it passes into the nasal cavity to
anastomose with the posterior artery of the septum, which is
an offset of the spheno-palatine artery.

The small palatine arteries spring from the descending pala-

tine, immediately before it becomes the great palatine artery,
in the upper part of the pterygo-palatine canal ; they descend
through the small palatine canals, and are distributed to the
soft palate, the palatine arches, and to the palatine tonsil.

Arteria Spheno-palatina. The spheno-palatine artery

enters the nasal cavity through the spheno-palatine foramen.
It gives off (i) a branch to the sphenoidal air sinus, (2) a
branch which passes backwards through the pharyngeal canal
(O.T. pterygo-palatine artery) to be distributed to the roof of
the posterior part of the nasal cavity and to the roof of
the pharynx; that branch anastomoses with the ascending
pharyngeal artery. Then the spheno-palatine artery divides
into lateral and septal posterior nasal branches. The lateral
branches are distributed to the lateral wall of the nasal
cavity, where they anastomose with the branches of the
posterior and anterior ethmoidal arteries, and with the lateral
nasal branch of the external maxillary. They supply not
only the muco-periosteum of the lateral wall of the nasal
cavity, but also the muco-periosteum of the air sinuses which
open into the cavity. The posterior septal branch of the
spheno-palatine artery accompanies the posterior nasal septal
nerve along the surface ot the vomer ; it anastomoses with
the great palatine artery, and with the septal branch of the
superior labial artery.

VOL. in 2]

322 HEAD AND NECK

THE LARYNX.

The portions of the mandible which are still attached,

by mucous membrane, to the sides of the tongue, should
be removed, and the dissection of the larynx should be
commenced.

General Construction and Position. The larynx is the

upper expanded portion of the wind-pipe which is specially
modified for the production of the voice. Its walls are
composed of cartilages, muscles, ligaments and membranes,
and it has an internal lining of mucous membrane. Before
proceeding with the dissection the student should study the
form and connections of the nine laryngeal cartilages in a
permanent specimen (v. p. 338).

The larynx is placed in the upper and anterior part of

the neck, where it forms a marked projection. It lies below
the hyoid bone and tongue, and is directly continuous with
the trachea inferiorly. Anteriorly it is covered by the skin
and fascise, and, on each side of the median plane, by two
thin strata of muscles viz., the sterno-hyoid and omo-hyoid ;
the sterno-thyreoid and the thyreo-hyoid. Frequently a
narrow process of the thyreoid gland, termed the pyramidal
lobe^ is continued upwards on its anterior surface. On each
side a lobe of the thyreoid gland is prolonged upwards upon
it, deep to the muscles ; and it is related to the great vessels
of the neck. Posteriorly it is in relation to the pharynx,
which separates it from the prevertebral muscles. If the
tip of the epiglottis is taken as its upper limit, the larynx, in
the adult, may be regarded as being placed anterior to that
portion of the vertebral column which extends from the lower
border of the second to the lower border of the sixth cervical
vertebra ; but the position is not fixed : it varies with the
movements of the head, and also during deglutition and
phonation.

Interior of the Larynx. The cavity of the larynx is

smaller than might be expected from an inspection of its
exterior. When its interior is examined from above, it will
be seen to be subdivided into three portions by two elevated
folds of mucous membrane which extend antero-posteriorly,
and project inwards from each side of the cavity. The upper
pair of folds are termed the plica ventriculares (O.T. false vocal
cords] ; the lower pair receive the name of the plica vocales

THE LARYNX

323

(O.T. true vocal cords}. The vocal folds are the chief agents
in the production of the voice, and the larynx is so con-
structed that changes in their relative position, and in their
degree of tension, are brought about by the action of the
muscles and the recoil of the elastic ligaments.

Vestibulum Laryngis. The vestibule is the upper sub-

division of the laryngeal cavity (Figs, in, 119); it extends
from the superior
aperture (aditus
laryngis) of the
larynx down to the
ventricular folds.
Its lower part

Epiglottis

Hyoid bone

is
compressed from

Side tO Side. ItS Ary-epiglottic fold

width, therefore,

diminishes from Tubercle of epiglottis

above downwards,
whilst, owing to the
obliquity of the
aditus, the anterior
wall is longer than
the posterior. The
anterior wall is
formed by the pos-
terior surface of
the epiglottis and
the thyreo-epiglot-
tic ligament, both
covered with
mucous membrane.
It descends ob-
liquely from above

downwards and slightly forward and becomes narrower as it

approaches the anterior ends of the ventricular folds. Each
side wall of the vestibule is formed by the medial surface of
a fold of mucous membrane called the ary-epiglottic fold.
For the most part it is smooth and slightly concave, but in its
posterior part the mucous membrane bulges medially, in the
form of two vertical elevations, placed one posterior to the
other. The anterior elevation is formed by the enclosed
cuneiform cartilage and a mass of glands associated with it ;

Thyreoid cartilage

Plica ventricularis
Ventricle of larynx

Plica vocalis

Musculus vocalis -

Cricoid cartilage

FIG. 1 1 8. Frontal section through the Larynx,

to show the Compartments.
324 HEAD AND NECK

the posterior elevation is due to the anterior margin of the

arytaenoid cartilage and the corniculate cartilage. A shallow
groove descends between the two elevations; it terminates
below by running into the interval between the ventricular
and the vocal folds. The posterior wall of the vestibule .is
narrow. It is formed by the mucous membrane which
covers the anterior surface of the arytaenoideus muscle and
it occupies the interval between the two arytsenoid cartilages.

The aditus laryngis has already been examined, in the

dissection of the pharynx (p. 291). The parts which bound
it should again be carefully studied.

The epiglottis projects upwards, posterior to the median

thyreo-hyoid ligament, the hyoid bone and the base of the
tongue. Its lingual or anterior surface is free in the upper part
of its extent only, and is attached to the pharyngeal part of
the tongue by a prominent median fold of mucous mem-
brane, termed the glosso-epiglottic fold. Two lateral folds are
also present ; they connect its margins with the walls of
the pharynx at the side of the tongue, and are called the
pharyngo-epiglottic folds. Between the two layers of mucous
membrane which constitute each of the three folds, there is a
small amount of elastic tissue. The depression on each side,
between the tongue and the epiglottis, which is bounded
by the glosso-epiglottic and a pharyngo-epiglottic fold is
termed a vallecula (Fig. 119). The posterior free surface of
the epiglottis forms the greater part of the anterior boundary
of the vestibule of the larynx. The upper part of this surface
is convex, owing to the manner in which the upper margin
is curved towards the tongue ; below the convexity there is a
slight concavity, and still lower there is a marked bulging,
over the upper part of the thyreo-epiglottic ligament. The
last projection is called the tubercle of the epiglottis ; it is a con-
spicuous object in laryngoscopic examinations of the larynx.

Each ary-epiglottic fold of mucous membrane encloses

between its two layers some connective tissue, the ary-
epiglottic muscle, and, posteriorly, the cuneiform cartilage,
and the corniculate cartilage, which surmounts the arytaenoid
cartilage. As already mentioned, the two small nodules of
cartilage produce elevations on the medial layer of the
posterior part of the ary-epiglottic fold, which are easily seen
when the larynx is examined with the laryngoscope.

The Middle Subdivision of the Laryngeal Cavity (Fig. 1 1 8)

THE LARYNX 325

is the smallest of the three sections. It is bounded by the

ventricular folds, above, and by the vocal folds below ; it
communicates with the vestibule above, and with the inferior
compartment of the larynx below.

Plicae Ventriculares (O.T. false Vocal Cords). The ventri-

cular folds are two prominent mucous folds which extend,
antero-posteriorly, across the side walls of the laryngeal cavity.
They are soft and somewhat flaccid, and their free borders
are slightly arched, with the concavities looking downwards.
Each fold contains (i) a ventricular ligament; (2)
numerous glands, which are aggregated chiefly in its middle
part ; and (3) a few muscle fibres. The interval between the
ventricular folds is termed the rima vestibuli\ it is consider-

Base of tongue

Tubercle
Plica vocalis

Cuneiform tubercle'

Corniculate tubercle

Fic. 119. The Larynx as seen in the living person by means of the
Laryngoscope.

ably wider than that between the vocal folds. It follows,

therefore, that the four folds are distinctively visible when the
cavity of the larynx is examined from above, but the vocal
folds alone can be seen when the cavity is examined from below.
Plica Vocales (O.T. True Vocal Cords). The vocal folds are
placed below the ventricular folds, and extend from the angle
between the lamina of the thyreoid cartilage, anteriorly, to the
vocal processes of the arytsenoid cartilages, posteriorly. Each
vocal fold is sharp and prominent, and its mucous membrane is
thin and is firmly bound down to the subjacent vocal ligament.
In colour it is pale, almost pearly white, whilst, posteriorly,
the point of the vocal process of the arytaenoid cartilage,
which stands out in relief, presents a yellowish tinge. In
frontal section each vocal fold is somewhat prismatic in form,
and the free border looks upwards and medially (Fig. 118).
in 21 6

326

HEAD AND NECK

The vocal folds are the agents by means of which the voice
is produced. The ventricular folds are of little importance
in that respect ; indeed, they can be destroyed, in great part,
without any appreciable effect upon the voice.

The rima glottidis is the elongated fissure by means of

which the middle compartment of the larynx communicates
with the lower subdivision. It is placed somewhat below

the middle of the

ligament ^ * B *

which it constitutes
the narrowest part.
Anteriorly, it is the
interval between the
vocal folds ; pos-
teriorly, it is the in-
terval between the
bases and vocal
processes of the
arytaenoid cartilages
(Fig. 121). It is
composed, there-
fore, of two very
distinct parts (i)
a narrow, anterior
portion, between
the vocal folds, in-
volving less than
two - thirds of its
length, and called
the pars intermem-
branacea ; (2) a
broader, shorter
portion, between
the arytaenoid cartilages, termed the pars inter cartilagima.
The form of the rima glottidis undergoes frequent alterations
in the living person. During ordinary quiet respiration it
is lanceolate in outline, and the intermembranous part has
the form of an elongated triangle, with the base directed
backwards. When the rima glottidis is widely opened the
broadest part of the cleft lies between the extremities of the
vocal processes of the arytaenoid cartilages, and there each
side of the rima presents a marked angle. The two vocal

Cartilage of epiglottis
Fatty pad
Thyreo-hyoid membrane

Thyreoid cartilage

Elevation produced by
, cuneiform cartilage
Ventricular fold

Philtrum ventriculi
Elevation produced
by arytaenoid cartilage
Laryngeal ventricle

Vocal fold

M. arytaenoideus

Processus vocalis

_ Lamina of
cricoid cartilage
Arch of
cricoid cartilage

FIG. 1 20. Median section through the Larynx,

to show the Side Wall of its Right Half. .

THE LARYNX 327

folds may, on the other hand, be approximated so closely to

each other, as when a high note is sung, that the inter-
membranous part is reduced to a linear chink. The length
of the entire fissure differs considerably in the two sexes.
In the male its average length is 23 mm. ; in the female,
17 mm.

In the side wall of the larynx, in the interval between the

ventricular and the vocal folds, there is a pocket-like depression
or recess, termed the ventriculus laryngis (O.T. laryngeal sinus).

Thyreoid cartilage

Vocal ligament

Rima glottidis

Vocal process of
_ arytaenoid cartilage
Arytaenoid
cartilage

FIG. 121. Diagram of the rima glottidis.

A. During ordinary easy breathing. B. Widely open.

The dissector should endeavour to gauge the extent of

the ventricle, by means of a probe bent at the extremity.
The recess passes upwards, undermining the ventricular fold,
and its mouth or orifice is narrower than its cavity. Under
cover of the anterior part of the ventricular fold a slit-like
aperture will be detected. It leads into the appendix
ventriculi (O.T. laryngeal saccule), a small diverticulum, which
ascends between the ventricular fold and the lamina of
the thyreoid cartilage. The appendix is of variable extent,
but, as a rule, it ends blindly at the level of the upper border
of the thyreoid cartilage,
in 21 c

328 HEAD AND NECK

Distend the ventricle, and, if possible, the appendix, with cotton

wadding. This will greatly facilitate the subsequent dissection.

The Lowest Subdivision of the Laryngeal Cavity (Fig. 1 18)

leads directly downwards into the trachea. Above, it is narrow
and compressed from side to side, but it gradually widens out
until in its lowest part it is circular. It is bounded by the
mucous membrane which covers the sloping medial surface
of the conus elasticus, and the inner aspect of the cricoid
cartilage. It is through the anterior wall of the lowest
compartment of the larynx that the opening is made in the
operation of laryngotomy.

Mucous Membrane of the Larynx. The mucous

membrane of the larynx is continuous, above, with that lining
the pharynx, and below, with the mucous lining of the
trachea. Over the laryngeal or posterior surface of the
epiglottis it is closely adherent, but elsewhere, above the level
of the vocal folds, it is attached loosely by submucous
tissue to the adjacent structures. As it passes over the
vocal folds it is very thin and tightly bound down, and in
inflammatory conditions of the larynx, attended with oedema,
that attachment usually prevents the infiltration of the sub-
mucous tissue from extending downwards below the rima
glottidis.

The mucous membrane of the larynx has a plentiful supply

of racemose glands which secrete mucus, but over the surface
of the vocal folds they are completely absent.

Dissection. Place the larynx upon a block so that its anterior

surface looks upwards, and fix it in that position with pins.
The branches which the external laryngeal nerve gives to the
crico-thyreoid muscle should in the first place be followed out ;
and, carefully preserving the superior and inferior laryngeal
vessels and the internal and inferior laryngeal nerves, the
dissector should in the next place proceed to remove the thyreoid
gland, and the omo-hyoid, sterno-hyoid, sterno-thyreoid, and
thyreo-hyoid muscles. The fibres of origin of the inferior
constrictor muscle also should be taken away from the thyreoid
and cricoid cartilages. The thyreo-hyoid membrane, the crico-
thyreoid ligament, and the crico-thyreoid muscles are now
exposed, and their attachments may be defined.

Membrana Hyo-thyreoidea. The thyreo-hyoid membrane

is a broad membranous sheet, which occupies the interval
between the hyoid bone and the thyreoid cartilage. It is not
equally strong throughout, but shows a central thick portion,
the median thyreo-hyoid ligament^ largely composed of elastic
THE LARYNX

329

Crico-thyreoid ligament

fibres, and cord-like right and left margins, the lateral thyreo-
hyoid ligaments, whilst in the intervals between the central
part and the lateral margins it is thin and weak. The median
ligament is attached, above, to the posterior aspect of the
upper margin of the body of the hyoid bone ; below, it is fixed
to the sides of the deep median notch on the upper border of
the thyreoid cartilage. The upper part of its anterior surface,
therefore, lies behind the hollowed-out posterior surface of
the body of the hyoid bone ; a mucous bursa is interposed
between them, and in certain movements of the head and
larynx the upper border
of the thyreoid cartilage
is allowed to slip up-
wards behind the hyoid
bone. On each side of
the strong central part,
the thy reo- hyoid mem-
brane is attached, below,
to the upper margin of
the lamina of the thyreoid
cartilage, and, above, to
the deep aspect of the
greater cornu of the
hyoid bone. It is pierced
by the internal laryngeal
nerve and superior laryn-
geal vessels. The lateral

FIG. 122. The Crico-thyreoid Muscle.

thyreo - hyoid ligament,

which forms the pos-
terior border of the membrane, on each side, is rounded and
cord-like, and is composed chiefly of elastic fibres. It extends
from the tip of the greater cornu of the hyoid bone to the
extremity of superior cornu of the thyreoid cartilage. In it
there is usually developed a small, oval cartilaginous or bony
nodule, termed the cartilago triticea (Fig. 127).
Musculus Crico-thyreoideus. Each crico-thyreoid muscle
is placed on the corresponding side of the cricoid cartilage,
and bridges over the lateral portion of the crico-thyreoid
interval. It takes origin from the lower border and outer
surface of the arch of the cricoid cartilage, whence its fibres
spread out in an upward and backward direction, and are
inserted into the inner aspect of the lower margin of the

330 HEAD AND NECK

thyreoid lamina, and also into the anterior border of its

inferior cornu. As a general rule, it is divided into two parts.
The anterior or straight part is composed of those fibres which
are attached to the lamina of the thyreoid cartilage ; the
posterior or oblique part is formed of those fibres which are
inserted into the inferior cornu of the thyreoid cartilage. It
is closely associated with the origin of the inferior constrictor
muscle. The crico-thyreoid muscle is supplied by the ex-
ternal laryngeal branch oi the superior laryngeal nerve. The
crico-thyreoid muscles are the chief tensors of the vocal
ligaments.

Conus Elasticus. Extending upwards, from the upper

border of the anterior and lateral parts of the cricoid cartilage
to the thyreoid and arytaenoid cartilages, is a strong elastic
membrane, the conus elasticus, which is separable into a
median and two lateral parts. The median part is the crico-
thyreoid ligament, which extends from the upper border of the
anterior part of the cricoid arch to the lower border of the
thyreoid cartilage. Each lateral part (O.T. lateral part of
crico-thyreoid membrane) runs upwards and medially and
terminates in a free, thickened border, called the ligamentum
vocale, which lies in the substance of the plica vocalis, and is
attached, posteriorly, to the vocal process of arytaenoid, and,
anteriorly, to the angle of union of the two laminae of the
thyreoid cartilage. The inner surface of the conus elasticus
is covered with the mucous membrane of the lowest section of
the cavity of the larynx, and the outer surfaces of the lateral
parts are in relation with the lateral crico-arytaenoid and the
thyreo-arytaenoideus muscles (Fig. 118).

Dissection. The position of the larynx must now be reversed.

Fix it upon the block in such a manner that its posterior aspect
is directed upwards. The oesophagus should then be slit open
by a median incision through its posterior wall. Next, remove
the mucous membrane which covers the posterior aspect of the
cricoid and arytaenoid cartilages. Whilst doing that, bear in
mind that the inferior laryngeal artery and the inferior laryngeal
nerve pass upwards, between the thyreoid and cricoid cartilages,
and must be preserved.

Upon the posterior aspect of the broad lamina of the cricoid

cartilage the dissector will now note the two posterior crico-
arytaenoid muscles, and the attachment of the tendinous band
through which the longitudinal fibres of the oesophagus are
fixed to the cricoid cartilage. The band takes origin from the
prominent median ridge on the posterior aspect of the cricoid
cartilage. ' On the posterior surface of the arytaenoid cartilages,

THE LARYNX

and bridging across the interval between them, are the transverse
and oblique parts of the arytaenoid muscle. Especial care must
be taken whilst that muscle is being cleaned, in order that the
connections of the superficial decussating fibres may be ascer-
tained fully.

The lateral layer of the left ary-epiglottic fold of mucous

membrane should now be cautiously removed, to expose the ary-
epiglottic muscle, the cuneiform cartilage, and the corniculate
cartilage of that side. This is perhaps the most difficult part of
the dissection, because the dissector has to establish the con-
tinuity of the sparse fibres, which compose the pale ary-epiglottic
muscle, with the decussating fibres of the arytaenoid muscle
(Fig. 123).

Epiglottis
/A Greater cornu of hyoid

Pr

"T "Ary-epiglottic fold

i > 4--Cartilago triticea

T - Thyreo-hyoid membrane

.-Tliyreoid cartilage

Union of oblique arytaenoi-

deus and ary-epiglotticus
M. arytaenoideus transversus

M. cricoarytaenoideus
posterior

Median ridge of cricoid

lamina

Cartilage ring of trachea

- Muscular part of trachea

FIG. 123. Muscles of the Posterior Aspect of the Larynx.

Musculus Crico-arytsenoideus Posterior. Each posterior
crico-arytaenoid muscle is somewhat fan-shaped (Fig. 123).
It springs, by a broad origin, from the depression which marks
the posterior surface of the cricoid cartilage, on the correspond-
ing side of the median ridge, and its fibres converge to be
inserted into the posterior surface of the muscular process or
projecting lateral angle of the base of the arytaenoid cartilage.

As the fibres pass from origin to insertion, they run with

different degrees of obliquity. The uppermost fibres are

332 HEAD AND NECK

short and nearly horizontal ; the intermediate fibres are the

longest, and are very oblique; whilst the lowest fibres are
almost vertical in their direction. The posterior crico-
arytsenoid muscles are abductors of the vocal folds. They
are supplied by the inferior laryngeal nerves.

Musculus Arytaenoideus. The arytasnoid muscle consists

of two portions a superficial part, termed the arytcenoideus
obliquus, and a deeper layer, called the arytcenoidens transversus.

Epiglottis'
Lesser cornu of hyoid bone

Body of hyoid bone -

Lamina of thyreoid f

cartilage r

Musculus vocalis

M. cricoarytaenoideus lateralis

M. cricoarytsenoideus posterior

Crico-thyreoid ligament

Trachea ..

FIG. 124. Side view of the Muscles of the Larynx. The fibres passing
backwards and upwards from the upper border of the musculus vocalis
are the fibres of the thyreo-epiglotticus. They blend above with the
ary-epiglotticus.

The aryt&noideus obliquus is composed of two bundles of

muscular fibres, each of which springs from the posterior aspect
of the muscular process of the corresponding arytgenoid
cartilage (Fig. 123). From those points the two fleshy slips
proceed upwards and medially, and cross each other in the
median plane like the limbs of the letter X. Some of the
fibres are inserted into the summit of the arytsenoid car-
tilage of the opposite side, but the greater proportion
are prolonged, round the base of the corniculate cartilage,

THE LARYNX 333

into the ary-epiglottic fold. There they receive the

name of the ary-epiglotticus muscle, and, as they approach
the epiglottis, they are joined by the fibres of the thyreo-
epiglotticus muscle. The oblique arytaenoid muscles may
be considered as constituting a weak sphincter muscle
for the superior aperture of the larynx. Each bundle
starts from the base of one of the arytaenoid cartilages and is
prolonged into the ary-epiglottic fold of the opposite side,
and onwards, along the fold, to the margin of the epiglottis.

The arytcenoideus transversus is an unpaired muscle. It is

composed of transverse fibres which bridge across the interval
between the two arytaenoid cartilages and are attached to
the posterior aspect of the lateral border of each arytaenoid
cartilage. Many of the fibres turn round the arytaenoid
cartilage and become continuous, on each side, with the fibres
of the thyreo-arytaenoid muscle. Both groups of fibres are
supplied by the inferior laryngeal nerves. The oblique
fibres form "a weak sphincter of the superior laryngeal
aperture. The transverse fibres adduct the arytaenoid
cartilages and abduct the vocal folds.

Dissection. The further dissection of the laryngeal muscles

should be confined to the left side of the larynx. The right
side should be reserved for the study of the nerves and vessels.
Place the larynx on its right side, and, having fixed it in that
position, remove the left crico-thyreoid muscle. The left
lateral part of the thyreo-hyoid membrane should next be
divided, and the left inferior cornu of the thyreoid cartilage
disarticulated from its facet on the side of the cricoid cartilage.
An incision should now be made through the left lamina of the
thyreoid cartilage, a short distance to the left side of the median
plane, and the detached piece must be carefully removed. Three
muscles are now exposed, and must be cleaned. They are
named, from below upwards :

1. The lateral crico-arytaenoid.

2. The thyreo-arytaenoid.

3. The thyreo-epiglotticus.

Musculus Crico-arytsenoideus Lateralis. Each lateral

crico-arytaenoid muscle is triangular in form, and smaller
than the posterior crico-arytaenoid (Fig. 124). It springs
from the upper border of the arch of the cricoid cartilage,
extending to the facet on the lamina which supports the
base of the arytaenoid cartilage; a few of its fibres take
origin from the conus elasticus also. From its lower attach-
ment its fibres run backwards and upwards, and converge

334 HEAD AND NECK

to be inserted into the anterior surface of the processus

muscularis of the arytaenoid cartilage. The superficial or
lateral surface of the muscle is covered by the lamina of the
thyreoid cartilage and the upper part of the crico-thyreoid
muscle; its deep surface is applied to the conus elasticus.
The lateral crico-arytomoid muscles are supplied by the
inferior laryngeal nerves. They are adductors of the vocal
folds.

Musculus Thyreo-arytsenoideus (O.T. Thyro-arytenoideus

Externus). Each thyreo-arytaenoid muscle springs from the
angle of union of the two laminae of the thyreoid carti-
lage, in close association with the vocalis. Its fibres pass
backwards, and are inserted into the lateral surface of the
arytaenoid cartilage. It protracts the arytaenoid cartilage,
and adducts and relaxes the vocal fold. It is supplied by the
inferior laryngeal nerve.

Dissection. The lateral crico-arytsenoid muscle should now

be carefully removed, and at the same time the dissector should
endeavour to disengage the fibres of the thyreo-arytaenoideus
from the deeper musculus vocalis, in order that the relation of
the vocalis to the vocal ligament may be studied. Finally,
remove the musculus vocalis. When the muscles are removed,
the lateral surface of the conus elasticus, the vocal ligament,
and the wall of the laryngeal ventricle will be displayed. By
carefully dissecting between the two layers of mucous membrane
which form the ventricular fold, the dissector may find the weak
ventricular ligament, which supports the fold, as well as a
number of racemose glands which lie in relation to it.

Musculus Thyreo - epiglotticus. Each thy reo - epiglottic

muscle springs from the thyreoid cartilage, immediately above
the corresponding musculus vocalis, with the upper border of
which it is more or less blended. Its fibres run backwards
and upwards, into the ary-epiglottic fold, where they blend
with the ary-epiglotticus, and they are inserted into the edge
of the lower half of the epiglottis. The thyreo-epiglottic
muscles depress the epiglottis. They are supplied by the
inferior laryngeal nerves.

Musculus Vocalis. Each musculus vocalis is a sheet of

muscular fibres which springs, anteriorly, from the angle of
union of the two laminae of the thyreoid cartilage. It runs
backwards, along the ligamentum vocale and the upper part of
the conus elasticus, and is inserted into the lateral surface
of the vocal process and the anterior surface of the body
of the arytaenoid cartilage. Its lower fibres blend with the

THE LARYNX

335

upper margin of the lateral crico-arytsenoid muscle, and the

medial fibres, which run along and to a certain extent are
attached to the ligamentum vocale, 1 form a bundle, triangular
in frontal section, to which the term internal thyro-arytaenoid
muscle was formerly applied. The vocalis muscles protract
the arytaenoid cartilages, and adduct and relax the vocal
folds. They are supplied by the inferior laryngeal nerves.

Ligamentum Vocale. There are two vocal ligaments,

right and left. Each is the thickened free upper border of

Epiglottis -

Ary-epiglotticus

Tubercle of epiglottis

Ventricular fold V

Ventricle of larynx - \

Vocal fold

Musculus vocalis

M. cricoarytaenoideus lateralis'

M. cricothyreoideus
Cricoid cartilage

FIG. 125. Frontal section of Larynx, showing Muscles.

the corresponding lateral part of the conus elasticus, and it

constitutes the support of the vocal fold. Anteriorly^ it is
attached, close to its fellow of the opposite side, to the
middle of the angular depression between the two laminae of
the thyreoid cartilage. Posteriorly -, it is attached to the tip
and upper border of the processus vocalis, which projects for-
wards from the base of the arytaenoid cartilage. The vocal liga-
ment is composed of yellow elastic fibres. Its medial border
is sharp and free, and is clothed with mucous membrane,

1 The fibres which are attached to the ligamentum vocale are called
collectively the ary-vocalis muscle.

336

HEAD AND NECK

which is thin and firmly bound down to the ligament. Em-

bedded in its anterior extremity there is a minute nodule of
condensed elastic tissue, called the sesamoid cartilage.

Dissection. By removing the mucous membrane in the

region of the rima glottidis and the laryngeal ventricle a good
view of the parts which bound the rima will be obtained
viz., anteriorly, the angle of the thyreoid cartilage ; posteriorly,
the arytaenoideus trans versus muscle ; on each side, the vocal

ligament, the

Arytaenoid cartilage P r . C e S S U S

vocalis, and the

medial surface
of the arytaen-
oid cartilage
(P- 343). They
are all clothed
with the lining
mucous mem-
brane of the
larynx.

Muscular process of
arytaenoid cartilage

Vocal process of
arytaenoid cartilage

Rima glottidis

Vocal ligament
Lateral part of
conus elasticus
Facet for inferior
cornu of thyreoid
cartilage
Cricoid cartilage

FiG. 126. Conus elasticus. The right lamina of

the thyreoid cartilage, etc., have been removed.

Ligamentum
Ventriculare.
The feeble ven-
tricular ligaments
support the ven-
tricular folds.
Each is weak and
indefinite, but
somewhat longer
than the corre-
sponding vocal
ligament. Anteriorly, each ventricular ligament is attached
to the angular depression between the two laminae of the
thyreoid cartilage, above the vocal fold and immediately below
the attachment of the thyreo-epiglottic ligament ; and it
extends backwards to a tubercle on the lateral surface of the
arytaenoid cartilage above the processus vocalis. It is com-
posed of connective tissue and elastic fibres, which are con-
tinuous with the fibrous tissue in the ary-epiglottic fold.

Dissection. Remove the remains of the ary-epiglottic fold,

the ventricular and the vocal folds, and the lateral part of the
conus elasticus, on the left side of the larynx, but be careful not
to injure the arytsenoid cartilage or the corniculate cartilage.
If the cuneiform cartilage is present in the ary-epiglottic fold
it should be detached and preserved. By this dissection a good
view of the side wall of the laryngeal cavity can be obtained.

THE LARYNX 337

The undissected vocal fold of the right side should be examined

again ; the laryngeal ventricle and appendix should be explored,
and their precise connections and extent determined. When
the dissector has satisfied himself about those points he can
proceed to display the vessels and nerves of the larynx. The
superior laryngeal artery and the internal laryngeal nerve reach
the pharynx by piercing the lateral thin part of the thyreo-hyoid
membrane, and they descend, along the lateral wall of the
recessus piriformis, to the larynx. By applying traction to the
nerve, and at the same time dividing the mucous membrane
upon the medial surface of the thyreo-hyoid membrane, the
dissector can easily find the nerve and artery. As the branches
into which they divide are followed, the mucous membrane
must be gradually removed from the wall of the larynx. The
inferior laryngeal artery and nerve enter from below and proceed
upwards, under cover of the lamina of the thyreoid cartilage.
They can be satisfactorily displayed only by the removal of that
piece of cartilage, but the dissector is not recommended to adopt
the method suggested unless another larynx is available for the
examination of the cartilages and joints. If the thyreoid cartilage
is drawn laterally the more important branches can be studied.

Ramus Interims Nervi Laryngei Superioris. In the dissec-

tion of the neck the internal laryngeal nerve of each side was
seen springing from the superior laryngeal branch of the
corresponding vagus. It is a sensory nerve, and its branches
are distributed chiefly to the mucous membrane of the
larynx. After piercing of the thyreo-hyoid men.brane, it
divides into three branches. The uppermost of the three
sends filaments to the ary-epiglottic fold, to the mucous
membrane which covers the epiglottis, to the folds anterior
to it, and to the lower and middle part of the back of
the tongue. The twigs which go to the epiglottis ramify
on its posterior surface, but many of them pierce the cartilage
to reach the mucous membrane on its anterior surface. The
middle branch of the internal laryngeal nerve breaks up into
filaments which are given to the mucous membrane lining
the side wall of the larynx. The lowest branch descends and
gives filaments to the mucous membrane on the lateral and
posterior aspects of the arytaenoid and cricoid cartilages.
It also gives off a fairly large twig which runs downwards
upon the posterior aspect of the cricoid cartilage to join the
laryngeal branch of the recurrent nerve.

Nervus Recurrens. Each recurrent nerve has previously

been seen arising from the corresponding vagus, and it has
been traced, in the neck, up to the point where it disappears
under cover of the lower border of the inferior constrictor
muscle and becomes the inferior laryngeal nerve, which ascends

VOL. Ill 22

338 HEAD AND NECK

upon the lateral aspect of the cricoid cartilage, immediately

posterior to the crico-thyreoid joint. There it is joined by
the communicating twig from the internal laryngeal nerve, and
almost immediately afterwards it divides into two branches.
The forger of the two proceeds upwards, under cover of the
lamina of the thyreoid cartilage, and breaks up into filaments
which supply the lateral crico-arytsenoid, the thyreo-arytsenoid,
the vocalis and the thyreo-epiglottic muscles; the smaller or
posterior branch inclines upwards and backwards, upon the
posterior aspect of the cricoid cartilage, and under cover of
the posterior crico-arytsenoid muscle. It supplies twigs to
that muscle, and is then continued onwards to end in the
arytaenoid muscles.

The inferior laryngeal nerve is, therefore, the motor nerve

of the larynx. It supplies all the muscles, with the exception
of the crico-thyreoid, which obtains its nerve-supply from the
external laryngeal. The inferior laryngeal nerve, however,
contains a few sensory fibres also. Those it gives to the
mucous membrane of the larynx below the rima glottidis.

Laryngeal Arteries. The superior laryngeal artery, a

branch of the superior thyreoid, accompanies the internal
laryngeal nerve ; the inferior laryngeal artery, which springs
from the inferior thyreoid, accompanies the inferior laryngeal
nerve. The two vessels ramify in the laryngeal wall and
supply the mucous membrane, glands, and muscles.

Laryngeal Cartilages and Joints. The cartilages which

constitute the skeleton of the larynx and give support to its
wall are the following :

i. Thyreoid, 1 4 _ Arytgenoid> >

3. Carnage of the \ sin le ' |- Consulate, paired,

epiglottis, J 6 " Cuneiform,

They are connected by certain ligaments.

Dissection. The mucous membrane and muscles must be

carefully removed from the cartilages, and the ligaments must
be defined. Exercise great caution while cleaning the arytaenoid
cartilages and the corniculate cartilages, in order that the latter
may not be injured.

Cartilage Epiglottica. The epiglottic cartilage is a thin,

leaf-like lamina of yellow nbro-cartilage which is placed posterior
to the tongue and the body of the hyoid bone, and anterior
to the upper aperture of the larynx. When divested of the

THE LARYNX 339

mucous membrane which covers it posteriorly and also, to

some extent, anteriorly, the epiglottic cartilage has the form
of an obovate leaf; it is indented by pits, and shows
numerous perforations. In the pits glands are lodged, and
through the foramina vessels and, in some cases, nerves
pass. The broad end of the cartilage is directed upwards,
and is free; its lateral margins are to a large extent enclosed
within the ary-epiglottic folds. The anterior surface is free
only in its upper part. That part is covered with mucous
membrane, and looks towards the tongue. The posterior
surface is covered, throughout its whole extent, with the
mucous membrane of the larynx. The pointed lower end
of the cartilage is called the petiolus, and is connected by a
stout fibrous^lDand, termed the thyreo-epiglottic ligament, to
the angle between the laminae of the thyreoid cartilage.

Epiglottic Ligaments. - - The epiglottis is bound by

ligaments to the base of the tongue, to the side wall of the
pharynx, to the hyoid bone, and to the thyreoid cartilage.
The glosso-epiglottic fold and the two pharyngo-epiglottic folds
have been studied already. In each there is a small quantity
of elastic tissue. The hyo -epiglottic ligament is a short,
broad elastic band which connects the anterior face of the
epiglottis to the upper border of the body of the hyoid bone.
The thyreo-epiglottic ligament is strong, elastic, and thick. It
proceeds downwards, from the lower pointed extremity of the
epiglottis, and is attached to the angular depression between the
two laminae of the thyreoid cartilage, below the median notch.

The triangular interval which is left between the lower

part of the cartilage of the epiglottis and the median part of
the thyreo-hyoid membrane contains a pad of soft fat, and it
is imperfectly closed above by the hyo-epiglottic ligament.

Cartilage Thyreoidea. The thyreoid cartilage is the

largest of the laryngeal cartilages. It is composed of two
broad and somewhat quadrilateral plates, termed the lamina,
which meet anteriorly at an angle, and become fused along
the median plane. Posteriorly, the laminae diverge from each
other and enclose a wide angular space. The anterior borders
of the laminae are fused only in their lower parts. Above, they
are separated by a deep, narrow V-shaped notch, called the
incisura thyreoidea superior. In the adult male, the angle formed
by the meeting of the anterior borders of the two laminae,
especially in the upper part, is very projecting ; and, with the

340

HEAD AND NECK

margins of the superior thyreoid notch, which lies above, it

constitutes a marked subcutaneous prominence in the neck,
which receives the name of the laryngeal prominence (O.T.
pomum Adami). The posterior border of each lamina is thick
and rounded, and is prolonged, beyond the superior and
inferior borders of the lamina, in the form of two slender
cylindrical processes, termed the cornua. The superior cornu,

Hyoid

Epiglottis

Cartilage triticea

Thyreo-hyoid membran

Superior cornu of
thyreoid cartilage
Thyreoid notch

Prominentia laryngea
Crico-thyreoid ligament

Inferior cornu of thyreoid

Arch of cricoid cartilage

FIG. 127. Anterior aspect of the Cartilages and Ligaments of Larynx.

longer than the inferior cornu, gives attachment to the lateral

thyreo-hyoid ligament. The shorter, stronger inferior cornu
curves slightly medially. On the medial aspect of its tip there
is a facet which articulates with the side of the cricoid cartilage.
The superior border of the lamina is for the most part slightly
convex, and anteriorly it dips down to become continuous
with the margin of the superior thyreoid notch. The inferior
border is to all intents and purposes horizontal, but it is
divided by a projection, termed the inferior tubercle, into

THE LARYNX

34i

a short posterior part and a longer anterior part. The lateral

surface of the lamina is relatively flat. Immediately below
the posterior part of the upper border, and anterior to the root
of the superior cornu, there is a distinct prominence called the
superior tubercle. From that point an oblique ridge descends
towards the inferior tubercle on the lower border of the lamina.
The ridge gives attachment to the sterno-thyreoid, thyreo-hyoid
and the inferior

constrictor muscles, ff\ Epiglottis

and divides the

lateral surface of
the lamina into an
anterior and a pos-
terior part. To the
posterior part, which
is much the smaller
of the two, is at-
tached the inferior
constrictor muscle
of the pharynx.
T.he medial surface of
the lamina is smooth
and slightly concave.
To the angular
depression between
the two laminae are
attached the thyreo-
epiglottic ligament,
the ventricular and
the vocal ligaments.
Crico-thyreoid
Joints. The articu-
lation, on each side,
between the tip of the inferior cornu of the thyreoid car-
tilage and the side of the cricoid cartilage, belongs to the
diarthrodial variety. The opposed surfaces are surrounded
by an articular capsule which is lined with a synovial stratum.
The movements which take place at the joints are of a
twofold character viz., (i) gliding; (2) rotatory. In the
first case the cricoid facets glide upon the thyreoid surfaces in
various directions. The rotatory movement is one in which
the cricoid cartilage rotates around a transverse axis which

Hyoid

Cartilago triticea

Thyreo-hyoid

"membrane

Superior cornu
of the thyreoid
cartilage

Superior tubercle

Oblique line
Inferior tubercle
Inferior cornu
Conus elasticus
Cricoid cartilage

FIG. 128. Profile view of Cartilages and

Ligaments of Larynx.

342
HEAD AND NECK

passes through the centres of the two joints. Each articular

capsule is strengthened by stout bands on the posterior
aspect of the joint (Fig. 129).

Dissection. Divide the ligaments which surround the crico-

thyreoid joint, and remove the thyreoid cartilage.

Cartilage Cricoidea. The cricoid cartilage is shaped like

Hyoid

Cartilage triticea

Thyreo-epiglottic
ligament

Superior cornu

Corniculate cartilage
Arytaenoid

Muscular process
of arytaenoid

Inferior cornu
of thyreoid

FIG. 129. Posterior aspect of Cartilages and Ligaments of Larynx.

a signet ring. The broad, posterior part, called thelamina,

is somewhat quadrangular in form. Its superior border
presents a faintly marked median notch, and on each side
of the notch there is an oval, convex facet which articulates
with the base of the arytaenoid cartilage. The posterior
surface of the lamina is divided, by an elevated median ridge,
into two slightly hollowed -out areas which give attachment
to the posterior crico-arytaenoid muscles. The median ridge

THE LARYNX 343

itself gives origin to a tendinous band which proceeds upwards
from the longitudinal fibres of the oesophagus. The anterior
part of the cricoid cartilage is the arch* and it narrows
anteriorly. The lower border of the arch is horizontal, and
is connected to the first tracheal ring by membrane, the
crico - tracheal ligament. The upper border is connected,
anteriorly, to the lower border of the thyreoid cartilage 'by
the crico -thyreoid ligament. Posteriorly, the upper border
rapidly ascends, and to it is attached the corresponding half
of the conus elasticus. Upon the posterior part of the lateral
surface of the cricoid cartilage there is a circular, slightly
elevated, convex facet, which looks laterally and upwards, for
articulation with the inferior cornu of the thyreoid cartilage.
Internally, the cricoid cartilage is lined with mucous mem-
brane.

The narrow band-like part of the anterior arch of the

cricoid cartilage lies below the lower border of the thyreoid
cartilage, whilst the lamina is received into the interval
between the posterior portions of the laminae of the
thyreoid cartilage.

Cartilagines Corniculatae. Before proceeding to the study

of the arytaenoid cartilages the dissector should examine the
corniculate cartilages and the manner in which they are
held in position. They are two minute pyramidal nodules
of yellow elastic cartilage which are placed on the summits
of the arytaenoid cartilages, and are directed backwards and
medially. Each corniculate cartilage is enclosed within the
corresponding ary-epiglottic fold of mucous membrane, and
is joined to the apex of the arytaenoid cartilage by a
synchondrodial joint.

Cartilagines Arytaenoideae. Commence the study of the

arytaenoid cartilages by noting their relation to one another
and to the cricoid cartilage. Then remove one cartilage and
examine its surfaces and borders. Retain the other cartilage
in position for the purpose of examining the crico-arytaenoid
joint and the movements which can be performed at that
articulation.

The arytcenoid cartilages are pyramidal in form, and they

surmount the upper border of the lamina of the cricoid
cartilage. The apex of each is directed upwards, and it
curves backwards and medially. It supports the corniculate
cartilage. Of the three surfaces, one looks medially, towards

344 HEAD AND NECK

the corresponding surface of the opposite cartilage, from which

it is separated by the rima glottidis ; another looks back-
wards ; whilst the third is directed antero-laterally. The
medial surface is narrow, vertical and even, and is clothed
with mucous membrane. The posterior surface is concave ; it
lodges and gives attachment to the arytaenoideus transversus
muscle. The antero-lateral surface is the most extensive of
the three, and is uneven for muscular and ligamentous attach-
ments. Upon that aspect of the arytaenoid cartilage the
musculus vocalis and the thyreo- arytsenoid muscle are in-
serted. The surfaces of the arytaenoid cartilage are separated
by three borders, viz., an anterior, a posterior, and a lateral.
The lateral border is the longest, and, at the base of the
cartilage, it bulges backwards and laterally in the form of a
stout, prominent angle or process, termed \he processus muscu-
laris. It gives attachment, anteriorly, to the crico-arytaenoideus
lateralis muscle ; and, posteriorly, to the crico-arytaenoideus
posterior. The anterior border of the arytaenoid cartilage is
prolonged into the projecting anterior angle of the base,
which is called the processus vocalis. The vocal process is
sharp and pointed, and gives attachment to the vocal ligament
(O.T. true vocal cord). The base of the arytaenoid cartilage
presents an elongated concave facet, on its under aspect, for
articulation with the upper border of the lamina of the cricoid
cartilage.

Crico-arytaenoid Joints. The crico-arytaenoid joints are of

the diarthrodial variety. Each has a distinct joint cavity, sur-
rounded by an articular capsule, which is lined with a synovial
stratum. The cricoid articular surface is convex ; that of the
arytaenoid is concave ; both are elongated in form, but they
are placed in relation to each other so that the long axis of
the one intersects or crosses that of the other, and in no
position of the joint do the two surfaces accurately coincide.
The movements allowed at the joints, as the dissector can
readily determine, are of a twofold kind (i) gliding, by
which the arytaenoid is carried medially or laterally, or, in
other words, a movement by which the arytaenoid advances
towards or retreats from its fellow; (2) rotatory, by which the
arytaenoid cartilage rotates round a vertical axis. By that
movement the vocal process is swung laterally or medially, so
as to open or close the rima glottidis.

The dissector should note that the capsule of each joint

THE LARYNX 345

is strengthened posteriorly by a strong band which restricts

movement of the arytaenoid cartilage.

Cartilagines Cuneiformes. The cuneiform cartilages are

two little rod-shaped nodules of yellow elastic cartilage, which
are placed one in each ary-epiglottic fold near its posterior
end (Fig. 120). They are not always present.

Actions of the Laryngeal Muscles. The dissector should

now consider the manner in which the muscles of the larynx
operate upon the vocal folds, in the production of the voice.
Tension of the vocal folds is produced by the contraction of
the crico-thyreoid muscles. The straight parts of the muscles
pull the upper border of the cricoid cartilage upwards, whilst
the oblique portions, through their insertions into the inferior
cornua, draw the cricoid cartilage backwards, thereby increas-
ing the distance between the angle of the thyreoid cartilage
and the vocal processes of the arytoenoid cartilages. When
the" crico-thyreoid muscles cease to contract, the relaxation of
the vocal folds is brought about by the elasticity of the
ligaments. The vocalis and the thyreo-arytaenoideus must
be regarded as antagonistic to the crico-thyreoid muscles.
When they contract they approximate the angle of the
thyreoid cartilage to the arytsenoid cartilages, and still further
relax the vocal folds, and when they cease to act, the elastic
ligaments of the larynx again bring about a state of equilibrium.

The width of the rima glottidis is regulated by the arytae-

noid^us muscle, which draws together the arytaenoid carti-
lages. The lateral and posterior crico-arytaenoid muscles
also modify the width of the rima glottidis. When they act
together they assist the arytaenoid muscle in closing the rima
glottidis, but when they act independently they are antago-
nistic muscles. Thus the crico-arytanoidei posteriores, by draw-
ing the muscular processes of the arytaenoid cartilages back-
wards and laterally, swing the processus vocales and the vocal
folds laterally, and thus open the rima. The crico-arytanoidei
laterales act in exactly the opposite manner. By drawing the
muscular processes in an opposite direction they close the
rima.

But the muscles of the larynx have another function to

perform besides that of vocalisation. It was formerly thought
that the superior aperture of the larynx was closed, during
deglutition, by the folding back of the epiglottis ; that, in
fact, the epiglottis, during the passage of the bolus of food,

346 HEAD AND NECK

was applied like a lid over the entrance to the vestibule of

the larynx. The investigations of Anderson Stuart have
shown that the superior aperture of the larynx is closed
during swallowing by the close apposition and the forward
projection of the two arytaenoid cartilages, which are forced
against the tubercle of the epiglottis. The muscles chiefly
concerned in that movement are the thyreo-arytaenoid muscles
and the transverse arytaenoid muscle. They form, collectively,
a true sphincter vestibuli. The ary-epiglottic muscles also
assist in the closure.

THE TONGUE.

The tongue is a mobile organ which lies on the floor of

the mouth. It consists of a mass of muscles covered with
mucous membrane, and interspaced with a small amount of
fat and some glands. It is closely associated with the
functions of taste, mastication, deglutition, and articulation.

It has the form of a shoe turned upside down, and through

the opening of the shoe, which corresponds with the root of
the tongue, pass the muscles which connect the tongue with
the hyoid bone and the mandible (Figs. 131, 133).
The free part of the tongue possesses a lower surface, and
a dorsum. The dorsum is separable into an oral or upper
portion, which is also called the upper surface and which ter-
minates anteriorly at the apex, and a posterior or pharyngeal
portion, which is also called the base. The lower surface, which
is smooth, rests on the floor of the mouth. The upper surface
is rough ; it lies in relation to the roof of the mouth (Figs.
72, no, and 114); the apex touches the incisor teeth, and
the base forms a part of the anterior wall of the pharynx
(Fig. no). The upper border of the base is continuous
with the upper surface and it forms the lower boundary of
the isthmus of the fauces. The upper surface is separated
from the lower surface, on each side, by a distinct but
rounded border (Fig. 134).

The Mucous Membrane. The tongue is covered with

mucous membrane, which is continuous with the general
lining of the oral cavity and pharynx, but which presents very
different appearances on different areas of the tongue. In
the middle line of the tongue, at the junction of the upper
surface with the pharyngeal surface, there is a median pit in

THE TONGUE

347

the mucous membrane called the foramen ccecum. From the

foramen caecum the two limbs of a V-shaped sulcus diverge
antero-laterally, to terminate on the margins of the tongue at
the attachments of the glosso-palatine arches. The V-shaped
sulcus is called the sulcus terminalis ; it is an indication of
the double origin of the tongue ; the part anterior to the
sulcus, which lies in the floor of the mouth, and is, therefore,
called the oral part ', is developed from the mandibular arches
and the associated tuberculum impar of the embryo ; the

Tip of tongue,
turned up

Deep lingual vein

Orifice of.
submaxillary duct
|::| ^Frenulum linguae
Plica fimbriata

Plica sublingualis

FIG. 130. The Sublingual Region in the interior of the mouth.

posterior or pharyngeal part is developed from the second pair

of visceral arches.

The mucous membrane of the pharyngeal surface lies in

relation with the soft palate and the posterior wall of the
pharynx, and it is continuous laterally with the mucous mem-
brane of the palatine tonsils, and, posteriorly, with that of the
epiglottis. Where it covers the pharyngeal surface of the
tongue it is smooth and glossy and it has no projecting papillae,
but it is studded with low elevations, produced by masses of
lymph follicles embedded in the submucous tissue, and in each
elevation there is usually a small central pit. As the mucous
membrane passes from the tongue to the epiglottis it is raised
into a small median fold called the glosso-epiglottic fold.

348 HEAD AND NECK

Anterior to the foramen caecum and sulcus terminalis the

mucous membrane which covers the dorsum, sides, and tip
of the oral part of the tongue is studded with papillae of
different kinds. As these are individually visible to the naked
eye the mucous membrane presents a very characteristic
appearance. Further, a median groove or sulcus extends back-
wards from the tip of the tongue to the foramen caecum, and
divides the anterior two-thirds of the dorsum into two halves.

On the inferior surface of the tongue the mucous mem-

brane is smooth and comparatively thin. In the median
plane it forms \hefrenulum lingua, which has been studied
at an earlier stage. On each side of the median line the
deep lingual vein may be noticed, in the living subject, extend-
ing forwards towards the tip. To the lateral side of the vein,
and, therefore, somewhat nearer the border of the tongue, is a
delicate and feebly marked ridge of mucous membrane, from
the free border of which a row of fringe-like processes or
fimbriae project. It is termed the plica fimbriata ; as it extends
forwards, towards the tip of the tongue, it inclines towards
the median plane. On the side of the tongue, immediately
anterior to the lingual attachment of the glosso -palatine
arches, five short vertical fissures in the mucous membrane,
separated by intervening folds, may be noticed. The folds are
called \hz papilla foliattz. They are the representatives of leaf-
like folds of the mucous membrane which are much more
highly developed in certain of the lower animals (hare and
rabbit), and which are specially concerned in receiving the
impressions of taste.
Papillae Linguales. The papillae are of four kinds, and
differ in size, shape, and in the position they occupy on
the surface of the tongue. They are termed the vallate,
the fungiform, the conical, and the filiform.

Papillce Vallata. The vallate papillae (O.T. circumvallate),

seven to twelve in number, are the largest, and are placed
immediately anterior to the sulcus terminalis, in two rows
which diverge from each other in an antero-lateral direction,
like the two limbs of the letter V. The foramen caecum
lies immediately posterior to the median vallate papilla, which
forms the apex of the V. In form, a vallate papilla is
broad and somewhat cylindrical, slightly narrower at its
attached end than at its free extremity, and it is sunk in a pit.
It is thus surrounded by a deep trench, the outer wall of

THE TONGUE

349

which, termed the vallum, is slightly raised beyond the general

surface of the mucous membrane, and forms an annular eleva-
tion which encircles the free extremity or summit of the
papilla.

Papilla Fungiformes. The fungiform papillae are much

smaller, but are present in much greater numbers. They are
found chiefly on the tip and sides of the tongue, but they are
scattered, at irregular intervals, over the upper surface also.
Each papilla presents a large, full, rounded, knob-like ex-
tremity, while it is greatly constricted at the point where it

M. stylo-hyoideus

M. digastricus
(posterior belly)

M. digastricus (anterior belly) M. mylo-hyoideus M. genio-hyoideus

FIG. 131. Muscles of the Tongue. (From Gegenbaur.)

springs from the mucous surface. In the living tongue the

fungiform papillae are distinguished by their bright red colour.
Papillce Conictz, The conical papillae are present in very
large numbers. They are smaller than the fungiform variety,
and although they are quite visible to the naked eye they
can be more conveniently studied with an ordinary pocket
lens. They are minute conical projections which taper
towards their free extremities, and they occupy the dorsum
and sides of the tongue, anterior to the sulcus terminalis.
They are arranged in parallel rows which are 'placed close
together. On the posterior part of the upper surface the
rows diverge from the median sulcus in an antero-lateral

35 HEAD AND NECK

direction. Towards the tip of the tongue the rows of conical

papillae become more or less transverse in direction, and on
the sides of the tongue they are arranged perpendicularly.

Papilla Filiformes. The filiform papillae are similar in

general characters to the conical papillae, but the epithelial
cap at the apex of the cone is broken up into thread-like
processes.

Muscles of the Tongue. The tongue is composed almost

entirely of muscular fibres, with some adipose and glandular
and fibrous tissue intermixed. It is divided into two halves
by a median septum, and the muscles in connection with each

M. glosso-palatinus

M. stylo-glossus
: ^4- Septum linguae
M. longitudinal is

inferior
M. hyo-glossus

M. genio-glossus

FIG. 132. Transverse section through the posterior part of

the Tongue. (From Gegenbaur.)

half consist of an intrinsic and an extrinsic group. They

are as follows :

t i. Genio-glossus.
I 2. Hyo-glossus.

Extrinsic Muscles, A 3. Chondro-glossus.

) 4. Stylo-glossus.

I 5. Glosso-palatinus.
f i. Superior longitudinal.

T *. is i I 2. Inferior longitudinal.

Intrinsic Muscles, -f y , j

[ 4. Transverse.

The extrinsic muscles take origin from parts outside the

tongue, and thus are capable not only of giving rise to changes
in the form of the organ, but also of producing changes in
its position. The intrinsic muscles, which are placed entirely
within the substance of the tongue, are, for the most part,
capable of giving rise to alterations in its form only.

Dissection. With the exception of the chondro-glossus, the

extrinsic 'muscles have been studied already, but the dissector
should now take the opportunity of examining more fully their
insertions, and the manner in which their fibres are related to
one another and to those of the intrinsic muscles. To display

THE TONGUE

351

the details, carefully, reflect the mucous membrane from the

right half of the tongue, and follow the muscles into that side
of the organ. At the same time the lingual nerve and the
profunda linguae artery should be preserved. On the under
surface of the tongue, near the tip, the removal of the mucous
membrane will expose a group of glands, aggregated together
so as to form a small oval mass on each side of the median plane.
The mass of glands is known as the apical gland or the gland of
Nuhn.

The stylo-glossus will be seen running along the side of

the tongue to the tip, where the muscles of opposite sides
become, to a certain extent, continuous. The hyo-glossus
extends upwards to the side of the tongue, and its fibres pass,
for the most part, under cover of those of the stylo-glossus to
reach the dorsum, over the posterior part of which they spread
out, beneath the mucous membrane. The genio-glossus sends

M. longitudinalis
superior

Lamellae of
M. transversus
M. genio-glossu

M. genio-hyoideus PW *

\ l^-
Hyoid bone

FIG. 133. Longitudinal section through the Tongue. (FromAeby.)

its fibres upwards into the tongue on each side of the

median septum, and its insertion stretches from the tip to the
base. The fibres of the glosso-palatinus become continuous
with the intrinsic transverse fibres.

The chondro-glossus is not always present. It is separated from the

deep surface of the hyo-glossus by the lingual vessels. It is a slender
muscular band which takes origin from the medial aspect of the root of
the lesser cornu, and the adjoining part of the body of the hyoid bone.
Its fibres ascend, to enter the tongue, where they finally spread out on the
dorsum, under cover of the superior longitudinal muscle.

Musculus Longitudinalis Superior. The superior longitudi-

nal muscle lies immediately beneath the mucous membrane,
and is a continuous layer of longitudinal fibres which covers
the entire dorsum of the tongue, from the root to the tip.
Towards the base of the tongue it is thinner than in front,
and there it is overlapped by the transverse fibres of the hyo-

352 HEAD AND NECK

glossus, and is intermixed with the fibres of the chondro-

glossus.

Musculi Longitudinales Inferiores. The inferior longi-

tudinal muscles are two rounded, fleshy bundles placed upon
the inferior aspect of the tongue, one on each side. Pos-
teriorly, each inferior longitudinal muscle lies in the interval
between the hyo -glossus and the genio -glossus, and is
attached to the hyoid bone ; anteriorly, it is prolonged
to the apex of the tongue between the medial border of
the stylo-glossus and the genio-glossus ; with the former it is
more or less blended.

Musculus Transversus Lingua. The fibres of the trans-

verse muscle lie under the superior longitudinal fibres, and

M. longitudinalis

superior ^

M. transversus

M. stylo-glossus
M. longitudinal!:
inferior

M. hyo-glossus^
M. genio-glossus

Hyoid bone M. genio-hyoideus

FIG. 134. Transverse section through the Tongue. (From Aeby. )

constitute a thick layer which extends laterally, from the

surface of the septum linguae, to the side of the tongue. The
fibres of the genio-glossus ascend through the transverse
stratum and break it up into numerous lamellae (Fig. 134).
It is joined by the fibres of the glosso-palatinus (Henle) (Fig.

I 3 2 )-

Musculus Verticalis Lingua. The vertical fibres extend in

a curved direction from the dorsum to the inferior aspect of
the tongue, and decussate with the fibres of the transverse
muscle.

Nerves and Vessels of the Tongue. The nerves of the

tongue are (i) the glosso-pharyngeal ; (2) the lingual; (3)
the hypoglossal; and (4) a few twigs from the internal
laryngeal. They should be traced on the left side of the
tongue, where the mucous membrane is still in position.

The glosso-pharyngeal nerve has been traced up to the point

THE TONGUE 353

where it disappears under cover of the hyo-glossus muscle.

There it divides into two branches. The smaller of the two
extends forwards, upon the side of the tongue, and may be
traced as far as a point midway between the root and the tip.
The larger branch turns upwards, and is distributed to the
mucous membrane which invests the posterior third of the
dorsum linguae. It gives twigs to the vallate papillae, and
some fine filaments may be followed to the anterior surface
of the epiglottis. The glosso-pharyngeal nerve is a nerve of
taste and of common sensibility.

The lingual and hypoglossal nerves are described on pages

182 and 196, and their terminal branches should now be
traced as far as is possible.

The internal laryngeal nerve gives a few delicate filaments

to the glosso-epiglottic and pharyngo-epiglottic folds and the
mucous membrane of the pharyngeal aspect of the tongue.

The arteria profunda linguae, should be followed to the tip

of the tongue, where it forms a small loop of anastomosis with
its fellow of the opposite side.

Septum Linguae. The septum of the tongue can be seen

best in a transverse section through the organ. Such a
section will also display, in a measure, the transverse and
vertical muscular fibres. The septum is a median fibrous
partition. It is strongest posteriorly, where it is attached
to the hyoid bone. It does not reach the dorsum of the
tongue, being separated from it by the superior longitudinal
muscle.

ENCEPHALON THE BRAIN.

BEFORE the dissector commences the dissections of the brain

he must be familiar with its main features and with the
general arrangement of its parts. For this purpose he should
obtain the half of a brain which has been divided by a
median sagittal section, and from which the membranes have
been removed, or a cast of such a specimen, and examine it
from both its medial and its lateral sides (see Figs. 135, 136).

The brain is that portion of the central nervous system

which lies in the cranial cavity, where it is surrounded by
three membranes, the dura mater, which has already been
examined (p. 99), and the arachnoid and the pia mater, which

VOL. in 23

354

THE BRAIN

still cover the dissector's own specimen and which will be

examined at a later stage.

The main part of the brain is formed by two somewhat

hemispherical masses, called the cerebral hemispheres, which
are so large, in the human subject, that when the brain is

Anterior central gyrus

Central sulcus
Posterior central gyrus
Upper post-central sulcus

Supra-marginal gyrus
Interparietal sulcus (proprius)
Angular &>' rus ^^
Post-parietal gyrus ^jff^
Paroccipital sul
Arcus parieto-
occipitalis
Parieto-occipital ',
fissu

Upper precentral sulcus

I_ ower precentral sulcus

Superior frontal sulcus

; Superior frontal gyrus

Middle frontal gyrus

Calcarine

fissure '
Sulcus lunatus

Transverse occipital
sulcus

Olfactory bulb
Inferior frontal gyrt
Anterior horizontal brand
ateral fissure

Anterior ascending branch

of lateral fissure

.Posterior branch of lateral fissure

Superior temporal gyrus

Olive of medulla oblongata

Lateral occipital sulcus

Horizontal sulcus of cerebellum

Right hemisphere of cerebellu

Part of cerebellum which extends into foramen magnum

FIG. 135. Lateral surface of Right Half of the Brain (semi-diagrammatic).
The horizontal dotted line completes the separation between the parietal
and temporal areas, and the oblique dotted line, which runs from the
parieto-occipital fissure to the pre-occipital notch, separates the occipital
from the parietal and temporal areas.

examined from above they entirely conceal all the other parts

(Fig. 137).

The two hemispheres are connected together by (i) a

large transverse commissure called the corpus callosum (Fig.
136); (2) two smaller transverse commissures: (a) the
transverse fibres of the fornix and (b) the anterior com-

MAIN SUB-DIVISIONS 355

missure; (3) by a thin membrane called the lamina terminalis,

through which the fibres of the anterior commissure run
(Figs. 136, 156, 159, 173).

The two hemispheres constitute, together, the telencephalon,

which is the last formed, but the most highly developed,
portion of the brain. Each hemisphere contains a cavity
called the lateral ventricle, and there are, therefore, in the
telencephalon two lateral ventricles, a right and a left, known
also, though less commonly, as the first and the second
(Figs. 163, 164, 165).

Immediately below and between the two cerebral hemi-

spheres lies a portion of the brain called the diencephalon.
It is continuous, posteriorly, with the mesencephalon or mid-
brain, and, anteriorly and laterally, with the cerebral hemi-
spheres. In the interior of the diencephalon there is a cavity
called the third ventricle (Figs. 136, 168). The cavity is
continuous, anteriorly, through apertures called the inter-
ventricular foramina, with the lateral ventricles of the telen-
cephalon, and, posteriorly, with a canal, called the aquaductus
cerebri, which runs through the mid-brain and connects the
cavity of the diencephalon with that of the rhomb encephalon
or hind-brain.

When examined from its ventricular side, each half of the

diencephalon is seen to be separated into two parts, a dorsal
and a ventral, by an antero-posterior sulcus called the sulcus
hypothalamicus ; the dorsal part is called the thalamus, the
ventral part is the hypothalamus. In Fig. 136 the point and
the adjacent part of the arrow lie in the hypothalamic
sulcus.

The dorsal wall of the. cavity of the diencephalon is called

the roof of the third ventricle, and from it a conical mass, called
the pineal body, projects backwards over the mid-brain ; it
forms part of the epithalamus. The remainder of the epi-
thalamus lies anterior and lateral to the pineal body, on the
upper and posterior part of the thalamus, and it consists of the
habenula and the trigonum habenulcz, on each side (Fig. 176).

Forming part of the ventral wall of the diencephalon are

two round, white bodies, called the corpora mamillaria, and
further forwards is a conical projection called the tuber
cinereum, which is connected with the hypophysis by a thin
stalk, called the infundibulum (Figs. 136, 139). All the parts
of the ventral wall are parts of the hypothalamus.
in 23 a-

356

THE BRAIN

Behind and somewhat below the diencephalon lie^ the

mesencephalon or mid-brain. It is separable into ( i ) a dorsal
portion, the lamina quadrigemina or tectum, which is divided

Massa intermedia

Fornix

Gyrus cinguli

Caudate nucleus in lateral ventricle '\ \

Remnant of septum pcllucidum
Genu of corpus callosvim '
Superior frontal gyrus \

Callosal sulc
Sulcus cingu

Inferior surface of fornix

I Superior surface of thalamus
i Upper end of central sulcus
I r Splenium of corpus callosum
,' { r Paracentral lobule

lian part of transverse fissure

Pineal body

Lamina quadrigemina
UectumJ

rietal sulcus
Calcarine fissure
Gyrus rectus
Rostrum of corpus callosu

Anterior commissure
Lamina terminals
Supra-optic recess'

Optic chiasma /
Arrow passing through inter-
ventricular foramen '

Infundibulum /

Mamillary body
Oculo-motor nerve

Peciunculus cerebri

ngual gyrus
Cerebellum

^ Fourth ventricle

Median aperture of fourth ventricle

entral canal of spinal medulla

Medulla spinalis

FIG. 136. Medial surface of the Right Hemisphere, and the structures seen
after a sagittal section has been made through the Corpus Callosum, the
Fornix, the Diencephalon, the Mesencephalon, and the Rhomben-
cephalon, and after the Septum Pellucidum has been removed from
between the Corpus Callosum and the Fornix. The arrow passes
through the interventricular foramen from the right lateral ventricle to
the third ventricle, where it lies in the hypothalamic sulcus in the side
wall of the third ventricle.

by a longitudinal and a transverse sulcus into four rounded

bodies called the colliculi or corpora quadrigemina (Fig. 195) ;
and (2) a ventral part, cut by a depression, the interpeduncular
fossa, into two rounded columns, the pedunculi cerebri. The
mid-brain is traversed, between the lamina quadrigemina and
GENERAL FEATURES 357

the pedunculi, by a canal, termed the aquaeductus cerebri,

which connects the third ventricle, in the diencephalon, with
the fourth ventricle, in the hind-brain.

Still lower and more posteriorly that is, below and behind
the mid-brain is the rhombencephalon or hind-brain. It also
is separable into dorsal and ventral portions, and between
them is the cavity of the hind-brain, called \hefourth ventricle
(Fig. 136). The dorsal portion is the cerebellum ; it lies im-
mediately below the posterior parts of the cerebral hemi-
spheres and above and behind the fourth ventricle. The
ventral part of the hind-brain consists of an upper part, called
the pons, which is continuous with the pedunculi of the mid-
brain, and a lower part, called the medulla oblongata, which is
continuous, below, with the spinal medulla.

When the brain was removed, the dissector noticed that

the cerebral hemispheres occupied the anterior and middle
fossae of the cranium and that, more posteriorly, they lay on
the tentorium cerebelli a fold of dura mater which separated
them from the hind-brain (Figs. 32, 35). The dissector noted
also, after the removal of the tentorium cerebelli, that the
hind-brain occupied the posterior fossa of the cranium,
and that the mid- brain passed from the posterior fossa
to the middle fossa through an oval notch, the incisura
tentorii.

The brain is surrounded by three membranes the dura

mater, the arachnoid, and the pia mater ; and between the
arachnoid and the pia mater lie the main trunks of the blood
vessels of the brain.

The dura mater was examined during and after the removal
of the brain from the cranial cavity (pp. 99-102); but,
before the arachnoid, the pia mater, and the blood vessels
which lie between them, are studied, the dissector must be
acquainted, not only with the main subdivisions of the brain,
but he must have also a good knowledge (i) of the names of
the fissures and sulci of the cerebral hemispheres, (2) of the
names and positions of their various borders, surfaces, and
lobes, and (3) of the position of the cerebral nerves. He
should, therefore, obtain a brain from which the membranes
have been detached and in which the mid-brain has been
divided horizontally so that the lower part of the mid-brain
and the hind-brain can be removed. He should obtain also
a cerebral hemisphere which has been separated from its
in 23 &

358

THE BRAIN
fellow of the opposite side and from the mid-brain, and from
which the membranes have been removed.

If actual specimens cannot be obtained good casts will

serve the present purpose.

Superior frontal gyrus

Superior frontal sulcus

Middle frontal sulcu

Upper part of middle,

frontal gy

Inferior precentral
sulcus

Superior pre-
central sulcus
Anterior
central gyrus
Lower buttre

CENTRAL

SULCUS '

Upper.

buttress

Posterior
central gyrus
Inferior post-
central sulcus

Lateral fissure

(posterior

ramus)

Interparietal
sulcus -
(proprius)
Superior
tempera"

:SU1CUS

Superior post
central sulcus

Superior parietal
lobule

Sulcus frontalis paramedialis

Superior frontal sulcus

Interparietal sulc
(proprius)

Interparietal sulcus
(occipital part)
Middle temporal sulcus

Interparietal sulcus (occipital part)

Parieto-occipital fissure

FIG. 137. View of the Hemispheres from above (semi-diagrammatic).

Transverse occipital sulcus

Parieto-occipital fissure

Having obtained the specimens, he must examine them

from above, from below, from the lateral and the medial
sides ; and he should commence the inspection by examining
the upper aspects of the specimens. As he does that he
will note the difference between the blunt and rounded

GENERAL FEATURES 359

anterior end, which is called the frontal pole, and the more
pointed posterior end, called the occipital pole, and he cannot
fail to note that the surface of each hemisphere, at which
he is looking, is convex and is directed upwards and later-
ally, and may therefore be termed the supero-lateral surface,
and he will note, further, that it is moulded into numerous
curved ridges of cerebral substance. The ridges are called
gyri, and they are separated more or less completely from
one another by narrow depressions, some of which are called
sulci and others fissures. All the fissures and some of the
sulci are named, but there are many small unnamed sulci.

A mere glance will convince the dissector that the majority

of the gyri, at which he is looking, run antero-posteriorly, but
that two gyri on each side, which lie a little posterior to the
centre of the antero-posterior length of the hemispheres, have
an entirely different direction ; they run obliquely from below
upwards and backwards. They form, therefore, distinct
landmarks ; they are known as the anterior and posterior
central gyri, and the cleft which lies between them is called
the central sulcus (Figs. 135, 137) (O.T. fissure of Rolando) ; in
the majority of cases its upper end cuts the upper or supero-
medial border of the hemisphere.

Between the upper end of the central sulcus and the

occipital pole of the hemisphere, but nearer the latter than
the former, a deep cleft cuts the supero-medial border of
the hemisphere, and extends for a short distance, laterally,
on the supero-lateral surface ; it is the lateral part of the
parieto-occipital fissure (Fig. 137).

The dissector should, if possible, insert the brain, or the

model with which he is working, into a sagittal section of a
skull of convenient size, and note that the upper end of the
central sulcus corresponds with a point on the vertex of the
skull which lies 12 mm. (half an inch) behind the centre point
between the root of the nose and the external occipital pro-
tuberance, the nasion arid the inion respectively, and that
the parieto-occipital fissure is placed about 6 mm. in front of
the lambda.

When the dissector has satisfied himself regarding the

points mentioned, he should examine the supero-lateral
surface of the hemisphere from the lateral side. Again he
will note the general antero-posterior direction of the gyri and
sulci, and the markedly different direction of the central

360 THE BRAIN

sulcus and the anterior and posterior central gyri. He will

note also that, immediately below the lower end of the central
sulcus, more rarely continuous with it, there is a very well-
marked antero-posterior cleft ; it is the posterior ramus of the
lateral fissure (Sylvian) (Fig. 135). The lateral fissure com-
mences on the inferior surface of the hemisphere (Fig. 138),
and divides, immediately after it reaches the lateral surface,
into anterior horizontal, anterior ascending, and posterior rami,
all of which the dissector must identify (Figs. 135, 152). The
posterior ramus is always easily identified, but the anterior
rami may present difficulty.

The part of the hemisphere which lies below the lateral

fissure is the anterior part of the temporal lobe; it ends
anteriorly in a rounded point called the temporal pole.

The dissector should next turn his attention to the borders

of the hemisphere as seen from the lateral side (Fig. 135).
They are supero-medial, infero-lateral, and superciliary.

The supero-medial border is convex. It extends from the

frontal pole to the occipital pole, along the side of the
superior sagittal venous sinus, and separates the supero-lateral
surface from the medial surface.

The infero-lateral border is concavo-convex. It extends

from the occipital to the temporal pole. Its posterior and
larger part lies along the line of the transverse venous sinus,
and its anterior part runs along the line of the petro-squamous
suture. It separates the supero-lateral surface from the
posterior part of the inferior surface of the hemisphere. On
this border, about a third of its length from the occipital
pole, there is a distinct notch, called the pre-occipital notch,
caused by the terminal portion of a vein which descends on
the hemisphere to the transverse sinus.

The superciliary border extends from the temporal pole to

the frontal pole. It corresponds in position, anteriorly, with
the superciliary arch of the skull, and it separates the supero-
lateral surface from the anterior or orbital part of the inferior
surface. The dissector should verify the above statements by
placing his specimen, if possible, in sagittal and horizontal
sections of skulls of convenient size.

For purposes of description and localisation the greater

part of each hemisphere is divided, by means of fissures and
sulci, into areas called lobes, and within the area of each lobe
there are, as a rule, several gyri.

GENERAL FEATURES 361

Portions of four of the lobes, the frontal, the parietal, the

occipital and the temporal, are visible on the supero-lateral
surface.

The frontal lobe lies anterior to the central sulcus and

above the stem and the anterior part of the posterior ramus of
the lateral fissure. In it, immediately anterior to the central
sulcus, is the anterior central gyrus, in which is the motor
area of the cerebral cortex (Fig. 153). The anterior central
gyrus is partially separated from the more anterior part of the
frontal lobe by a precentral sulcus, which is generally divided
into upper and lower portions. Anterior to the pre-central
sulcus there are three gyri which run antero-posteriorly ; they
are named from above downwards, the superior, middle, and
inferior frontal gyri (Figs. 135, 137).

The dissector should note (i) that the anterior horizontal

and anterior ascending rami of the lateral fissure cut into the
inferior frontal gyrus; and (2) that, whilst the frontal lobe is
partly covered by the frontal bone, a considerable part of its
posterior portion, including the anterior central gyrus and
the posterior parts of the antero-posterior gyri, is under cover
of the anterior part of the parietal bone (Fig. 177).

The parietal lobe is bounded, anteriorly, by the central

sulcus ; posteriorly, by the parieto-occipital fissure and a line
prolonged from it to a notch (Fig. 135) on the infero-lateral
border called the pre-occipital notch \ inferiorly, by the posterior
ramus of the lateral fissure, and a line prolonged backwards
from the point where that fissure turns from a horizontal to a
vertical direction to the line from the parieto-occipital fissure
to the pre-occipital notch. The supero-lateral surface of the
parietal lobe is separated into three main areas. Immediately
posterior to the central sulcus is the posterior central gyrus.
It is bounded, posteriorly, by the post-central sulcus, and it is
the region of ordinary sensation (Fig. 153). Behind the
post-central sulcus the parietal lobe is separated into an upper
and a lower parietal lobule, by an antero-posterior sulcus called
the sulcus interparietalis proprius.

The occipital lobe lies behind the parieto-occipital fissure

and the line which connects that fissure with the pre-occipital
notch. Its surface is divided into four areas by three sulci.
The area in the region of the occipital pole is marked off by
a curved sulcus, concave backwards, called the sulcus lunatus.
The larger anterior part is divided by two antero-posterior

362 THE BRAIN

sulci, called the lateral occipital sulcus and paramedial occipital

sulcuS) into three gyri the superior, middle, and inferior.

The lateral surface of the temporal lobe is divided by two

sulci, which run antero-posteriorly, into superior, middle, and
inferior temporal gyri.

When the survey of the supero-lateral surface is completed,

a specimen should be examined in which the lips of the
lateral fissure have been separated or removed. In such a
specimen it will be obvious that at the bottom of the fissure
there is a sunken area of the brain cortex (Fig. 157). It is
called the insula, and it is separated from the adjacent parts
by a sulcus called the circular sulcus.

After the general relations of the supero-lateral surface

have been noted the medial surface of the hemisphere should
be examined. Upon it, nearer its anterior than its posterior
end, and nearer its lower than its upper border, will be seen
the surface of section of the severed corpus callosum (Fig. 136).
The corpus callosum consists of a trunk, which terminates
posteriorly in a free, thick, rounded posterior end, called the
splenium, and anteriorly in a bent anterior extremity called
the genu. From the genu a tapering portion of the corpus
callosum, termed the rostrum^ passes downwards and back-
wards. It ends below in a thin lamina, called the lamina
terminalis, which descends till it reaches the ovoid transverse
section of the optic chiasma, which connects together the two
optic nerves. The lamina terminalis passes behind the optic
chiasma, and joins the tuber cinereum in the floor of the
third ventricle (Figs. 136, 159). The transverse, small and
round, white bundle which passes through the lamina termin-
alis, above the optic chiasma, is the anterior commissure.

In the median plane, in the angle between the body, genu,

and rostrum of the corpus callosum, there is a thin vertical
lamina called the septum pellucidum. It is bounded below
and behind by a flat band of white matter, called the fornix
(Figs. 136, 156).

The boundaries of the medial surface of the hemisphere

are (i) The supero-medial border, which extends from the
frontal pole to the occipital pole, and separates the medial
from the supero-lateral surface. (2) The medial occipital
border, which extends from the occipital pole to the splenium
of the corpus callosum ; it separates the medial surface from
the posterior part of the inferior surface. (3) The medial

GENERAL FEATURES 363

orbital border, which runs from a point immediately in front

of the optic chiasma to the frontal pole, separating the medial
surface from the anterior part of the inferior surface.

Between the medial occipital and the medial orbital

borders the lower boundary of the medial surface is formed
by the lower margin of the splenium and the lower margin of
the fornix, which lie immediately above the diencephalon.

The corpus caliosum is separated from the gyrus cinguli,

which is immediately adjacent to it, by the callosal sulcus
(Fig. 136).

The gyrus cinguli is separated from the adjacent parts of

the medial surfaces of the frontal and parietal lobes by the
sulcus cinguli, which turns upwards at its posterior end, and
cuts the supero-medial border of the hemisphere, a short
distance behind the upper end of the central sulcus (Figs.
136, 156).

Some distance in front of its posterior end, the sulcus

cinguli gives off a branch which ascends towards the supero-
medial border. That branch is not named but it lies parallel
with, or slightly in front of, the pre-central sulcus on the
supero-lateral surface of the hemisphere. The portion of
the medial surface of the hemisphere which lies between the
posterior end of the sulcus cinguli and the unnamed upturned
branch, corresponds in a general way with the upper ends
of the posterior and anterior central gyri, and it is termed the
paracentral lobule (Figs. 136, 159).

The part of the medial surface above the sulcus cinguli

and between the frontal pole and the paracentral lobule
is the medial part of the superior frontal gyrus ; and the part
which extends from the frontal pole to the optic chiasma,
below the sulcus cinguli, is the gyrus rectus, which will be
seen also on the inferior surface.

Behind the upturned, posterior end of the sulcus cinguli,

but in direct line with its main portion, is a small separate
sulcus, called the subparietal sulcus ; and cutting the supero-
medial border of the hemisphere about a fourth of its length
from the occipital pole is the parieto-occipital fissure, which
crosses the posterior part of the medial surface. The lower
end of the parieto-occipital fissure joins an important fissure
called the cakarine at an acute angle. That part of the
medial surface which lies above the sub-parietal sulcus, and
between the parieto-occipital fissure and the upturned end of

3 6 4

THE BRAIN

the sulcus cinguli, is termed the prcecuneus \ it is the medial

part of the superior parietal lobule.

Cutting the supero-medial border a short distance above

the occipital pole is the calcarine fissure. It is a deep fissure

Olfactory bulb
Medial orbital gyrus ' t

Orbital sulcus
Anterior orbital gyr

Lateral orbital gyrus_.X

asterior orbital gyrus./^ ^-

Stem of lateral
fiss

Rhinal
Gyrus rectus

Olfactory sulcus

Olfactory tract (cut)

Optic

Anterior perforated
substance

Infundibulum
,- Optic tract
^Mamillary body

fissure
Fusifo

gyrus
Inferior
temporal
sulcus
Inferior
temporal
gyrus
Calcarine
fissure

Medial occipital
border crossing
gyrus lingualis

Calcarine fissun

Infero-lateral border

Sulcus lunatus

Calcarine fissure
Sulcus lunatus

Calcarine fissure

Sulcus for superior sagittal sinus

FIG. 138. Inferior surfaces of Hemispheres (semi-diagrammatic).

which runs forwards on the medial surface. It turns down-

wards across the anterior part of the medial occipital border
and at that point it is joined by the parieto-occipital fissure.
Then it runs obliquely downwards and forwards in the
posterior part of the inferior surface below the splenium of the

GENERAL FEATURES 365

corpus callosum. The wedge-shaped region of the cortex of

the hemisphere between the calcarine fissure and the parieto-
occipital fissure is called the cuneus ; and the portion of the
medial surface of the hemisphere below the calcarine fissure
is the posterior portion of the lingual gyms, the remainder of
which is on the inferior surface. Both the cuneus and the
lingual gyrus are parts of the occipital lobe.

In the majority of cases the posterior part of the medial

surface of the occipital lobe is marked by a definite vertical
depression caused by the posterior part of the superior
sagittal sinus (Fig. 154).

After the examination of the medial surface is completed,

the dissector should examine the lower surface of a specimen
from which the hind-brain and the lower part of the mid-
brain have been removed (Fig. 138).

Upon each side he will note the three poles of the

corresponding hemisphere frontal, temporal, and occipital.

The part anterior to the temporal pole is the anterior

part of the inferior surface, and at the same time it is the
inferior surface of the frontal lobe.

It is bounded, anteriorly and laterally, by the superciliary

border; medially, by the medial orbital border; and,
posteriorly, in the lateral and greater part of its extent, by
the stem of the lateral fissure, which separates it from the
temporal lobe, but the medial part of its posterior boundary
is a sulcus which intervenes between it and a small
triangular area at the side of the optic chiasma, called the
anterior perforated substance. Lying parallel with the medial
orbital border is a sulcus, the olfactory sulcus, in which the
olfactory bulb and the .olfactory tract are lodged. The gyrus
which lies to the medial side of the olfactory sulcus is the
gyrus rectus, already seen on the medial surface of the hemi-
sphere. The portion of the surface which lies lateral to the
olfactory sulcus is concave, the concavity being due to the
upward projection of the roof of the orbit on which it rests,
and the gyri of this area are called orbital gyri. As a rule,
there are four orbital gyri, a medial, a lateral, an anterior,
and a posterior ; they are separated from one another by a
series of sulci, the orbital sulci, which have, collectively, an
H-shaped outline.

The posterior part of the inferior surface, which lies

behind the temporal pole, looks downwards and medially,

3 66

THE BRAIN

when the brain is in position in the cranium. It rests, in

the posterior part of its extent, upon the tentorium cerebelli,
and, more anteriorly, upon the anterior surface of the petrous

Olfactory bulb

.Olfactory tract

Optic nerve

Substantiate
forata anteric

Optic tract

Motor root of
facial nerve
Acoustic nerve

Sensory root of
facial nerve

Glosso-pharyngeal
nerve

Hypoglossal
nerve

Pyramid

Vagus nerve
Accessory nerve

Hypoglossal nerve

Spinal medulla (cut)

FIG. 139. The Base of the Brain with the Cerebral Nerves attached.

portion of the temporal bone and the great wing of the

sphenoid. On account of its relation to the tentorium, it is
frequently called the tentorial surface.

The posterior part of the inferior surface is bounded

GENERAL FEATURES 367

anteriorly by the temporal pole, posteriorly by the occipital

pole ; laterally by the infero-lateral border, which separates it
from the supero-lateral surface; medially, in the posterior
part of its extent, by the medial occipital border, which
separates it from the medial surface, and, more anteriorly, by
a fissure called the chorioidal fissure, which lies between it and
the sublentiform portion of the hemisphere.

Upon the part which rests upon the petrous portion of the
temporal bone, a short distance posterior to the temporal
pole, will be seen a depression produced by the eminentia
arcuata of the temporal bone. The part of the brain cortex
which lies immediately antero-lateral to the depression rests,
in the ordinary position, on the tegmen tympani and the
petro-squamous suture. It lies, therefore, immediately above
the epi-tympanic recess or attic of the tympanic cavity, from
which it is separated merely by its membranes and a very
thin plate of bone.

Crossing the medial occipital border, a short distance

posterior to the corpus callosum, is the stem or anterior part
of the calcarine fissure, already mentioned. It runs forwards
for a short distance on the posterior part of the inferior
surface. The part of the cortex between it and the splenium
of the corpus callosum is the isthmus ; it is continuous, above,
with the gyrus cinguli, and, below, with the hippocampal gyrus.
The hippocampal gyrus runs forwards and its anterior end
turns upwards forming a hook-shaped bend, called the uncus.
The posterior part of the hippocampal gyrus is termed the
paradentate area (Fig. 156), and the anterior part is known
as the piriform area. Continuous with the paradentate
area, but lying posterior to it and below the stem of the
calcarine fissure, is the lingual gyrus, which runs backwards
and turns round the medial occipital border to the medial
surface of the occipital lobe, where it was previously noted.
Lateral and anterior to the piriform area, and on a lower
plane, is a small but definite fissure, called the rhinal
fissure, and posterior to the rhinal fissure and lateral to the
paradentate area and the lingual gyrus, on a lower plane, is
a definite sulcus, which runs antero-posteriorly, and is called
the collateral fissure. The gyrus which lies below and lateral
to the collateral fissure has been termed the fusiform gyrus ;
it- is also called the occipito-temporal gyrus. Between it and
the infero-lateral border lies the inferior temporal sulcus,

'368 THE BRAIN

which separates it from the inferior part of the inferior

temporal gyrus (Fig. 138).

When the survey of the inferior surfaces of the cerebral

hemispheres is completed, the inferior aspect of a brain, or
a cast, in which the mid- and hind-brain sections are still in
situ, or in which they can be replaced, should be examined.

When that is done it will be noted that the posterior

sections of the inferior surfaces of the hemispheres are
concealed by the cerebellum, but the more anterior parts of
the inferior surfaces are still visible. Between the anterior
parts of the inferior surfaces, in the median plane, is the
anterior part of the longitudinal fissure. Behind the
anterior part of the longitudinal fissure lies the optic chiasma,
but if the chiasma is carefully turned backwards, the lamina
terminalis will be seen passing upwards and forwards into the
longitudinal fissure (Fig. 162). At its antero-lateral angles
the optic chiasma receives the optic nerves, and from each
postero-lateral angle it gives off an optic tract, which runs
postero-laterally and disappears from view under cover of
the piriform area.

Behind the optic chiasma is the tuber cinereum with the

infundibulum projecting from its apex to connect it with the
hypophysis. Behind the tuber cinereum lie two round white
bodies called the corpora mamillaria, and still more posteriorly
is the deepest part of the interpeduncular fossa, which lies
between the medial borders of the pedunculi cerebri. The
superior boundary of the interpeduncular fossa is the posterior
perforated substance.

The pedunculi cerebri run upwards, forwards and laterally,

at the sides of the interpeduncular fossa. The upper end
of each disappears into the base of the corresponding hemi-
sphere, and its lower end is continuous with the pons of the
hind-brain.

Springing from the medial side of each pedunculus is the

corresponding oculo- motor nerve, and curving round its
lateral side is the trochlear nerve.

Below the pedunculi cerebri of the mid-brain is the pons

of the hind-brain, which is connected, on each side, with the
corresponding hemisphere of the cerebellum.

Springing from each side of the pons, immediately medial to

the corresponding hemisphere of the cerebellum, are the motor
root and sensory root of the trigeminal nerve of that side.

GENERAL FEATURES 369

Below the pons, in the vallecula between the hemispheres

of the cerebellum, is the medulla oblongata. Springing from
the sulcus between the medulla oblongata and the pons, are
the abducens, the facial, and the acoustic nerves, in that
order from the median plane to the lateral border, on each
side.

The medulla oblongata is cleft, in the median plane, by an

anterior longitudinal fissure which is bounded, on each side, by
a longitudinal elevation called a pyramid. At the lateral side
of the upper part of each pyramid is an oval prominence
called the olive, and between the olive and the pyramid
lie the fila of the hypoglossal nerve ; whilst attached to the
sides of the medulla oblongata, a little dorsal to the olive,
are the fila of the glosso-pharyngeal, the vagus, and the
accessory nerves, in that order from above downwards.

At the sides of the pons and the medulla oblongata are

the inferior surfaces of the hemispheres of the cerebellum.

When the positions of the fila of origin of the cerebral

nerves have been noted, the hind-brain and the lower part
of the mid-brain should be removed. When that has been
done the posterior sections of the inferior surfaces of the
hemispheres will be exposed. They are separated from
each other, posteriorly, in the median plane, by the posterior
part of the longitudinal fissure, but they are united, more
anteriorly, immediately dorsal to the anterior part of the mid-
brain, by the splenium of the corpus callosum (Fig. 138).

When the points mentioned above have been verified the

dissector should examine the dorsal aspect of the hind-brain,
which is formed by the cerebellum, and he should note that
it is separable into two hemispheres united by a median ridge
called the superior vermis. The antero- posterior length of
the superior vermis is not so great as the antero-posterior
length of the hemispheres ; therefore the hemispheres are
separated, anteriorly, by an anterior notch and, posteriorly, by
a posterior notch.

The dissector should terminate his inspection of the general

features of the brain by gently separating the medulla oblongata
from the inferior aspect of the cerebellum, if he is dealing
with a specimen and not a cast ; when he has done that, he
will be able to convince himself that the roof of the cleft or
vallecula, in which the medulla oblongata lies, is formed by
the inferior part of the middle portion of the cerebellum,

VOL. Ill 24

370 THE BRAIN

which projects downwards into the vallecula, and is called

the inferior vermis.

When the inspection of specimens from which the mem-

branes have been removed is finished, the dissector should
turn to the examination of the membranes which still cover
his own specimen; they are the arachnoid and the pia mater.

Arachnoidea Encephali. The arachnoid forms an inter-

mediate covering for the brain. It is placed between
the dura mater and the pia mater; it is directly continuous
with the arachnoid of the spinal medulla ; and it is con-
nected with the dura mater and the pia mater along the
nerve roots and along the blood vessels of the brain. It
is an exceedingly thin and delicate membrane, which can
be seen best on the base of the brain, because, in that
locality, it is not so closely applied to the pia mater as
elsewhere. Unlike the pia mater it does not (except in
the case of the longitudinal and the lateral fissures) dip
into the sulci or fissures on the surface of the cerebrum and
cerebellum. It bridges over the inequalities on the surface
of the brain and it is spread out in the form of a very distinct
sheet over the medulla oblongata, the pons, and the hollow
on the lower surface of the brain which lies anterior to the
pons. The cut ends of several of the cerebral nerves will
be seen passing through the arachnoid ; whilst, anteriorly,
immediately to the lateral side of the optic nerve, the internal
carotid artery will be noticed piercing it.

Cavum Subarachnoideale. The interval between the arach-

noid and the pia mater receives the name of the subarachnoid
space. It contains the subarachnoid fluid, and is broken up
by a meshwork of fine filaments and trabeculae, which connect
the two bounding membranes (viz., the arachnoid and the pia
mater), in the most intimate manner, and which form a
delicate sponge-like interlacement between them. Where
the arachnoid passes over the summit of a cerebral gyrus,
and is consequently closely applied to the subjacent pia mater,
the meshwork is so close and the trabeculse so short that the
two membranes cannot be separated from each other. To
the dissector they appear to form a single lamina. In the
intervals between the rounded margins of adjacent gyri distinct
angular spaces exist between the arachnoid and the pia mater.
In those spaces the subarachnoid tissue can be studied, and
it will be seen that the spaces serve as communicating
MEMBRANES

channels for the free passage of the subarachnoid fluid from

one part of the brain to another. The larger branches of
the arteries and veins of the brain traverse the subarachnoid
space; their walls are directly connected with the subarachnoid
trabeculse and are bathed by the subarachnoid fluid.

Cisternae Subarachnoideales. In certain situations the

arachnoid is separated from the pia mater by intervals of
considerable depth and extent. Such expansions of the
subarachnoid space are termed subarachnoid cisterns. In
them the subarachnoid tissue is relatively reduced. There

Subarachnoid space and trabeculae

""Dura mater
-~~~Subdural space
\ "Arachnoid
Pia mater

FIG. 140. Diagrammatic section through the Meninges of

the Brain. (Schwalbe. )

co. Grey matter of cerebral gyri.

is no longer a close meshwork ; the trabeculae connecting the

two bounding membranes take the form of long filamentous
intersecting threads which traverse the spaces. The dissector
will obtain a beautiful demonstration of the conditions de-
scribed by dividing the sheet of arachnoid which is spread
over the medulla oblongata and pons, and turning the two
pieces gently aside. The division must be made in the
median plane with scissors.

Certain of the cisternse require special mention. The

largest and most conspicuous is called \hz l risterna cerebello-
medullaris (O.T. magna) (Fig. 141). It is a direct upward
continuation of the posterior part of the subarachnoid space
of the spinal meninges into the posterior part of the cranium.
It is formed by the arachnoid membrane bridging over the

in 24 a

372
THE BRAIN

wide interval between the medulla oblongata and the

posterior part of the inferior surface of the cerebellum.

The cisterna pontis is the name given to another of the

subarachnoideal spaces. It is the continuation upwards,
on the floor of the cranium, of the anterior part of the sub-

Arrow in interventricular foramen

Caudate nucleus in right lateral ventricle /
Genu of corpus callosum
Subarachnoid space
Arachnoid membrane

Fornix

i Massa intermedia

arachnoid tissue in tela chorioidea

Layers of pia mater of tela chorioidea oi
I Supra-pineal recess third vent

L Pineal body

Aquaeductus cerebri
Lamina quadrigemi
(Tectum). The poi
crosses the cisU
venae magnae cei

Anterior
commiss
Cisterna ch

Optic chiasma

Hypophysis

Cisterna

- 11 "' - s ' -+JF/ /

,sure^ ' ,' ft

. s ' X ' '

lasmatis ,' V_ ' y I */ yM'
ic chiasma / / s\Jk.L ?' '-' /

Hypophysis / / /* -^

interpeduncularis / / , '
Cisterna pontis / / / \ !
Pia mater on pons / / /

po

Pedunculus cerebri
Posterior commissure

Fourth ventricle

"" Cisterna cerebello-medulla

Median aperture of
fourth ventricle

FIG. 141. Diagram showing some of the Subarachnoid Cisterns. Dark

blue line indicates arachnoid membrane. Pale blue, Subarachnoid tissue
containing cerebro-spinal fluid. Dark red indicates cut margin of pia
mater. Pale red, surface of pia mater from which arachnoid has been
removed. Purple indicates epithelial lining of the cavities of the brain.

arachnoid space of the spinal meninges. In the region^ of

the medulla oblongata it is continuous, on each side, with
the cerebello-medullary cistern, so that that subdivision of
the brain is completely surrounded by a wide Subarachnoid
space. Within the cisterna pontis are the vertebral and
basilar arteries.

MEMBRANES 373

Anterior to the pons the arachnoid membrane crosses

between the projecting temporal lobes, and covers in the
deep hollow in that region of the base of the brain. The
space so enclosed is called the cisterna interpeduncularis, and
within it are placed the large arteries which take part in the
formation of circulus arteriosus. The cisterna interpedun-
cularis is continuous, anteriorly, with the cisterna chiasmatis,
which lies anterior to the optic chiasma and lodges the anterior
cerebral arteries (Fig. 141).

All the subarachnoid cisterns communicate in the freest

manner with one another, and also with the narrow sub-
arachnoid intervals on the surface of the cerebrum. The
subarachnoid space does not communicate in any way with
the subdural space. In certain localities, however, it com-
municates with the ventricular system of the brain by small
apertures. Three such apertures are described in connection
with the fourth ventricle, whilst another slit, on each side,
is said to lead from the cisterna interpeduncularis into the
lower and anterior end of the corresponding inferior horn of
the lateral ventricle.

Extending laterally from the cisterna interpeduncularis,

on each side, is the cisterna fossa lateralis cerebri, which
runs along the stem of the lateral fissure into the lateral fossa,
which is the recess in which the insula lies. In it lie the
middle cerebral vessels. Anteriorly, the cisterna chiasmatis
is continuous with a prolongation which extends into the
longitudinal fissure along the anterior cerebral vessels. A
dilatation of the subarachnoid space over the dorsum of
the mid-brain, around the great cerebral vein (O.T. vena
rnagna Galeni), is called, the cisterna vence magnce, cerebri.

The cisterna venae magnae cerebri was opened when the

mid-brain was divided, during the removal of the brain.
The dissector should now examine the other cisternae by
carefully dividing the arachnoid, where that has not already
been done.

Dissection. Divide the arachnoid, in the median plane,

along the anterior surfaces of the medulla oblongata and the
pons (if the division has not been made previously), and turn
the flaps to the sides. When that has been done the upper ends
of the vertebral arteries, and the basilar artery, which is formed
by their union, will be exposed, lying in the cisterna pontis.

Carry an incision backwards and laterally, through each flap

of arachnoid, into the angle between the medulla oblongata and
in 24 &

374 THE BRAIN

the posterior part of the inferior surface of the cerebellum, and

so open the large cisterna cerebello-medullaris. It lies between
the inferior verrnis of the cerebellum and the dorsal surface of
the medulla oblongata, and it communicates, through the thin
dorsal wall of the medulla oblongata, with the cavity of the
hind-brain, which is called fourth ventricle. Note that a large
branch of each vertebral artery, called the posterior inferior
cerebellar, passes into the cerebello-medullary cistern, on its
way to its distribution to the posterior part of the inferior aspect
of the cerebellum.

Turn again to the lower surface of the pons, and carry the
median incision in the arachnoid, forwards, into the inter-
peduncular region, as far as the posterior border of the in-
fundibulum, and so open the cisterna interpeduncularis. Note
that the arachnoid which forms the floor or inferior wall of the
interpeduncular cistern is perforated posteriorly, on each side,
by the oculo-motor nerve, and anteriorly and more laterally by
the internal carotid artery.
Take away the arachnoid which forms the lower wall of the
cisterna interpeduncularis, and so expose the basilar artery as
it terminates in its two posterior cerebral branches. Find also
the two posterior communicating arteries, which run forwards,
one on each side, from the corresponding posterior cerebral
artery, to join the internal carotid arteries, which enter the
antero-lateral angles of the cisterna interpeduncularis.

Draw the optic chiasma carefully backwards and cut through

the arachnoid immediately in front of it, to open the cisterna
chiasmatis. Carry the incision in the arachnoid of the cisterna
chiasmatis laterally, round the lateral borders of the optic
chiasma, and note that the cisterna chiasmatis communicates,
round the margins of the chiasma, with the cisterna inter-
peduncularis. Take away the arachnoid which has already
been divided, and note that beyond the lateral borders of the
optic chiasma, both the cisterna interpeduncularis and the
cisterna chiasmatis are prolonged laterally, on each side, between
the frontal and the temporal regions of the brain, into the stem
of the lateral fissure.

Clean the internal carotid arteries as they lie at the sides of

the optic chiasma, and note (i) that each communicates with
the corresponding posterior cerebral artery by means of the
posterior communicating artery ; (2) the division of each
internal carotid into a middle and an anterior cerebral branch.
The middle cerebral branch runs laterally into the stem of the
lateral fissure, and the anterior cerebral turns medially above the
optic chiasma, in the cisterna chiasmatis, to reach the longi-
tudinal fissure, into which it passes ; but as it enters the fissure
it is connected with its fellow of the opposite side by the anterior
communicating artery.

It is not advisable to follow the cerebral arteries further

at this stage.

Granulationes Arachnoideales (O.T. Pacchionian Bodies).

The connection of the arachnoideal granulations with the
arachnoid has been referred to already (p. 100).

MEMBRANES

375

Pia Mater Encephali. The pia mater forms the immediate

investment of the brain. It is finer and more delicate than
the corresponding membrane of the spinal medulla, and it
follows closely all the inequalities on the surface of the brain.
Thus, in the case of the cerebrum, it forms a fold within
every sulcus and lines both sides of the cleft. On the cere-
bellum the relation is not so intimate ; it is only the larger
fissures of the cerebellum which contain folds of pia mater.
It has been noted that the larger blood vessels of the
brain run in the subarachnoid space j the finer twigs enter the

Lateral lacuna

Arachnoideal
granulation

Arachnoideal granulation
Lateral lacuna

Dura mater

mater
Subarachnoid space

Arachnoid

Falx cerebri

FIG. 142. Diagram of a frontal section through the middle portion of the
cranial vault and subjacent brain to show the membranes of the brain
and the arachnoideal granulations.

pia mater, where they ramify and anastomose before passing

into the substance of the brain. As they enter the brain they
carry with them sheaths derived from the pia mater. Con-
sequently, if the dissector raises a portion of that membrane
from the surface of the cerebrum, a number of fine processes
will be seen to be withdrawn from the cerebral substance.
They are the blood vessels, and they give the deep surface
'of the membrane a rough and flocculent appearance.

The pia mater is not confined to the exterior of the brain.

A fold is carried into its interior. This will be exposed in
the dissection of the brain, and will be described under the
name of the tela chorioidea (O.T. velum interpositum) of the
third ventricle (Fig. 174).
in 24 c

376 THE BRAIN

BLOOD VESSELS OF THE BRAIN.

The dissector should commence his study of the blood
vessels of the brain by an inspection of the veins of the brain.
He will readily find and easily follow some of the venous
blood channels, but he will have considerable difficulty in
tracing others from their commencements to their termina-
tions. Indeed, it may be that he will have to refer to specially
prepared specimens for confirmation of some of the points
about to be noted.

The Veins of the Brain. The venous channels of the

brain include the venous blood sinuses of the dura mater,
and the veins which open into them. The venous sinuses
were noted when the dura mater was studied after the
removal of the brain (pp. 113, 114, 115).

Veins of the Cerebral Hemispheres. The veins which

join the venous sinuses of the dura mater, and their tributaries
are still in situ. The majority of them lie in the subarachnoid
space on the surfaces of the hemisphere, but a few issue from
the interior of the brain. One of the latter, the great cerebral
vein, was seen when the upper parts of the brain were re-
moved from the cranium (p. 108). It emerges from beneath
the splenium of the corpus callosum, and runs upwards and
backwards, in the cistern of the great cerebral vein, to terminate
by joining the anterior end of the straight sinus in the tentorium
cerebelli (p. 107, Fig. 35). The cut end of it can still be
seen lying in the cistern, immediately posterior to the splenium
of the corpus callosum.

Entering the great cerebral vein on each side is a tributary

called the basal vein ; it runs round the side of the
pedunculus cerebri, from the region of the anterior perforated
substance. The basal vein is formed, in the subarachnoid
space below the anterior perforated substance, by the union
of three veins, viz., (i) the anterior cerebral vein with (2) a vein
from the surface of the insula, called the deep middle cerebral
vein^ and (3) the anterior striate vein, which issues from the
substance of the brain. The anterior cerebral vein drains the
greater part of the medial surface of the hemisphere of the
same side and issues from the anterior part of the longitudinal
fissure, immediately anterior to the optic chiasma; then it

BLOOD VESSELS OF THE BRAIN

377

crosses the anterior perforated substance, on its way to its

termination in the basal vein.

The dissector may find it difficult or even impossible to

demonstrate the basal vein and its tributaries if the veins are
empty, but in a certain number of specimens they are found
without difficulty.
The veins of the supero-lateral surface of the hemisphere
are divided into two groups the superior and the inferior
cerebral veins.

A superior cerebral vein' Cut edge of dura mater

Great anastomotic vein - -:-~ l j,;V~ ' \ Superior cerebral ve

Superior sagittal

Transverse sinus
Inferior anastomotic vein

An inferior cerebral .vein

Superficial middle cerebral vein

An inferior cerebral vein

Sigmoid part of transverse sinus

FIG. 143. Veins of the supero-lateral surface of the Hemisphere. The

dura mater has been removed, but the arachnoid and pia mater are in situ.

The superior cerebral veins run upwards towards the supero-

medial border of the hemisphere where they terminate in the
superior sagittal sinus. They vary in number from six to
twelve. The more anterior veins enter the sinus at right
angles, but the orifices of the more posterior veins are directed
obliquely forwards that is, against the blood stream in the
sinus (Fig. 143).

The majority of the inferior cerebral veins converge towards

the posterior ramus of the lateral fissure, where they terminate
in the superficial middle cerebral vein, which runs forwards,
along the fissure, and then, leaving the posterior branch of

378 THE BRAIN

the fissure, it turns medially, along the stem of the fissure, and
ends in the cavernous sinus. If the vein is traced, its ter-
minal cut end will be found in the region of the anterior part
of the interpeduncular fossa.

The inferior cerebral veins which do not terminate in the

superficial middle cerebral vein run downwards, towards the
infero-lateral border of the hemisphere, and they end in the
transverse sinus.
In almost all cases there is a direct communication
between the superior sagittal sinus and the posterior part of
the superficial middle cerebral vein, by means of a vein which
is called the great or superior anastomotic vein ; and, very
frequently, the posterior part of the superficial middle
cerebral vein communicates with the transverse sinus, through
one of the inferior cerebral veins which opens into both, and
which is called the inferior or small anastomotic vein. Both
the communications may become of importance in cases in
which the posterior part of the superior sagittal sinus or the
commencements of both transverse sinuses are obstructed.

The majority of the veins on the medial surface of the

hemisphere terminate in the anterior cerebral vein, which
runs along the upper surface of the corpus callosum, but some
end in the inferior sagittal sinus, and some ascend to the
superior sagittal sinus.

The veins from the anterior part of the inferior surface of

the hemisphere join either the superficial middle cerebral vein
or the anterior cerebral vein ; those from the posterior part
of the inferior surface pass to the basal vein, to the superior
petrosal sinus, to the straight sinus, and to the transverse
sinus. The veins from the interior of the hemispheres
which join the great cerebral vein will be described later
(see p. 444).

Veins of the Mid-Brain. There are no large veins from

the mid-brain, and the small veins which return the blood
from that part of the brain end either in the great cerebral
vein, or in the basal veins, or in both.

Veins of the Cerebellum. The veins on the superior

surface of the cerebellum pass forwards ; some terminate in
the great cerebral vein, others in the superior petrosal
sinuses. Some of the veins of the inferior aspect of the
cerebellum end in the straight sinus, others in the transverse
sinus, the occipital sinus, or an inferior petrosal sinus.

BLOOD VESSELS OF THE BRAIN 379

Veins of the Pons. The veins from the upper part of the
pons join the basal vein, and those from the inferior part
either join the cerebellar veins or they end in the inferior
petrosal sinuses.

Veins of the Medulla Oblongata. The smaller veins of

the medulla oblongata converge to an anterior and a posterior
median vein, or they run along the roots of the last four
pairs of cerebral nerves. The anterior median vein com-
municates, above, with the veins of the pons, and, below,
with the veins of the spinal medulla. The posterior median
vein also communicates, below, with the veins of the spinal
medulla, and it terminates, above, either in the inferior
petrosal sinuses or in the basilar plexus. The efferents
which accompany the last four cerebral nerves end either in
the inferior petrosal sinuses, in the upper parts of the internal
jugular veins, or in the pharyngeal plexus.

Arteries which supply Blood to the Brain. Four main

arterial trunks carry blood into the cranium for the supply
of the brain viz., the two internal carotid arteries and the
two vertebral arteries. The vertebral arteries enter through
the foramen magnum, whilst the internal carotid arteries gain
admittance through the lacerate foramina, after traversing the
carotid canals. Both the vertebral and the internal carotid
arteries were divided when the brain was removed from the
cranium. The cut ends of the internal carotids will be seen,
at the base of the brain, close to the sides of the optic
chiasma. When the remains of the membranes are taken
away from around it, each internal carotid will be found to
divide, a short distance above its cut extremity and immedi-
ately below the anterior perforated substance, into a larger
branch, the middle cerebral artery, which runs laterally, and
a smaller branch, the anterior cerebral artery, which runs
medially.

The vertebral arteries curve round the sides of the medulla

oblongata and they unite at its upper border, in the median
plane, to form the basilar artery, which runs to the upper
border of the pons, where it divides into the two posterior
cerebral arteries.

But the cerebral arteries which spring from the internal

carotid arteries of opposite sides are brought into association
with one another, and with the posterior cerebral arteries,
which spring from the basilar, by a remarkable and complete

THE BRAIN

series of anastomoses which take place at the base of the

brain, as well as by the anastomoses of their terminal branches
in the pia mater on the surfaces of the hemispheres.

The more striking series of anastomoses are those at the

base of the brain ; they constitute the circulus arteriosus
(Willis), and the arteries which take part in the formation of
the circle lie in the cisterna interpeduncularis and the cisterna
chiasmatis.

Circulus Arteriosus (O.T. Circle of Willis). The series

of anastomoses which forms the arterial circle lies at the

.Anterior cerebral artery

Anterior communicating

Internal, carotid
W
Middle cerebral

Antero-lateral central arteries

Posterior communicating

Postero-median central arteries

Posterior cerebral artery

Superior cerebellar artery

FIG. 144. Diagram of the Circulus Arteriosus.

base of the brain, in the deep hollow anterior to the pons

and around the optic chiasma. The so-called circle has,
in reality, a heptagonal or hexagonal outline, and the vessels
which compose it lie, as already stated, in the cisterna inter-
peduncularis and the cisterna chiasmatis. Anteriorly it is
formed by the anterior communicating artery, which links
together the two anterior cerebral arteries. On each side is
the posterior communicating artery, connecting the internal
carotid (from which the anterior cerebral springs) with the
posterior cerebral. The arterial ring is completed posteriorly

BLOOD VESSELS OF THE BRAIN

by the bifurcation of the basilar artery into the two posterior

cerebral vessels (Fig. 144). As a rule, the circulus arteriosus
is not symmetrical. One posterior communicating artery is
almost invariably larger than its fellow of the opposite side.

Two systems of branches, both going to the cerebrum but

differing greatly in their mode of distribution, proceed from
the cerebral arteries. One system consists of very numerous,

Optic nerve

Internal carotid
artery

Trigeminal nerve
Trochlear nerve
Glosso-pharyn-
geal nerve

Accessory nerve

Section through

the medulla

oblongata

Posterior
communicating
artery

Oculo-motor nerv
Posterior cerebr
artery
Superior
cerebellar arte
Tentorium

Basilar
artery

Vertebral
artery

Superior petrc

sinus

Transverse sinu<

Transverse sinus

Occipital sinus

Straight sinus (divided)

Superior sagittal sinus

FIG. 145. Floor of the Cranium after the removal of the Brain and the
Tentorium Cerebelli. The blood vessels forming the Circulus Arteriosus
have been left in place.

slender twigs, which, as a rule, come off in groups in certain

localities, and at once pierce the substance of the cerebrum
to gain its interior. It is the system of central or basal
branches. The other system is composed of branches which
ramify over the surface of the cerebrum, and it is termed the
system of cortical branches. The central parts of the brain,
including the basal ganglia, receive their blood supply from

382 THE BRAIN

the central system, and the vessels which constitute that

group do not anastomose with each other. The cortical
vessels supply the cerebral cortex and the finer branches,
which ramify in the pia mater, anastomose with one another ;
therefore, the neighbouring vascular districts of the cerebral
cortex are not sharply cut off from one another.

Arteriae Vertebrates. Each vertebral artery enters the sub-

arachnoid space, in the upper part of the vertebral canal, by
piercing the dura mater and the arachnoid. Gaining the
interior of the cranium, through the foramen magnum, it
runs upwards, at first, on the side of the medulla oblongata,
but it soon inclines to the anterior aspect of the medulla
oblongata, and, meeting its fellow of the opposite side in
the median plane, it unites with it, at the lower border of
the pons, to form the basilar artery.

The branches given off from the intracranial part of the

vertebral artery are :

1. Posterior spinal. 3. Anterior spinal.

2. Posterior inferior cerebellar. 4. Bulbar.

Arteria Spinalis Posterior. The posterior spinal artery is

the first branch given off from the vertebral artery after it
pierces the dura mater. It passes, downwards, on the spinal
medulla along the line of the posterior nerve-roots (p. 90).

Arteria Cerebelli Inferior Posterior. The posterior inferior

cerebellar artery is the largest branch of the vertebral artery.
It takes origin immediately above the posterior spinal artery,
and pursues a tortuous course backwards, on the side of the
upper part of the medulla oblongata, between fila of the
hypoglossal nerve, and then between fila of the vagus.
Finally, turning round the restiform body, it gains the vallecula
of the cerebellum and enters the cisterna cerebello-medullaris,
where it ends by dividing into two terminal branches. One
of the branches ramifies on the posterior part of the inferior
surface of the corresponding cerebellar hemisphere, the other
runs backwards, in the vallecula, in the groove between the
vermis and the hemisphere supplying both. The trunk of
the artery gives branches to the medulla oblongata which
supply the olive, and the fibres of the spino-cerebellar, the
spino-thalamic, the rubro-spinal, and the olivo-cerebellar
tracts, as well as the nuclei of the vagus and glosso-pharyngeal
nerves (Bury and Stopford).

Arteria Spinalis Anterior. The anterior spinal artery arises

BLOOD VESSELS OF THE BRAIN

383

near the lower border of the pons, and it is rare to find the
vessels of the two sides of equal size. They converge, on
the anterior surface of the medulla oblongata, and unite
to form the commencement of the median vessel which
extends downwards on the ventral face of the spinal medulla.
The bulbar arteries are minute vessels which enter the
substance of the medulla oblongata ; they spring both from the
vertebral artery itself and also from its branches.

Intermediate medial frontal

Posterior medial frontal

Anterior medial frontal

Anterior
medial
frontal
branches

Medial orbital
branches
Anterior cerebral artery

Calcarine branch Posterior cerebral artery

Temporal branches
FIG. 146. Medial and Tentorial Surfaces of the left Cerebral Hemisphere.
The district supplied by the anterior cerebral artery is tinted purple ; by
the middle cerebral artery, blue ; and by the posterior cerebral artery,
red. (Semi-diagrammatic.)

Arteria Basilaris. The basilar artery runs from the lower

border to the upper border of the pons, occupying the median
groove of the pons and lying in the median part of the cisterna
pontis. It is formed, at the lower border of the pons, by the
union of the two vertebral arteries, and it divides, at the upper
border, into the two posterior cerebral arteries. It is sup-
ported anteriorly by the basilar portion of the occipital bone
and the dorsum sellae of the sphenoid (Fig. 38).

The majority of the branches which spring from the basilar

artery arise from its sides and pass laterally from it. They

are :-

1. Pontine.

2. Internal auditory.

3. Anterior inferior cerebellar.

4. Superior cerebellar.

5. Posterior cerebral.

384 THE BRAIN

Rami ad Pontem. The pontine branches are numerous

slender twigs which run, laterally, on the surface of the pons
before they enter its substance.

Arteria Auditiva Interna. The internal auditory artery

will be seen amongst the pontine branches. It accompanies
the acoustic nerve into the internal acoustic meatus, and is
distributed to the internal ear.

Arteria Cerebelli Inferior Anterior. The anterior inferior

cerebellar artery inclines postero-laterally to reach the anterior
part of the inferior surface of the cerebellum.

Arteria Cerebelli Superior. The superior cerebellar artery,

on each side, is a large vessel which springs from the basilar
close to its termination. It winds laterally and backwards,
round the corresponding pedunculus cerebri, along the upper
border of the pons, to the upper surface of the cerebellum,
where its terminal branches ramify before entering the grey
matter.

Arteria Cerebri Posterior. Immediately beyond the origin

of the two superior cerebellar arteries the basilar artery
bifurcates into the two posterior cerebral arteries, which
diverge from each other and curve laterally and backwards
round the mesencephalon. Then they run backwards towards
the inferior surface of the splenium of the corpus callosum.
In the first part of its course each posterior cerebral artery lies
deeply, in the interval between the corresponding pedunculus
cerebri and the hippocampal gyrus ; then it enters the cal-
carine fissure, and ends, in the fissure, by dividing into two
terminal branches, viz., the calcarine and the parieto-occipital
(Figs. 146, 147).

The oculo-motor nerve passes forwards in the interval

between the posterior cerebral and the superior cerebellar
arteries, close to the place where they arise from the basilar ;
and the small trochlear nerve winds round the pedunculus
cerebri below the posterior cerebral artery.

The following branches spring from each posterior

cerebral artery :

f Postero-median.
Central or basal -j Postero-lateral.

Posterior chorioidal.

( Temporal.

Cortical \ Calcarine.

Parieto-occipital.

The postero- median central arteries arise close to the origin of the parent
trunk. They proceed upwards, in the interval between the pedunculi cerebri,
and, after piercing the substantia perforata posterior (O.T. posterior per-

BLOOD VESSELS OF THE BRAIN 385

forated spot), they supply the hypothalamus, the thalamus, and the medial
part of the pedunculus cerebri.

The postero -lateral central arteries are small slender twigs which arise
on the lateral surface of the pedunculus cerebri, and go to the lamina
quadrigemina and the thalamus.

The posterior chorioidal artery goes to the tela chorioidea of the third
ventricle and the chorioid plexus of the lateral ventricle (Figs. 148 and
163).

The cortical branches are distributed to the medial,

inferior, and supero-lateral surfaces of the posterior part of
the hemisphere (Figs. 146, 147, 148).

The temporal branches, two or three in number, turn laterally, over the
hippocampal gyrus, and ramify on the inferior surface of the temporal lobe
of the cerebrum (Figs. 146 and 147).

The calcarine branch follows the calcarine fissure to the occipital pole
of the cerebral hemisphere, round which it turns to reach the lateral surface
of the occipital lobe. It is the chief artery of supply to the cuneus and the
lingual gyrus, and is therefore specially concerned in the nutrition of the
visual centres of the cerebral cortex (Fig. 146).

The parieto-occipital artery is the smaller of the two terminal branches

of the posterior cerebral. It runs upwards in the parieto-occipital fissure,
and at the supero-medial margin of the hemisphere it curves laterally to
reach the supero-lateral surface of the occipital lobe. It supplies branches
to the cuneus and praecuneus (Figs. 146, 148).

Arteria Carotis Interna. The cut extremity of the internal

carotid artery will be found at the lateral side of the optic
chiasma, in the angle between the optic nerve and the optic
tract. Thence the artery turns laterally, below the substantia
perforata anterior, close to the commencement of the lateral
fissure, and it ends by dividing into the anterior and middle
cerebral arteries (Fig. 144). The middle cerebral artery is the
larger of the two terminal branches. It appears to be the
continuation of the parent trunk and it runs laterally into the
stem of the lateral fissure. The anterior cerebral artery, on
the other hand, passes ' medially from the internal carotid,
almost at a right angle. Consequently emboli pass more
frequently into the middle cerebral than into the anterior
cerebral artery. From each internal carotid artery, after it
has emerged from the cavernous sinus (p. 239), the following
branches arise :

1. Ophthalmic (already studied, I 3. Chorioidal.

p. 252). 4. Middle cerebral.

2. Posterior communicating. 5. Anterior cerebral.

Arteria Communicant Posterior. The posterior communi-

cating artery, as a rule, is a slender branch which passes
VOL. in 25

386
THE BRAIN

backwards to join the posterior cerebral, between its postero-

median and postero-lateral groups of central twigs (Fig. 144).

Arteria Chorioidea. The chorioidal artery enters the

inferior cornu of the lateral ventricle, and passes into the
chorioid plexus in that cavity (Fig. 147).

Arteriae Cerebri Anteriores. Each anterior cerebral artery

runs first horizontally, above the optic chiasma, towards the
median plane (Figs. 146, 147). Then, bending sharply upon

Medial .orbital branches

Olfactory sulcus

Lateral orbital branches

1; j \V/ 1 / W ^~~^\W/\

Anterior cerebral artery

Anterior communicating

artery \

Internal carotid artery

Middle cerebral artery

Posterior communicating .-'

artery

Superior cerebellar artery

Basilar artery

Posterior chorioidal artery

Posterior cerebral artery

Calcarine fissure -

Chorioidal branch of
internal carotid

. Temporal
branches
Inferior temporal
sulcus

Collateral fissure

FIG. 147. Inferior surface of the Cerebral Hemisphere. The districts sup-
plied by the three cerebral arteries are tinted differently : posterior cerebral
artery, red; middle cerebral artery, blue; anterior cerebral artery, purple.

itself, it turns upwards, in the anterior part of the longitudinal

fissure, anterior to the lamina terminalis, and along the rostrum
to the genu of the corpus callosum, round which it bends ;
then it passes backwards, along the medial face of the corre-
sponding hemisphere, on the upper surface of the corpus
callosum, to the parieto-occipital fissure (Fig. 146). As it
lies anterior to the lamina terminalis it is connected with the
opposite anterior cerebral artery by the anterior communicating

BLOOD VESSELS OF THE BRAIN 387

artery, and as it passes along the longitudinal fissure, between

the hemispheres, it lies close to its fellow of the opposite side.
Numerous branches proceed from each anterior cerebral artery :
Basal or central { Antero-medial.
( Medial orbital.
r , . , J Anterior medial frontal.

I Intermediate medial frontal.

I Posterior medial frontal.

The ant ero -medial arteries pierce the base of the brain anterior to the
optic chiasma. They supply the rostrum of the corpus callosum, the
lamina terminalis, and the septum pellncidum.

The cortical branches supply the greater part of the

medial surface of the hemisphere and parts of the orbital
and supero-lateral surfaces (Figs. 146, 147, 148).

The medial orbital branches are two or three in number. They turn
round the margin of the longitudinal fissure to reach the medial part of the
orbital surface of the frontal lobe. They supply the gyrus rectus, the olfactory
tract and bulb, and the medial orbital gyrus (Figs. 146 and 147).

The anterior medial frontal artery ramifies upon the anterior part of the
medial surface of the frontal lobe, and its terminal twigs turn round the
upper margin of the cerebral hemisphere, and supply the upper part of the
supero-lateral surface of the frontal lobe (Fig. 146).

The intermediate medial frontal artery ramifies on the medial surface

of the frontal lobe posterior to the preceding branch. Its terminal part
passes over the paracentral lobule, and reaches the adjacent portion of the
supero-lateral surface of the cerebral hemisphere (Figs. 146, 148).
The posterior medial frontal artery ramifies on the medial surface of
the prsecuneus, and its terminal twigs turn round the upper margin of
the cerebral hemisphere to gain the supero-lateral surface.

Arterise Cerebri Mediae. At first each middle cerebral

artery passes laterally, along the stem of the lateral fiss-ure,
and then upwards in the lateral fossa, where, on the surface
of the insula, it breaks up into a number of large terminal
branches. Before the posterior ramus of the lateral fissure
is opened up to expose the insula in the lateral fossa, the
terminal branches may be seen emerging from between its
two lips (Fig. 148). Then they diverge and supply a wide
area of cortex on the supero-lateral surface of the hemisphere.

The branches which spring from each middle cerebral

artery may be classified as follows :

Lateral orbital.
Inferior lateral frontal.
Ascending frontal.
Cortical branches. parieta] { Ascending parietal<

Parieto-temporal.
Temporal.

3 88

THE BRAIN

The arteries of the ant ero -lateral central group are very numerous. They
pierce the substantia perforata anterior and supply the lentiform nucleus,
the internal capsule and the external capsule, the caudate nucleus, and a
portion of the thalamus.

The cortical branches supply the greater part of the

supero-lateral surface of the hemisphere, the lateral half of
the orbital surface, the lower surface of the interior part of
the temporal lobe and the temporal pole (Figs. 147, 148).

The frontal and parietal branches turn round the upper lip of the
posterior ramus of the lateral fissure and ascend on the supero-lateral
surface of the hemisphere. The frontal branches are : ( I ) lateral orbital,

Ascending parietal artery Central sulcu

Ascending frontal artery

Precentral sulcus
Inferior frontal
sulcus

Parieto-temporal artery

Superior
frontal
sulcus

Parieto-

occipital

fissure

(Lateral

part)

Inferior lateral frontal

artery
Posterior ramus of lateral fissure

Temporal branches

FIG. 148. Supero-lateral surface of the Cerebral Hemisphere. The districts

supplied by the three cerebral arteries are tinted differently : anterior
cerebral, purple ; middle cerebral, blue ; posterior cerebral, red. (Semi-
diagrammatic. )

to the lateral part of the orbital surface of the frontal lobe ; (2) inferior
lateral frontal, to the inferior and middle frontal gyri ; (3) ascending frontal ',
which runs upwards in relation to the anterior central gyrus (Figs. 147, 148).

The ascending parietal branch extends, in an upward and backward

direction, in relation to the posterior central gyrus, and its terminal twigs
supply the greater part of the cortex of the superior parietal lobule (Fig. 187).

The parieto -temporal branch is a very large artery which issues from
the posterior part of the posterior ramus of the lateral fissure ; it sends
branches upwards to the inferior parietal lobule, and others which incline
downwards over the posterior part of the temporal lobe. Its twigs, as
a rule, do not encroach upon the supero-lateral surface of the occipital
lobe (Fig. 148).

The temporal branches, two or three in number, issue from the posterior
ramus of the lateral fissure, and, turning downwards and backwards, over
its lower lip (i.e. the superior temporal gyrus), they ramify upon the
lateral surface of the temporal lobe (Fig. 148).

BLOOD VESSELS OF THE BRAIN 389

The dissector should note that the branches of the middle

cerebral artery supply the greater part of the motor area of
the cortex, the greater part of the area for ordinary sensa-
tion, and area for hearing (cp. Figs. 148 and 153).

Dissection. When the distribution of the branches of the

cerebral arteries has been noted, the dissectors must remove
the blood vessels and the remains of the arachnoid first from
the base of the brain and then from the supero -lateral surfaces
of the hemispheres, commencing with the base. The dissection
must be done with forceps and a pair of scissors. In the basal
region very delicate manipulation is necessary, because the
cerebral nerves, at their points of attachment to the brain, are
so intimately connected with the pia mater that any undue
traction applied to the membranes will tear the nerves away.
Indeed, in the case of the medulla oblongata, the dissector is
advised to leave the pia mater in position until the nerve-roots
have been studied. The relation of the pia mater to the fourth
ventricle also renders this desirable.

The removal of the arachnoid and pia mater from the supero-
lateral surface must be commenced at the margins of that
surface, and the membranes must be reflected towards the
lateral fissure. When the margins of the fissure are reached
they must be pulled apart, then the larger branches and the
associated parts of the membranes, which lie in the fissure, can
be seen, but they must not be removed at present. Cut through
the membranes and the vessels along the margins of the fissure,
but leave their deeper parts in situ. Of course, at the present
stage, the membranes cannot be removed from every part of
the brain ; but as the dissection proceeds, opportunities for
completing the process will arise.

After the vessels and the membranes are removed from the
base and from the supero-lateral surfaces of the hemispheres,
the dissectors should commence their more detailed study of
the brain by the investigation of the base.

THE BASE OF THE BRAIN.

When the membranes and the blood vessels are removed

from the base of the brain two large rope-like strands,
called the pedunculi cerebri (O.T. crura), will be seen
issuing from the upper part of the pons. As the peduncles
emerge from the pons they are close together, but they
diverge as they pass upwards and forwards, and, finally,
each peduncle disappears into the base of the corresponding
cerebral hemisphere. As each peduncle passes into the corre-
sponding hemisphere it is embraced, on its lateral side, by the
hippocampal gyrus, but between the gyrus and the peduncle
is a white, flattened band, called the optic tract^ which is closely

in 25 a

390 THE BRAIN

applied to the side of the peduncle. The two optic tracts

converge as they pass forwards, and, finally, they are joined
together by a short, transverse commissural portion termed
the optic chiasma. The optic chiasma lies at the anterior end
of the interpeduncular fossa, and below the posterior end of
that portion of the longitudinal fissure which intervenes between
the inferior surfaces of the frontal lobes of the brain. The
optic nerves enter the antero-lateral angles of the chiasma.

Fossa Interpeduncularis. The interpeduncular fossa is

the rhomboidal region which is bounded posteriorly by the
pons, postero-laterally by the cerebral peduncles, antero-
laterally by the optic tracts, and anteriorly by the optic
chiasma ; within the limits of the fossa the following parts
are situated (i) the oculo-motor nerves; (2) the substantia
perforata posterior ; (3) the corpora mamillaria ; and (4)
the tuber cinereum, with the infundibulum.
. Nervus Oculomotorius. Each oculo-motor nerve issues
from the medial side of the corresponding cerebral peduncle,
below the posterior perforated substance (Fig. 149).

Substantia Perforata Posterior (O.T. Posterior Perforated

Space). The posterior perforated substance forms the roof or
superior wall of the posterior and deepest part of the inter-
peduncular fossa. It is a layer of grey matter in which there
are numerous small apertures. The apertures are caused by
the postero-medial central branches of the posterior cerebral
arteries, which were withdrawn from the apertures when the
pia mater was removed.

Corpora Mamillaria. The mamillary bodies are two small,

white, pea-shaped eminences, placed side by side immediately
anterior to the posterior perforated substance. They form
part of the hypothalamic region, and, at a later stage of the
dissection, their connections with the columns of the fornix
will be displayed.

Tuber Cinereum. The tuber cinereum is a slightly raised

field of grey matter which occupies the interval between the
optic chiasma, anteriorly, the corpora mamillaria, posteriorly,
and the optic tracts laterally. Springing from the anterior
part of the tuber cinereum, immediately posterior to the optic
chiasma, is the infundibulum or stalk of the hypophysis. When
the brain was removed the connection of the infundibulum
with the hypophysis was severed (p. 106).

Substantise Perforate Anteriores. The anterior perfor-

THE BASE OF THE BRAIN 391

ated areas are small triangular districts of grey matter, one

on each side. Each is bounded, posteriorly, by the uncinate
extremity of the hippocampal gyrus; anteriorly, by the
diverging striae of the olfactory tract; and, medially, by
the optic tract. Laterally, it passes into the roof of the
lateral fissure, and is perforated by the antero-lateral central
arteries (Figs. 147, 149). The grey matter of each anterior
perforated area is continuous, above, with a mass of grey
matter in the base of the corresponding cerebral hemisphere
which is called the corpus striatum (Fig. 185).

Lamina Terminalis. The lamina terminalis, which was

originally the anterior wall of the brain, will be displayed if
the optic chiasma is pulled gently backwards. It is a thin
lamina which passes upwards from the chiasma into the longi-
tudinal fissure, to become connected with the rostrum of the
corpus callosum. It closes the third ventricle anteriorly, and
is continuous, on each side, with the grey matter of the sub-
stantia perforata anterior (Fig. 186).

Superficial Attachments of the Cerebral Nerves. Twelve

cerebral nerves arise from or enter the brain, on each side of
the median plane. They are the olfactory or first, consisting
of about twenty separate filaments ; the optic or second ; the
oculo-motor or third ; the trochlear or fourth ; the trigeminal or
fifth; the abducent or sixth; the facial or seventh ; the acoustic
or eighth ; the glosso-pharyngeal or ninth; the vagus or tenth;
the accessory or eleventh ; and the hypoglossal or twelfth.

A thirteenth pair of cerebral nerves, called the nervi terminates ; is

known. Each nervus terminalis is attached to the cerebrum posterior
to the olfactory stride. Its fibres run alongside the corresponding olfactory
tract, and are distributed with the olfactory nerves to the upper parts of
the wall of the nasal cavity-. The functions of the nervi terminales are
unknown.

Each nerve is said to have a " superficial attachment " and

a "deep" origin or termination. By the term "superficial
attachment " is meant the region where its fibres enter or leave
the brain surface ; the terms " deep termination and origin "
indicate the connections which are established by the fibres
of the different nerves with nuclei or clusters of nerve-cells
within the substance of the brain. The nuclei are of two
kinds: (i) those in connection with which the afferent or
entering nerve fibres end; and (2) those from which the
efferent or emerging nerve fibres arise. It is the superficial
in 25 b

392
THE BRAIN

attachments only which come under notice of the dissector

at the present time.

No fewer than eight pairs of the cerebral nerves, from the

fifth to the twelfth inclusive, have a superficial attachment to

Optic chiasma

Infundibulum

Olfactory bulb

Olfactory tract

Abducen
nerve

Hypoglossal
nerve

Trigeminal

Motor root of
facial nerve
Acoustic nerve

nsory root of
facial nerve

Glosso pharyngeal
nerve

Pyramid
Vagus nerve
Accessory nerve

Spinal medulla (cut) Hypoglossal nerve

FIG. 149. The Base of the Brain with the Cerebral Nerves attached.

the medulla oblongata and the pons that is to the ventral part
of the hind brain.

Nervus Hypoglossus. Upon the lateral aspect of the upper

half of the medulla oblongata there is a very conspicuous oval

THE BASE OF THE BRAIN

393

prominence called the olive. Medial to the olive is a large

elongated strand of the medulla oblongata, termed the
pyramid ; it is separated from the olive by a groove or sulcus
which is prolonged downwards for some distance beyond the
olive. From the part of the sulcus between the olive and the
pyramid spring the fila of the hypoglossal nerve (Figs. 149,
150) ; and from the lower part of the sulcus some of the fila
of the anterior root of the first cervical nerve issue.

Optic chiasma

Optic tract-
Corpus geniculatum/d:

Corpus geniculati

mediale

Substantia perforata
posterior

Junction of pons and

brachium pontis
Restiform body
Olive

Pyramid
External arcuate
fib

Decussation of
pyramids'

Optic nerve
Infundibulum
Tuber cinereum

Corpus mamillare

Oculo-motor nerve

(in.)

Trochlear nerve

(iv.) winding round

pedunculus cerebri

Trigeminal nerve (v.)

Abducens nerve (vi.)
Facial nerve (vn.)
Acoustic nerve (vm.)

Vago-glosso-pharyn-
geal nerve (x. and ix.)

Fila of hypoglossal
nerve (xn.) cut short

Accessory nerve (xi.)

Anterior root of
first cervical nerve

FIG. 150. Anterior aspect of the Medulla Oblongata, Pons, and

Mesencephalon of a full-time Foetus.

Nervi Glossopharyngeus et Vagus et Accessorius. Pos-

terior to the olive is the post-olivary sulcus, and a little more
dorsally lies the postero-lateral sulcus of the medulla oblongata,
in which a continuous row of nerve fila is attached. The fila
in question extend downwards, beyond the level of the olive,
and are attached to the whole length of the medulla oblongata
in linear order. They belong to three nerves, but it is im-
possible at present (seeing that the nerve-trunks which they
build up are divided) to determine precisely the number of

394

THE BRAIN

fila which belong to each. From below upwards, the nerves

which they form are the accessory, the vagus, and the glosso-
pharyngeal. The fila of the vagus and the glosso-pharyngeal
are much more closely crowded together than those of the
accessory (Fig. 150).

The roots of the accessory which spring from the medulla

oblongata constitute only one part of the nerve. The spinal
part springs from the spinal medulla, as low down as the sixth

Trochlear nerve

Sensory root of the trigeminal nerve

/ Motor root of the trigeminal

Oculo-motor nerve

Abd

ngemi

ucens nerve
Motor root of facial
erve

Cut edge of the

tentorium

Sensory root of
,/ facial nerve
"'--Acoustic nerve
Right transverse
Glosso-pharyngeal
nerve
Vagus nerve

Accessory nerve

Vertebral artery
Hypoglossal nerve
First spinal nerve
Accessory nerve

FIG. 151. Section through the Head a little to the right of the Median
Plane. It shows the posterior cranial fossa and the upper part of the
vertebral canal after the removal of brain and the spinal medulla.

cervical nerve, by a series of roots which issue from the lateral

funiculus, posterior to the attachment of the ligamentum
denticulatum (p. 83) (Figs. 149, 151).

Nervus Acusticus et Nervus Facialis. The acoustic and

facial nerves are attached, close together, at the lower border of
the pons, and immediately above the restiform body, which
extends from the medulla oblongata to the cerebellum
(p. 479) (Figs. 150, 151). The acoustic nerve is the larger
of the two, and it lies on the lateral side of the facial.
Its two roots embrace the restiform body ; the dorsal of

THE BASE OF THE BRAIN 395

the two is the cochlear root, the ventral is the vestibular

root.

The facial nerve is attached at the lower border of the

pons, just to the medial side of the acoustic nerve, by two roots
a large motor root, and a small sensory root (O.T. pars
intermedia) (Figs. 150, 151). The two roots unite in the
internal acoustic meatus.

Nervus Abducens. The abducens is a small nerve which

emerges from the groove between the lower border of the pons
and the lateral part of the pyramid. It is flattened out near
its origin and a surface view of it in that region gives a
deceptive idea of its size (Figs. 149, 150).

Nervus Trigeminus. The trigeminal is the largest of all

the cerebral nerves. It is attached to the side of the pons,
nearer its upper than its lower border, by two roots a large
sensory root and a small motor root, which are in a line
with the facial and acoustic nerves. The large, sensory root
(portio major) is composed of a great number of fila loosely
held together, but the small, motor root (portio minor) is
more compact, and it emerges antero-medial to the point at
which the sensory root enters the pons (Figs. 149, 151).

Nervus Trochlearis. The superficial origin of the trochlear

or fourth nerve can be seen when the anterior part of the
superior vermis of the cerebellum is displaced backwards.
It emerges from the anterior medullary velum, on the dorsal
aspect of the brain-stem, immediately below the quadri-
geminal lamina. It is a slender nerve and it has a long
intracranial course. In the first part of its course it winds
round the lateral side of the pedunculus cerebri, between the
cerebrum and cerebellum, to reach the interpeduncular region
(Figs. 149, 150).

Nervus Oculomotorius. The oculo-motor nerve issues, by

several fila, from the sulcus oculomotorius on the medial
face of the cerebral peduncle in the interpeduncular fossa
(Figs. 149, 150).

Nervus Opticus. The optic nerve is a large round nerve

which joins the antero-lateral angle of the optic chiasma
(Fig. 149).

Nervi Olfactorii. The olfactory nerves, about twenty in

number on each side, arise in the nasal mucous membrane.
They pass into the cranium through the cribriform lamina of
the ethmoid, and they terminate in the olfactory bulb. It is

396 THE BRAIN

not probable that the dissector will find any trace of them on
the brain.

THE CEREBRUM.

The term cerebrum includes (i) the two cerebral hemi-

spheres which, together, form the telencephalon and (2) the
boundaries of the third ventricle which, collectively, form the
diencephalon. The two parts, that is the telencephalon and
the diencephalon, are intimately connected with one another.

Each hemisphere is separated from its fellow of the oppo-

site side by a deep fissure called the longitudinal fissure.
Anteriorly and posteriorly the longitudinal fissure completely
separates the two hemispheres, but in the intermediate
region the hemispheres are connected with one another,
across the bottom of the longitudinal fissure by a large trans-
verse commissure called the corpus callosum, which can be
seen when the hemispheres are drawn apart.

Cerebral Hemispheres. It has been pointed out already

that each cerebral hemisphere possesses three surfaces, three
poles and five borders. The surfaces are supero- lateral,
medial and inferior. The poles are frontal, occipital and
temporal. The borders are supero -medial, infero- lateral,
superciliary, medial orbital and medial occipital.

The frontal pole is the most projecting part of the anterior

extremity of the hemisphere. It is blunt and rounded, and
it lies behind the medial part of the superciliary eminence
of the frontal bone. The occipital pole is the posterior ex-
tremity of the hemisphere. It is more pointed than the
frontal pole. It lies immediately above and lateral to the
external occipital protuberance (inion). In a well-hardened
brain the occipital pole of the right hemisphere is usually
marked, on its medial aspect, by a broad groove caused by
the posterior end of the superior sagittal sinus.

The supero-lateral surface is convex and is adapted to the

concavity of the cranial vault. The medial surface is flat
and, when the brain is in situ, it is more or less completely
separated from the corresponding surface of the opposite
hemisphere by the falx cerebri and the prolongations of the
arachnoid and the pia mater which occupy the longitudinal
fissure between the two hemispheres. The inferior surface is
irregular and is adapted to the floors of the anterior and

THE CEREBRUM 397

middle cranial fossae, and to the upper surface of the ten-

torium cerebelli. It is separated into anterior and posterior
parts by a deep transverse fissure called the stem of the
lateral fissure. The anterior or orbital part lies on the floor
of the anterior fossa, that is on the roof of the orbit. It is
concave, and it looks downwards and laterally ; consequently
it is partially visible when the hemisphere is viewed from the
lateral side (see Figs. 152, 155). The posterior part is
concavo-convex. It looks downwards and medially. Its
anterior extremity forms the rounded temporal pole, which
abuts against the posterior part of the lateral wall of the
orbit. Behind the temporal pole its anterior convex part
lies on the anterior part of the floor of the middle cranial
fossa which separates it from the infra-temporal fossa. The
anterior part of its concave portion rests upon the anterior
surface of the petrous part of the temporal bone which
separates it from the tympanic cavity, the internal ear and
the carotid canal. It is separated from the anterior surface
of the apex of the petrous part of the temporal bone by the
semilunar ganglion of the trigeminal nerve, and it is marked
near its lateral margin by a depression caused by the eminentia
arcuata of the temporal bone.

The posterior and longer part of the concave area rests

upon the tentorium cerebelli which intervenes between it and
the cerebellum.

The supero-medial border extends from the frontal to the

occipital pole ; it is convex and is in relation with the wall of
the superior sagittal sinus.

The infero-lateral border is concave in the posterior part

of its extent, where it rests upon the tentorium cerebelli and
is in relation with the wall of the transverse sinus ; and the
anterior part, which lies along the line of union of the
squamous with the petrous part of the temporal bone, is
convex.
The superciliary border extends from the frontal to the
temporal pole. It lies parallel with and above the supra-
orbital margin. It separates the supero-lateral surface from
the orbital part of the inferior surface.

The medial orbital margin can be seen at the base of the

brain ; it extends from the frontal pole to the optic chiasma,
along the side of the inferior part of the anterior portion of
the longitudinal fissure. It lies above the roof of the nose.

398 THE BRAIN

It separates the orbital part of the inferior surface from the

medial surface.

The medial occipital border can be seen from below, after

the hind-brain and the mid-brain have been cut away from
the cerebrum, or from behind, when the posterior parts of
the hemispheres are separated from one another. It extends
from the occipital pole to the posterior end of the corpus
callosum. It lies along the margin of the inferior part of
the posterior portion of the longitudinal fissure, in relation
with the wall of the straight sinus; and it separates the medial
surface from the posterior part of the inferior surface.

Fissura Longitudinalis. The longitudinal fissure is the

great median cleft between the two cerebral hemispheres ;
anteriorly and posteriorly, it completely separates the hemi-
spheres from each other, but the intermediate part is
bounded below by the corpus callosum which passes between
the hemispheres and connects them together. If the two
sides of the longitudinal fissure are gently drawn asunder,
the upper surface of the corpus callosum will be displayed.
When the brain is in situ the longitudinal fissure contains
the falx cerebri of the dura mater (p. 104), a fold of arachnoid,
the pia mater covering the medial surfaces of the hemispheres,
the anterior cerebral arteries and veins, with their branches
and tributaries. The falx cerebri was removed when the
brain was taken from the skull ; the other membranes and
the vessels are still in situ, and they should not be disturbed
till the medial surfaces of the hemispheres can be examined
(p. 419).

Dissection. Separate the cerebellum, pons and medulla from

the cerebrum, if that has not already been done, by cutting
transversely through the upper part of the mid-brain. Then,
if two brains are available, split one of them in the median
plane by placing a long knife in the longitudinal fissure and
dividing carefully the various parts which connect the two
halves together. All three surfaces of each hemisphere will
then be exposed, the gyri and sulci can be studied fully and
satisfactorily, and the terminal parts of the anterior and posterior
cerebral arteries (pp. 384, 386) can be examined. If only one
brain is at the disposal of the dissectors they should not, at this
stage, separate the cerebral hemispheres from each other, but
should endeavour to follow out the gyri and sulci with the
various parts of the brain in position. No doubt they will
study the hemispheres in that way at some disadvantage, but
as the dissection proceeds, opportunities will occur which will
enable them to examine those districts of the surface which
they can see only imperfectly? a*t present.

'

THE CEREBRUM 399

Cerebral Gyri and Sulci. The surface pattern which is

presented by the cerebral gyri and sulci is, in its general
features, the same in all human brains ; but when the com-
parison is pushed into more detail many differences become
manifest, not only in the brains of different subjects but
also in the two cerebral hemispheres of one subject.

The depressions which intervene between the cerebral

gyri vary in depth. Some are due to folding of the whole
thickness of the wall of the cerebrum, and consequently they
correspond with elevations of the walls of the cavities of the
cerebrum which are called the lateral ventricles. Such
depressions are called complete fissures. In this category are
included (i) the anterior portion of the calcarine fissure;
(2) a portion of the collateral fissure; and (3) the chorioidal
fissure. The incomplete fissures and the sulci are merely
furrows of varying depth which do not produce any effect
on the surface of the ventricular walls.

General Structure of the Cerebral Hemispheres. Each

cerebral hemisphere is composed of an outside coating of grey
matter, spread in a continuous and uninterrupted layer over its
surface, and an internal core of white matter. The grey coat-
ing is termed the cerebral cortex^ whilst the white internal part
is called the medullary centre. Each gyrus shows a corre-
sponding structure. It has an external covering of grey
matter supported upon a core of white medullary matter. But,
in addition to the grey matter on the outside, there are certain
large deposits of grey matter embedded in the substance of
each hemisphere in its basal part, Those deposits constitute
the basal ganglia, and although to a certain extent they are
isolated from the grey matter on the surface, nevertheless, at
certain points, they are directly continuous with it (Fig. 186).

By means of the gyri and sulci the grey matter on the

surface of the hemisphere is increased, and its close
association with the vascular pia mater is maintained without
any unnecessary increase of the bulk of the organ. The
vascular pia mater dips into every fissure and sulcus, and
opportunity is, therefore, afforded for the cortical vessels to
break up into twigs of exceeding fineness before they
enter the substance of the hemisphere. The distribution of
the blood to the grey cortex is in that way rendered uniform.

Cerebral Lobes and Interlobar Fissures and Sulci. For

purposes of localisation and -dription, it is customary to
400

THE

divide the hemispheres into districts termed Mes, and, for

that purpose, certain fissures and sulci are chosen which are
termed interlobar fissures and sulci \ they are the following :

1. The lateral fissure (O.T. Sylvian).

2. The central sulcus (O.T. fissure

of Rolando).

3. The parieto-occipital sulcus.

Anterior central gyrus

Inferior precentral sulcus ,

Superior frontal sulcus

Middle frontal sulcus i
Superior frontal gyrus

Middle frontal gyrus

4. The collateral fissure.

5. The circular sulcus (O.T. limiting

sulcus of Reil).

Anterior central gyrus (lower buttress)

Anterior central gyrus (upper buttress)

i Central sulcus

Inferior post -central sulcus

Supra-marginal gyrus

Interparietal sulcus (prop

Angular gyrus
Pronto-marginal
sulcus

Inferior frontal sulcus

Inferior frontal gyrus

Pars orbitalis
Lateral fissure (ant. horiz. branch)

Pars triangular

Lateral fissure

Pars basilaris
Sulcus diagonalis
Lateral fissure (posterior branch)

Superior temporal gyrus

Superior temporal sulcu

CE

fissur
bram

I Sulcus occ
| paramedia!
I Lunate sulcus

Middle temporal sulcus

Middle temporal gyrus

| Lateral occipital sul

nferior temporal gyrus

Posterior central gyrus Superior temporal sulcus

FIG. 152 Supero-lateral aspect of Left Hemisphere (semi-diagrammatic).

The orbital surface is shaded.

The lobes which are mapped out by the fissures mentioned

are (i) the frontal; (2) the parietal; (3) the occipital; (4)
the temporal; (5) the insula. To them may be added a
sixth lobe, in no way related to the interlobar fissures, viz.,
the olfactory lobe.

Fissura Lateralis (O.T. Sylvian). The lateral fissure is

the most conspicuous fissure on the surface of each cerebral
hemisphere. It is composed of a short main stem, from the
lateral extremity of which three branches radiate. The stem
is placed on the inferior surface of the cerebrum (Fig. 138).

THE CEREBRUM 401

It begins at the substantia perforata anterior. Thence it

passes laterally, forming a deep cleft between the temporal
pole and the orbital area of the inferior surface of the
hemisphere. When it reaches the lateral surface of the
hemisphere, the fissure immediately divides into three
radiating branches (i) the ramus posterior ; (2) the ramus
anterior horizontalis ; and (3) the ramus anterior ascendens.

The posterior branch (Figs. 138, 152) is the longest and

the most important of the three. It extends backwards, with
a slight upward inclination, for a distance of 7.5 cm. (three
inches} or more, between the temporal lobe, which is placed
below it, and the frontal and parietal lobes, which lie above it.
Finally, it turns upwards, into the parietal lobe, in the form
of an ascending terminal piece (Figs. 138, 152).

The anterior horizontal branch (Fig. 152) runs forwards in

the frontal lobe, for a distance of about 19 mm. (three-quarters
of an inch), immediately above and parallel to the posterior
part of the superciliary margin of the hemisphere.

The anterior ascending branch (Figs. 138, 152) passes

upwards, with a slight anterior inclination, into the lower
part of the lateral surface of the frontal lobe for a distance
of about 25 mm. (one inch). In many cases the two anterior
limbs spring from a common stem of variable length.

Sulcus Circularis (O.T. Limiting Sulcus of Reil). If the

lips of the posterior ramus of the lateral fissure are gently
pulled asunder, the insula (O.T. island of Reil) will be seen
at the bottom of the cleft which is termed the lateral fossa
(Fig. 157). It is surrounded by a sulcus, called the circular
sulcus, which is separable into three parts, viz., an upper
part, bounding the insula above, a lower part, marking it
off below, and an anterior part limiting it anteriorly. The
insula thus mapped out is somewhat triangular in outline,
and over its surface ramify branches of the middle cerebral
artery.

Opercula Insulae. The present is a good time to study

the manner in which the insula is shut off from the surface
of the hemisphere. When the lateral fissure is held widely
open, it will be noted that the insula is overlaid by portions
of cerebral cortex which appear as if they were undermined.
The overlying portions are called the opercula insula, and it is
their opposed margins which form the boundaries of the
lateral fissure. The opercula are four in number, and are

VOL. Ill 26

402

THE BRAIN

named (i) temporal, (2) fronto- parietal, (3) frontal, and

(4) orbital. They are easily distinguished.

The temporal operculum extends upwards over the insula

from the temporal lobe ; it forms the lower lip of the posterior
ramus of the lateral fissure (Fig. 152).

The fronto-parietal operculum is carried downwards over the

insula to meet the temporal operculum. Its margin forms
the upper lip of the posterior ramus of the lateral fissure.

Superior extremity are

Inferior extremity area

Anterior central gyms i
Trunk area

Central sulcus

j Sensory area

Posterior central gyrus

Face area
Posterior branch of lateral fissure

Superior temporal gyrus Acoustic

Visual area j

Calcarine fissure
FIG. 153. Lateral aspect of Left Hemisphere, showing
Sensory Areas. (After Elliot Smith. )

Motor and

The frontal operculum is the small triangular piece of

cerebral cortex between the anterior ascending and horizontal
branches of the lateral fissure. It is sometimes termed the
pars triangularis.

The orbital operculum is for the most part on the under

surface of the hemisphere. It lies below the anterior horizontal
limb of the lateral fissure, and passes backwards from the
orbital aspect of the frontal lobe over the anterior part of
the insula.

Sulcus Centralis (O.T. Fissure of Bolando). The central

sulcus runs obliquely across the supero-lateral surface of the

THE CEREBRUM 403

hemisphere, somewhat nearer the posterior than the anterior

end. It lies between two gyri which, though they are
obliquely placed, are still the most vertical gyri on the supero-
lateral surface, and it separates the frontal from the parietal
lobe. The upper end of the sulcus frequently cuts the
supero-medial border of the hemisphere, and, in such cases,
it appears on the medial surface of the hemisphere. The
lower end, as a rule, is separated from the posterior ramus of
the lateral fissure by a small bounding gyms. The sulcus
does not take a straight course between its two extremities ;
on the contrary, it is bent upon itself several times, on
account of buttress-like projections from its bounding walls
(Figs. 138, 153). The two most prominent buttresses spring
from the anterior wall, which is formed by the anterior central
gyrus. From its upper end the sulcus runs, at first, downwards
and forwards to the base of the upper buttress ; then it bends,
first round the upper and next round the lower buttress;
finally, its lowest part runs almost vertically downwards from
the base of the lower buttress. The anterior central gyrus,
which forms the anterior boundary of the central sulcus,
constitutes the motor region of the cerebral cortex, and by
means of the buttresses which spring from its posterior face
it is possible to define in a fairly accurate manner the various
motor areas. The lower limb area extends from the upper
end of the central sulcus to the apex of the upper buttress ;
the trunk area corresponds with the lower face of the upper
buttress ; the upper limb area corresponds with the region of
the lower buttress ; and the head area corresponds with the
anterior boundary of the central sulcus below the lower
buttress.
When the margins of the central sulcus are gently separated,
a transverse annectant gyrus will be found crossing its floor
and uniting together the anterior and posterior central gyri.
It lies at the level of the lower part of the upper buttress of
the anterior central gyrus.

Fissura Parieto-occipitalis. The greater part of the

parieto-occipital sulcus is situated on the medial surface of
the cerebral hemisphere (Fig. 159); only the small lateral
part appears on the supero-lateral face (Fig. 153).

The lateral part. of the parielo-occipital fissure (O.T. external

parieto-occipital] cuts the supero-medial border of the hemi-
sphere, in a transverse direction, from 37.5 to 50 mm. (one
in 26 a

404

THE BRAIN

and a half to tivo inches] anterior to the occipital pole. It is

about 12.5 mm. (half an inch} in length, and it is brought
to an abrupt termination laterally by an arching gyms, called
the arcus parieto-occipitalis, which winds round it (Fig. 154).

The medial part of the parieto-occipital fissure (Fig. 159)

will be seen when the medial surface of the hemisphere is
studied (p. 419).

The Lobes seen on the Supero-lateral Surface of the

Central sulcus Anterior central gyrus

Posterior central gyrus ^ j Central sulcus
Superior parietal lobule \ _^ j Superior post-central sulcus

Arcus parieto-
occipitalis, at lateral

end of parieto-
occipital fissure \

Angular gyrus
Superior
temporal
sulcus

Post-parietal,
gyrus

Middle
temporal

gyrus

Middle

temporal

sulcus

Inferior

temporal

gyrus

Lateral .-

occipital

sulcus

Sulcus lunatus

Inferior post-central
ulcus

Interparietal sulcus
- (proprius)

Par-occipital
-. sulcus

Superior

temporal sulcm

Transverse
"occipital sulcus

Middle

temporal sulcus
.Paramedial

occipital sulcns
. Lateral

occipital sulcus
-./.Sulcus lunatus

Calcarine fissure

alcarine fissure
Sulcus for superior sagittal sinus

FIG. 154. Posterior view of the Hemispheres of the Brain (semi-diagram-

matic). The posterior parts of the supero-medial borders are separated
and portions of the medial surfaces are seen (shaded).

Hemisphere, and the Insula. The dissector must understand

that the areas called the lobes of the cerebrum are defined
merely for purposes of description and localisation ; they
do not correspond with physiological areas, nor do they
correspond, exactly, in extent with the bones after which
they are named. For example, the lobes which can be seen
on the supero-lateral surface, without any disturbance of its
parts, are the frontal, the parietal, the occipital and the
temporal. It is true that all those lobes lie in relation with
the bones after which they are named, but only the parietal

PLATE IV

Hypophyseal fossa (pituitary)

Internal acoustic
meatus

)ondyle of mandible ~

Floor of tympanic ... '..'Vff.nj

Atlas

Sphenoidal sinus

;,^MM|
Frontal sinus

Ethmoidal eel

- Maxillary sim

FIG. 4 1. Lateral radiograph of a living Skull. (Gouldesbrough. )

PLATE V

Hypophyseal fossa (pituitary)

Petrous part of
temporal bone

Sphenoidal sinus

Condyle of m

Ana

FIG. 42. Lateral view of Skull showing hypophyseal fossa

and sphenoidal sinus. (Gouldesbrough. )

THE CEREBRUM 405

lobe is entirely under cover of the parietal bone ; whilst, on

the other hand, the parietal bone covers all the parietal lobe
and parts of each of the other lobes a considerable part of
the frontal lobe, and smaller portions of the occipital and
temporal lobes. Further, each of the lobes forms part not
only of the supero-lateral but also, at least, of one other surface
of the hemisphere, where it lies in relation with parts other
than the bones after which it is named (Fig. 177).

Lobus Frontalis. The frontal lobe appears on the supero-

lateral, the inferior, and the medial surfaces of the hemisphere.

The Supero-lateral Surface of the Frontal Lobe is bounded,

above, by the supero-medial border ; below, by the super-
ciliary border and the anterior part of the posterior ramus of
the lateral fissure; and it extends, antero-posteriorly, from
the frontal pole to the central sulcus. It is divided by three
sulci into four chief gyri. The sulci are the precentral, and
the superior and inferior frontal. The gyri are the anterior
central and the superior, middle and inferior frontal.

Sulcus Prcec entrails. The precentral sulcus consists of

two parts, superior and inferior : they run obliquely upwards
and backwards, parallel with the central sulcus of the hemi-
sphere, and although they are sometimes continuous in the
adult they are developed independently of one another. The
superior precentral sulcus is generally connected with the
superior frontal sulcus. The inferior precentral sulcus has
usually two limbs, a vertical, which lies parallel to the lower
part of the central sulcus, and a horizontal or oblique limb
which extends forwards into the middle frontal gyrus (Figs.
138, 152).

Sulcus Frontalis Superior (Figs. 138, 152). The superior

frontal sulcus extends forwards from the superior precentral
sulcus.

Sulcus Frontalis Inferior (Figs. 138, 152). The inferior

frontal sulcus commences posteriorly in the angle between
the vertical and the horizontal or oblique part of the inferior
precentral sulcus, and, not uncommonly, it is confluent with
one or other of the two parts. As it passes forwards it
descends towards the superciliary border and ends a short
distance from it in a terminal bifurcation.

Gyrus Centralis Anterior. The anterior central gyrus

extends, obliquely, across the supero-lateral surface of the
hemisphere, from the supero-medial border above, to the
in 26 b

406 THE BRAIN

posterior ram us of the lateral fissure, below. It lies between

the central and the precentral sulci and is the region of the
motor area of the brain. It is continuous, at its upper and
its lower ends, round the extremities of the central sulcus,
with the posterior central gyrus. From its posterior face
two buttresses, an upper and a lower, project backwards, as
pointed out on p. 403. The buttresses form excellent land-
marks for the delimitation of the parts of the motor area.
Anteriorly, the anterior central gyrus is continuous with the
superior, middle, and inferior frontal gyri, and, inferiorly, it
forms part of the fronto-parietal operculum (p. 401). Its
lower two-thirds are supplied by the middle cerebral artery,
and its upper third is supplied by the anterior cerebral
artery (Fig. 148).

Gyrus Frontalis Superior. The superior frontal gyrus lies

above the superior frontal sulcus. It forms also part of the
supero-medial border and part of the medial surface of the
hemisphere. It is continuous, posteriorly, with the anterior
central gyrus, and, anteriorly, round the frontal pole, with
the gyrus rectus and the medial orbital gyrus of the inferior
surface of the frontal lobe. The supero-lateral part of the
superior frontal gyrus is frequently divided into upper and
lower parts by an interrupted furrow called the paramedial
frontal sulcus (Fig. 137).

Gyrus Frontalis Medius. The middle frontal gyrus lies

between the superior and inferior frontal sulci. It is con-
tinuous, posteriorly, with the anterior central gyrus, and,
round the superciliary border, with the anterior orbital gyrus of
the inferior surface of the frontal lobe. The horizontal or
oblique limb of the inferior precentral sulcus cuts into its
posterior end (Fig. 138).

Gyrus Frontalis Inferior. The centre for speech has been

associated with the posterior part of the inferior frontal gyrus
of the left side ; therefore the inferior frontal gyrus is a
region of special interest. It extends forwards, from the
inferior precentral sulcus, and is continuous, round the
superciliary border, with the lateral and posterior orbital gyri
of the inferior surface of the frontal lobe. The inferior
frontal gyrus is divided into three parts by the anterior
ascending and the anterior horizontal rami of the lateral
fissure. The posterior part is sometimes called the pars
basilaris ; it lies between the anterior ascending ramus of the

THE CEREBRUM 407

lateral fissure and the inferior precentral sulcus, and is continu-

ous, posteriorly, with the anterior central gyrus. The
middle part, called also the pars triangularis, lies between
the anterior ascending and the anterior horizontal rami of the
lateral fissure. The anterior part, which has been termed the
pars orbitalis, is placed below and anterior to the anterior
horizontal ramus of the lateral fissure, and it is continuous with
the posterior orbital gyrus of the inferior surface (Fig. 152).

Additional Sulci of the Supero-lateral Surface of the Frontal Lobe.

There are four fairly constant sulci on the supero-lateral surface of the
frontal lobe, besides those which intervene between its principal gyri ; they
are the paramedial, the middle, the fronto-marginal, and the diagonal.

The paramedial siilcus is either a continuous sulcus which lies between

the supero-medial border and the superior frontal sulcus, and separates the
superior frontal gyrus into upper and lower parts, or it is represented by a
series of separate depressions (Fig. 137).
The middle frontal sulcus separates the middle frontal gyrus into
upper and lower parts. It terminates anteriorly, close to the superciliary
border of the hemisphere, in a transversely placed limb called the fronto-
marginal sulcus (Fig. 152).

The diagonal suiciis lies parallel with the inferior part of the inferior
precentral sulcus, in the posterior part of the inferior frontal gyrus, inter-
vening between two structurally different parts of that portion of the gyrus.

The Inferior Surface of the Frontal Lobe forms the orbital

or anterior part of the inferior surface of the hemisphere.
It rests upon the roof of the orbit and the roof of the
nose. It is bounded, anteriorly and laterally, by the super-
ciliary border, and, medially, by the medial orbital border.
Posteriorly, in the lateral part of its extent, its boundary is
the stem of the lateral fissure, but, more medially, it is
separated from the anterior perforated substance by a sulcus
which has been named the fissura prima.

The Sulci of the Inferior Surface of the Frontal Lobe are the
olfactory sulcus and the orbital sulci (Fig. 138).

Sulcus Olfactorius. The olfactory sulcus lies parallel with,

and a short distance from, the medial orbital border. It
lodges the olfactory bulb. and the olfactory tract.

Sulci Orbitales. The orbital sulci are irregular in arrange-

ment, but generally they assume, collectively, a somewhat
H-shaped form, the transverse bar of the H being at right
angles to the long axis of the hemisphere.

The Gyri of the Inferior Surface of the Frontal Lobe are the
gyrus rectus and the orbital gyri.

Gyms Rectus. The gyrus rectus is the district medial to

the olfactory sulcus, and it extends from the frontal pole to

408 THE BRAIN

the anterior perforated substance. It is continuous, round

the frontal pole, with the superior frontal gyrus, and it turns
round the medial orbital border on to the medial surface of
the hemisphere.

Gyri Orbitales. The orbital gyri are medial, lateral,

anterior and posterior. The medial and lateral are con-
tinuous with the anterior and posterior, both anteriorly and
posteriorly.

The medial orbital gyrus lies between the olfactory

sulcus and the medial limb of the H-shaped sulcus. The
anterior and the posterior orbital gyri are respectively
anterior and posterior to the transverse bar of the H-shaped
sulcus ; and the lateral gyrus is to the lateral side of the
lateral limb of the sulcus.

The medial orbital gyrus is continuous with the superior

frontal gyrus ; the anterior orbital gyrus is in continuity with
the middle frontal gyrus ; and the lateral orbital gyrus, with
the inferior frontal gyrus; whilst at the bottom of the stem
of the lateral fissure the posterior orbital gyrus is separated
from the temporal lobe by the lower part of the insula.

The medial surface of the frontal lobe will be examined at a later

period ; but the dissector should note that upon its medial surface are a
part of the superior frontal gyrus, a part of the gyrus cinguli and a part of
the paracentral lobule (Fig. 159). -

Lobus Parietalis. The parietal lobe appears on the

supero-lateral and the medial surfaces of the hemisphere,
and its lower portion forms the upper wall of the posterior
horizontal ramus of the lateral fissure. The part on the
medial surface which forms the precuneus, and takes part in
the formation of the paracentral lobule and the gyrus cinguli,
will be examined at a later period. The inferior portion
partly abuts against the temporal lobe, along the superficial
part of the posterior ramus of the lateral fissure, but, more
deeply, it is in close relation with the insula, from which it
is separated by the circular sulcus. The dissector should
verify these facts by gently separating the lips of the posterior
ramus of the lateral fissure.

The Supero-lateral Surface of the Parietal Lobe lies entirely

under cover of the parietal bone, and is bounded, above, by
the supero-medial border of the hemisphere ; below, by the
posterior ramus of the lateral fissure and by a line projected
horizontally backwards from the point where that fissure turns

THE CEREBRUM

409

upwards ; anteriorly, by the central sulcus ; and, posteriorly,

by the lateral part of the parieto-occipital fissure and a line
prolonged from it to the pre-occipital notch on the infero-
lateral border of the hemisphere (Figs. 155, 177).

Anterior central gyrus

Central sulcus
Posterior central gyrus ' .

Upper post-central sulcus

Supra-marginal gyrus
Interparietal sulcus (proprius)

Angular gyrus
Post-parietal gyrus

Paroccipital sulcus
Arcus parieto-
occipitalis
Parieto-occipital ',
fissure

Upper precentral sulcus

,' Lower precentral sulcus

Superior frontal sulcus

," Superior frontal gyrus

Middle frontal gyrus

Inferior frontal suli

Calcarine

fissure '
Sulcus lunatus

Transverse occipital
sulcus

Olfactory bulb
\ Inferior frontal gyru:

Anterior horizontal branch

lateral fissure
Anterior ascending branch
I | of lateral fissure

1 Posterior branch of lateral fissure

Superior temporal gyrus

Lateral occipital sulcus

Horizontal sulcus of cerebellum

Right hemisphere of cerebelh

Part of cerebellum which extends into foramen magnum

Olive of medulla oblongata

FIG. 155. Lateral surface of Right Half of the Brain (semi-diagrammatic).

The horizontal dotted line completes the separation between the parietal
and temporal areas, and the oblique dotted line, which runs from the
parieto-occipital fissure to the pre-occipital notch, separates the occipital
from the parietal and temporal areas.

The Sulci of the Supero laieral Surface of the Parietal Lobe.

The sulci of the supero-lateral surface of the parietal lobe are
the post-central sulci, the interparietal sulcus proper, and the
par-occipital sulcus.

Sulci Postcentrales. There are two post-central sulci a

superior and an inferior. They are developed independently,

4io THE BRAIN

and they run parallel with the central sulcus, from which
they are separated by the posterior central gyrus. Not un-
commonly, the two post-central sulci are continuous with
one another in the adult ; and either the one or the other may
be continuous with the sulcus interparietalis proprius (Figs.

152, 155)-

Sulcus Interparietalis Proprius. The interparietal sulcus

proper runs backwards, almost horizontally, about midway
between the upper and lower borders of the supero-lateral
surface of the parietal lobe. It separates the superior from
the inferior parietal lobule, and it may be continuous, anteriorly,
with one or other of the post-central sulci, and, posteriorly,
with the par-occipital sulcus.

Sulcus Paroccipitalis. In the adult, the par-occipital sulcus

is either directly continuous with, or it commences close to,
the posterior end of the sulcus interparietalis proprius. It
runs backwards, past the lateral end of the parieto-occipital
fissure, from which it is separated by a parieto-occipital
annectant gyrus called the arcus parieto-occipitalis ; and it
terminates, in the occipital lobe, in the transverse occipital
sulcus (Figs. 137, 152, 154).

In the past it was the custom to speak of an interparietal sulcus which

consisted of a vertical, a horizontal and an occipital portion. The vertical
part is the inferior post-central sulcus, the horizontal part is the sulcus
interparietalis proprius, and the occipital part is the par-occipital sulcus.

The Gyri of the Supero-lateral Surface of the Parietal Lobe.

The subdivisions of the supero-lateral surface of the
parietal lobe are the posterior central gyrus ; the superior
parietal lobule ; and the supra-marginal, the angular, and the
post-parietal gyri, which form collectively the inferior parietal
lobule (Fig. 152).
Gyrus Centralis Posterior. The posterior central gyrus lies
between the central and the post-central sulci. Along its
anterior face, which forms the posterior wall of the central
sulcus, and along the adjacent part of the supero-lateral surface
lies the main area of ordinary sensation (Fig. 153). It is
continuous, above and below, with the anterior central gyrus,
and posteriorly with the superior and inferior parietal lobules.

Lobulus Parietalis Superior. The superior parietal lobule

is bounded, anteriorly, by the superior post-central sulcus ;
posteriorly, by the parieto-occipital fissure ; above, by the
supero-medial border ; and, below, by the sulcus interparietalis

THE CEREBRUM 411

proprius. It is sometimes divided into anterior and posterior

parts by a small sulcus called the superior parietal sulcus.

Lobulus Parietalis Inferior. The anterior and the superior

boundaries, and the anterior part of the inferior boundary of
the inferior parietal lobule are quite definite, but the posterior
boundary and the posterior part of the inferior boundary
are arbitrary lines. The superior boundary is the sulcus
interparietalis proprius ; the anterior boundary is the inferior
post-central sulcus ; the inferior boundary is formed by the
posterior part of the posterior ramus of the lateral fissure, and
an imaginary line drawn backwards from the point where the
posterior ramus of the lateral fissure turns upwards, to a
second imaginary line, drawn from the lateral part of the
parieto -occipital fissure to the pre-occipital notch on the
infero-lateral border. The last-mentioned line, and the lateral
part of the parieto-occipital fissure form the posterior boundary
of the parietal lobe, and separate it from the occipital lobe

(Fig- i55)-

The Sulri of the Inferior Parietal Lobule are the upturned

ends of the posterior ramus of the lateral fissure, and the

superior and middle temporal sulci, which extend from the
temporal lobe into the inferior parietal lobule (Fig. 152).

The Gyri of the Inferior Parietal Lobule are three in number

the supra-marginal, the angular, and the post-parietal

The supra-marginal gyrus surrounds the upturned end of

the posterior ramus of the lateral fissure.

The angular gyrus surrounds the upturned end of the

superior temporal sulcus ; and, in a similar manner, the post-
parietal gyrus, when it is well marked, surrounds the upturned
end of the middle temporal sulcus. It is separated from the
arcus parieto-occipitalis by the sulcus par-occipitalis.

Lobus Temporalis. The temporal lobe appears on the

lateral and the inferior surfaces of the hemisphere, and it forms
the lower wall of the posterior ramus of the lateral fissure.
The Sulci on the Lateral Surface of the Temporal Lobe are
the superior and the middle temporal sulci.

Sulcus Temporalis Superior. The superior temporal sulcus

lies parallel with the posterior ramus of the lateral fissure
(Figs. 152, 155). It intervenes between the superior and
the middle temporal gyri ; and it consists of two genetically
distinct portions an anterior and a posterior, which some-
times remain separate, even in the adult.

412 THE BRAIN

Sulcus Tempuralis Medius. The middle temporal sulcus,

which lies between the middle and the inferior temporal gyri,
is very irregular in its mode of formation ; not infrequently it
is represented by two or more separate portions.

The Gyri of the Lateral Surface of the Temporal Lobe.

There are three gyri on the lateral surface of the temporal
lobe superior, middle, and inferior.

Gyrus Temporalis Inferior. The inferior temporal gyrus

lies below the middle temporal sulcus ; it forms the temporal
part of the infero-lateral border of the hemisphere, and will
be seen again on the inferior surface of the temporal lobe,
where it is separated from the fusiform gyrus by the inferior
temporal sulcus.

Gyrus Temporalis Medius. The middle temporal gyrus

lies between the middle and the superior temporal sulci, and
it is more or less continuous, posteriorly, with the angular and
the post-parietal gyri.

Gyrus Temporalis Superior. The superior temporal gyrus

lies between the superior temporal sulcus and the posterior
ramus of the lateral fissure, and it extends forwards to the tip
of the temporal pole of the hemisphere (Fig. 152).

The Upper Part of the Temporal Lobe^ which forms the

lower wall of the posterior ramus of the lateral fissure, is in
relation with the insula and the lower parts of the parietal
and frontal lobes. The dissector can display it by gently
separating the lips of the fissure, and upon it two gyri, running
backwards and medially, will be seen ; they are the anterior
transverse temporal gyms (Heschl's convolution) and the
posterior transverse temporal gyrus. The anterior transverse
temporal gyrus and the portion of the posterior part of the
superior temporal gyrus adjacent to its lateral end constitute
the acoustic area of the brain cortex (Fig. 153).

The Inferior Surface of the Temporal Lobe forms the

greater part of the posterior portion of the inferior surface of
the hemisphere, and in brains hardened in situ it is marked,
anteriorly, by an obvious depression due to the eminentia
arcuata of the anterior surface of the petrous part of the
temporal bone.
The Fissures and Sulci of the Inferior Surface of the
Temporal Lobe are : (i) part of the chorioidal fissure (Fig. 138);
(2) the collateral fissure ; (3) the stem of the calcarine fissure ;
(4) the rhinal fissure; and (5) the inferior temporal sulcus.

THE CEREBRUM

Fissura Chorioidea, The chorioidal fissure forms the an-

terior portion of the medial or upper boundary of the posterior
part of the inferior surface of the hemisphere. In the region of
the fissure the wall of the cavity of the hemisphere is reduced
to a thin layer of epithelium, and the fissure is produced by
the invagination of the epithelial wall, into the inferior cornu
of the lateral ventricle of the hemisphere, by a vascular fold
of pia mater.
r*y vX fl / k < *'* Su i

Sulcus cinjjuli

'ek Chorioidea of the third ventricle in chorioidal fissure

Central sulcus (

ippocampal rudiment (medial and lateral striae) *

L. \*'" ^

Splenium of corpus callosum ^K^L \

'arieto-occipital fissure
Calcarine fisst

Massa intermedia
i Fornix

| Interventricular foramen
i ' Anterior commissure

* Septum pellucidum
,' * Paraterminal body
! " ';' i ^ ' , Subcallosal gyrus
i- / / ( ",enu of corpus callosui

]- .'! ! ' I ^~L Hippocampalrudime

' y. " / Gyrus cinguli

Stem of cal-
:ariue fissure

Isthr
Hippocampus-' '

Fasciola cinerea / ' / I

Thalamus (cut)' / / /
-' / /

Pia mater in chorioidai fissure _J I I

Fascia dentata / /
Collateral fissure /
Paradentate acea

\ Olfactory bulb

Olfactory tract
Lamina terminalis (cut)
Medial stria of olfactory tract
\ Lateral 5triajoJ^glf_actory tract
J 1 \ Rhinaljssure

I \ PirLform area
| Cauda fasciae dentatce
Hippocampus

Pedunculus cerebri (cut)

f'dt.

FIG. 156. Diagram showing portions of the Hippocampus and associated

parts. The green line represents the indusium, which is a rudiment of
the hippocampal formation.

Below the posterior part of the chorioidal fissure the stem

of the calcarine fissure reaches the inferior surface, after cutting
across the medial occipital border of the hemisphere.

Fissura Collateralis. The collateral fissure is placed more

laterally and on a lower level than the chorioidal fissure. It
lies below the stem of the calcarine fissure and extends
forwards beyond its anterior extremity (Figs. 156, 159).

The Rhinal Fissure lies anterior to and slightly above or

medial to the anterior end of the collateral fissure.

414 THE BRAIN

Sulcus Temporalis Inferior. The inferior temporal sulcus

is below and lateral to the collateral fissure.

The Gyri of the Inferior Surface of the Temporal Lobe are

the hippocampal gyrus, the lingual gyrus, the fusiform gyrus,
and a part of the inferior temporal gyrus.

Gyrus Hippocampi. The hippocampal gyrus is bounded

by the rhinal and collateral fissures, infero-laterally, and the
chorioidal fissure, supero-medially. The posterior end of
the hippocampal gyrus is continuous, below the stem of the
calcarine fissure, with the anterior part of the lingual gyrus,
and, in front of the anterior end of the calcarine fissure, it
is connected by means of a narrow bridge, called the isthmus,
with the posterior part of the gyrus cinguli, which embraces
the corpus callosum, and which forms, with the isthmus and
the hippocampal gyrus, a continuous fold of the cortex termed
the gyrus fornicatus. The anterior end of the hippocampal
gyrus is turned upwards and backwards, and is called the
uncus (Fig. 138).

If the upper or medial border of the hippocampal gyrus,

behind the uncus, is displaced downwards a vertically notched
ridge of grey matter will be brought into view; it is the fascia
dentata, and it will be seen to much better advantage when
the inferior cornu of the lateral ventricle is studied. The
portion of the hippocampal gyrus which lies above and medial
to the rhinal fissure, including the uncus, is the piriform area,
and it is closely associated with the sensation of smell. The
more posterior part of the hippocampal gyrus forms the para-
dentate area (Fig. 156).

Gyrus Lingualis. The portion of the lingual gyrus which

appears on the inferior surface of the temporal lobe lies be-
tween the stem of the calcarine fissure and the posterior part
of the collateral fissure (Figs. 138, 159). It is continuous
anteriorly with the hippocampal gyrus, and, posteriorly, its
upper part crosses the medial occipital border of the hemi-
sphere and forms part of the medial surface of the occipital
lobe. It constitutes a portion of the striate area or area of
vision.

Gyrus Fusiformis. The fusiform gyrus lies between the

collateral fissure and the inferior temporal sulcus. It is con-
tinued posteriorly to the inferior surface of the occipital lobe.

Gyrus Temporalis Inferior. Only a part of the inferior

temporal gyrus appears on the inferior surface of the temporal
THE CEREBRUM 415

lobe ; the remainder forms the infero - lateral border of the

hemisphere, in the temporal region, and a part of the lateral
surface of the temporal lobe.

Lobus Occipitalis. The occipital lobe forms part of the

supero-lateral, part of the inferior, part of the medial surface of
the hemisphere, and the occipital pole. Its medial surface,
which will be seen more clearly at a later stage, is definitely
separated from the medial surface of the parietal lobe by
the parieto-occipital fissure. The boundary which separates
its supero-lateral surface from the adjacent parts of the parietal
and temporal lobes is the small, lateral part of the parieto-
occipital fissure, and a line drawn from that fissure to the
pre-occipital notch on the infero-lateral border of the hemi-
sphere. It is, therefore, largely artificial; and there is no
natural line of demarcation between the inferior surface of the
occipital lobe and the inferior surface of the temporal lobe
(Figs. 138, 156, 159).

The Sulci and Fissures of the Supero-lateral Surface of the

Occipital Lobe. On the posterior part of the supero-lateral
surface of the occipital lobe is the terminal part of the cal-
carine fissure which curls round the occipital pole, from the
medial to the lateral surface. The portion of the brain
cortex which immediately surrounds the extremity of the
calcarine fissure is part of the striate or visual area of the
cortex (Figs. 152, 154, 155).

Immediately anterior to the end of the calcarine fissure is

a curved sulcus, convex forwards, called the sulcus lunatus. It
forms the anterior boundary of the visual area on the supero-
lateral surface of the hemisphere. Anterior to the sulcus
lunatus, and at right angles with it, is the sulcus occipitalis
lateralis, which divides the larger, anterior part of the supero-
lateral surface of the occipital lobe into an upper and a lower
portion. Passing backwards from the parietal lobe into the
upper portion of the occipital lobe is the sulcus par-occipitalis.
It ends posteriorly in a sulcus, the sulcus occipitalis transversus,
which is at right angles with the sulcus par-occipitalis. In
some cases a small sulcus, the sulcus occipitalis paramedialis,
is recognisable, parallel with and close to the supero-medial
border of the occipital lobe (Figs. 152, 154). When it
is present the supero-lateral surface of the occipital lobe
is separated, by it and the lateral occipital sulcus, into
superior, middle, and inferior gyri.

416

THE BRAIN
The Sulci and Gyri of the Inferior Surface of the Occipital
Lobe. The posterior part of the collateral fissure extends
backwards from the temporal into the occipital lobe, separat-
ing the lingual gyms from the posterior part of the fusiform
gyrus, both of which enter into the formation of the inferior
surface of the occipital lobe (Figs. 138, 156).

After the study of the fissures, sulci, and gyri of the supero-
lateral and inferior surfaces of the hemispheres is completed

XX

S.R.a. '

S.R./

Tz.

FIG. 157. Fissures and Gyri on the Surface of the Insula.

(Eberstaller.)

i, 2, and 3. Three short gyri on the frontal

part of the insula.

4 and 5. Two long gyri on parietal part.

S.R.a. Anterior part of circular sulcus.
S.R.-r. Superior part of circular sulcus.
S.R./. Inferior part of circular sulcus.
L. Limen insulae.
P. Pole of the insula.

F. Orbital operculum (for the most part

removed).
T. Temporal pole.
Ti. Superior temporal gyrus.
Ta. Middle temporal gyrus.
x.y. Transverse temporal gyri.
s.i. Sulcus centralis insulae.
s.a. Sulcus praecentralis insulae.
m. Gyri on deep surface of temporal pole.
the dissector should separate the margins of the lateral fissure
from one another, and examine the insula, which lies under
cover of the boundaries of the fissure ; or if the brain is so
hardened that the margins of the fissure cannot be drawn
apart the dissector should cut away the portions of the frontal,
parietal, and temporal lobes which overlap and conceal the
insula.

THE CEREBRUM 417

Insula (O.T. Island of Reil). The insula is a pyramidal

area of the hemisphere which lies on a deeper plane than the
remainder of the surface of the hemisphere; it is hidden
from view by the adjacent margins of the frontal, parietal, and
temporal lobes, which overlap it and constitute the opercula
of the fossa lateralis. The fossa lateralis is the depression, at
the bottom of the lateral fissure, in which the insula lies.
Round the anterior, superior, and posterior borders of the
insula runs a sulcus, called the sulcus circularis. It separates
the insula from the adjacent parts of the hemisphere. At the
apex or lowest part of the insula there is a rounded fold of
the brain substance ; it is directly connected with the lateral
of the two striae which extend from the posterior end of the
olfactory tract and with the piriform area of the hippocampal
gyrus, and it forms part of the olfactory area of the hemi-
sphere. The region in which it is situated is known as the
limen insulce.

The surface of the insula is divided into an anterior or

frontal portion and a posterior or parietal portion by the
sulcus centralis insulcz, which is in a plane parallel with the
plane of the central sulcus on the supero-lateral surface of
the hemisphere. On both portions of the insula there are
two or more gyri.

At this stage, the dissector should study the portion of the

middle cerebral artery which was left in situ when the mem-
branes were removed from the hemisphere (p. 387). He
will find that it passes along the stem of the lateral fissure,
crosses the limen insulae, and breaks up on the surface of the
insula into the terminal branches which were noted on the
supero-lateral surface of the hemisphere (p. 388).

When the positions of the terminal branches of the

middle cerebral artery have been studied, the vessels and
the surrounding membranes may be removed.

Lobus Olfactorius. Each olfactory lobe consists of several

parts; they are: (i) the olfactory bulb; (2) the olfactory
tract ; (3) the olfactory striae, medial and lateral; and (4) the
olfactory trigone. The olfactory bulb^ which is the most
anterior part of the olfactory region of the brain, lies on
the lower surface of the frontal lobe, in the anterior part
of the olfactory sulcus. On its lower surface it receives the
olfactory nerves, which arise in the olfactory mucous mem-
brane of the nose and terminate in the olfactory bulb. They
VOL. Ill 27

418 THE BRAIN

are about twenty in number. The olfactory bulb is continuous,

posteriorly, with the olfactory tract, a triangular prismatic band
which runs backwards, in the olfactory sulcus, to the anterior
border of the anterior perforated substance, where it ends in
a pyramidal elevation, the trigonum olfactorium. From the
lateral angle-of the olfactory trigone the stria olfactoria lateralis
passes, backwards and laterally, along the lateral margin of
the anterior perforated substance and across the limeh insulae
to the piriform area of the hippocampal gyrus (Fig. 162). The
dissector should understand that under cover of the lateral
olfactory stria there is a layer of grey matter which represents
the anterior part of the piriform area.

Dissection. To display the course of the lateral olfactory

stria it will be necessary to raise the temporal pole and, pos-
sibly, it may be necessary to cut away the tip of the temporal
lobe ; but that must be done on one side only. .

From the medial angle of the olfactory trigone the medial

olfactory stria passes round the posterior end of the gyrus
rectus to the medial aspect of the hemisphere, towards the
subcallosal gyrus. The subcallosal gyrus is situated on the
under surface of the anterior part of the corpus callosum, and
it must be looked for at a later stage of the dissection (Figs.

Dissection. A dissection should now be made with the

object of displaying the upper surface of the corpus callosum.
For that purpose the upper portion of the hemisphere, on one
side, must be removed, and when that is done it will be possible
to study the gyri, fissures, and sulci on the medial surface of the
opposite hemisphere.

With a long knife slice off the upper part of the right hemi-
sphere down to the level of the sulcus cinguli on the medial surface
(see Fig. 161). The white medullary centre of the hemisphere,
enclosed within the grey cortex, which is brought into view
when the section is made, is termed the centrum semi-ovale.
From the centrum semi-ovale prolongations of the white matter
pass into all the surrounding gyri (Fig. 161).

A transverse incision must now be made through the centre

of the gyrus cinguli, which forms the medial boundary of
the semi - oval centre ; then the anterior and posterior parts
of the gyrus cinguli must be torn away from the hemisphere
in a lateral direction. If that is done successfully the manner
in which the fibres of the corpus callosum enter the hemisphere
will be demonstrated (Fig. 161).

If the student is dissecting the brain for the second time he

should not use the knife at all in carrying out this dissection.
The upper part of the hemisphere to the level of the gyrus cinguli
should be torn off and then the gyrus cinguli may be treated in

THE CEREBRUM 419

the same manner. By that expedient the fibres of the corpus

callosum may be traced into individual gyri.

Cingulum. Examine the deep surface of the gyms cinguli,

which has been torn away, and note that a large bundle of
longitudinally directed fibres is embedded in its substance.
The bundle is the cingulum. It is a longitudinarassociation
bundle, composed of several systems of fibres which run only
for short distances within it and then pass into the adjacent
parts of the gyrus fornicatus. It curves round the convexity
of the corpus callosum, commencing, in front, at the anterior
perforated substance and terminating, posteriorly, in the

Precuneus S} i FTl J-- Gyrus cinguli

Corpus callosum

Medial parieto-

occipital fissure

***>**

Posterior cuneo-^\/-*> Anterior part of the

lingual deep gyrus calcanne fissure

FIG. 158. Posterior part of medial surface of the Left Hemisphere. The
calcarine and the parieto-occipital fissures are widely opened up to show
the deep gyri within them.

hippocampal gyrus (Fig. 156). It can be easily displaced

from its bed by the exercise of a very slight degree'of traction.

The fissures and sulci and gyri on the medial surface of

the left hemisphere should now be studied.

The Fissures and Sulci on the Medial Surface of the Hemi-

sphere are the medial part of the parieto-occipital fissure ;
the posterior part of the calcarine fissure ; the callosal sulcus ;
the sulcus cinguli ; the subparietal sulcus ; and, possibly, the
upper end of the central sulcus.
Fissura Parieto-occipitalis. The medial part of the parieto-
occipital fissure descends on the posterior part of the medial
surface of the hemisphere between the occipital and parietal
lobes. It terminates a short distance behind the posterior
end of the corpus callosum, and close to the medial occipital
border, by joining the calcarine fissure. If the dissector
in 27 a

420 THE BRAIN

separates the margins of the fissure he will be able to con-

vince himself that the union of the two fissures occurs only
near the surface, and that the lower end of the deep part of
the parieto-occipital fissure is separated from the calcarine
fissure by a submerged ridge called the gyrus cunei.

Fissura Calcarina. The stem or anterior part of the

calcarine fissure has already been seen on the inferior surface
of the hemisphere (p. 413). It crosses the medial occipital
border and joins the parieto-occipital fissure on the medial
surface of the occipital lobe. Then it passes backwards to
the occipital pole, round which it turns ; and it ends, on the
supero-lateral surface of the occipital lobe, in a terminal
bifurcation. If the dissector separates the margins of the
fissure he will find that, immediately behind its union with
the parieto-occipital fissure, a submerged ridge, the cuneo-
Hngual gyrus, separates the anterior from the posterior portion
of the calcarine fissure. The ridge is an indication that the
two parts of the calcarine fissure arose separately and became
combined at a later period both ontogenetically and phylo-
genetically.

At this stage the dissector should make a frontal section

through the posterior part of the right occipital lobe, and
then examine the surface of the section of the grey matter in
the region of the posterior part of the calcarine fissure. If
the brain substance is in a state of good preservation he will
find a distinct white line, called the stria Gennari, which cuts
the grey matter into inner and outer parts, and which is not
present in the neighbouring regions. The portion of the
cortex marked by the line is called the area striata ; it is the
visual area of the cortex, and the line indicates that the portion
of the cortex in which it lies is associated with sight. It is
found in both walls of the posterior part of the calcarine
fissure and the adjacent parts of the cuneus and the lingual
gyrus which bound the fissure, but it occurs only on the
lower lip of the anterior part of the calcarine fissure, which is
situated, therefore, on the boundary line between the visual
and non-visual portions of the cortex.

Sulcus Corporis Callosi. The callosal sulcus runs round

the convex outline of the corpus callosum, separating the
corpus callosum from the gyrus cinguli.

Sulcus Cinguli, The sulcus cinguli runs parallel with the

callosal sulcus and is separated from it by the gyrus cinguli.
THE CEREBRUM

421

It commences below the anterior end of the corpus callosum

and runs at first forwards and upwards and then backwards,
parallel with the supero-medial border of the hemisphere, to
a point somewhat behind the upper end of the posterior
central gyrus, where it turns upwards, cuts the supero-medial
border, and terminates on the supero-lateral surface of the
hemisphere. It separates the gyrus cinguli, which embraces
the anterior and upper parts of the corpus callosum, from the
superior frontal gyrus and the upper ends of the anterior and
the posterior central gyri (Figs. 159, 160).

Massa intermedia

Thalamus
Paracentral lobule
Central sulcus (Rolandi)
Sulcus cinguli

Splenium of corpus callosum

Subparietal sulcus

Precuneus

Parieto-occipita
fissure

Cuneus^

Interventricular foramen
Callosal sulcus

Gyrus cinguli above callosal sulcus

Superior frontal gyrus
Fornix

Septum pellucidum

Gyrus cingul
i I

fissure L ingual gy;

Calcarine fissure
Calcarine fissure below isthmus of gyr

fornicatus ,' I ' j

Lamina quadrigemina

Pineal body : J

Aquaeductus cerebri j

Pedunculus cerebri

Pons
Oculrj-motor nerve Mamillary body

Superior
frontal gyrus

,| Genu of corpus callosum

| Subcallosal gyrus
| Paraterminal body
| Anterior commissure
\ Optic chiasma

\ Infundibuk
Tuber cinereun

lary body

FIG. 159. Medial surface of Left Hemisphere (semi-diagrammatic).

Sulcus Subparietalis. Behind the posterior end of the

sulcus cinguli, and sometimes continuous with it, is the sub-
parietal sulcus. It separates the medial part of the superior
parietal lobule, which is called the precuneus, from the
posterior part of the gyrus cinguli (Figs. 159, 160).

The Gyri of the Medial Surface of the Hemisphere. The

gyri on the medial surface of the hemisphere are the superior
frontal gyrus ; the upper ends of the anterior and the posterior
central gyri, the precuneus, the cuneus, part of the lingual
gyrus, the gyrus cinguli, and part of the gyrus rectus.
422 THE BRAIN

Gyrus Frontalis Superior. The superior frontal gyms has

been seen already on the supero-lateral surface of the hemi-
sphere (p. 406). It forms that part of the medial surface
which lies between the sulcus cinguli and the supero-medial
border, and anterior to the upper end of the anterior central
gyrus.

On its antero-inferior part are two or three secondary gyri

which run antero posteriorly or forwards and slightly upwards ;
they are known as the rostral gyri. The posterior end of the
medial aspect of the superior frontal gyrus is separated from
the upper end of the anterior central gyrus by an offshoot
from the sulcus cinguli.

Lobulus Paracentralis. The paracentral lobule corresponds

in position with the upper ends of the anterior and posterior
central gyri. It is bounded, posteriorly, by the upturned end
of the sulcus cinguli ; anteriorly, by an offset from the sulcus
cinguli. Its frontal portion is part of the motor area of the
cerebrum.

Pracuneus. The precuneus is the medial part of the

superior parietal lobule of the supero-lateral surface (p. 410).
It is bounded, behind, by the parieto-occipital fissure ; in
front, by the upturned end of the sulcus cinguli ; below, by
the sulcus subparietalis ; and, above, by the supero-medial
border of the hemisphere.

Cuneus. The cuneus forms the greater part of the medial

surface of the occipital lobe. It is bounded, anteriorly, by
the parieto-occipital fissure ; below, by the calcarine fissure ;
and, above and behind, by the supero-medial border of the
hemisphere.

Gyrus Lingualis. The lingual gyrus forms the lowest

part of the medial surface of the occipital lobe. On that
surface it lies between the calcarine fissure and the medial
occipital border, which separates the medial from the posterior
part of the inferior surface of the hemisphere. Anteriorly,
it crosses the medial occipital border and passes to the
inferior surface, where it has already been seen (Fig. 138).

After the study of the fissures, sulci, and gyri of the medial
surface of the hemisphere is completed, the dissector must
remove the upper part of the left hemisphere above the level
of the corpus callosum and anterior to the parieto-occipital
fissure, but the fissure itself, and the part of the brain behind
it, should be left intact so that a repeated study of the

THE CEREBRUM
423

calcarine fissure and its boundaries, and the relationships of

the occipital and temporal lobes on the inferior surface, can
be made at a later stage of the dissection.

Caudate nucleus in lateral ventricle

Remnant of septum pellucidu
Genu of corpus callosum
Superior frontal gyrus j
Callosal sulcu
Sulcus cinguli

Massa intermedia

Fornix
Gyrus cinguli

Inferior surface of fornix

Superior surface of thalamus

| , Upper end of central sulcus

Splenium of corpus callosum

i Paracentral lobule

Median part of transverse fissure

Pineal body

Lamina quadrigemina
urn)

Subparietal sulcus
Icarine fissure

Parieto-occipital
"ssure

Gyrus rectus -.!*

Rostrum of corpus callosum
Anterior commissure
Lamina terminalis
Supra-optic recess

Optic chiasma ./ j
Arrow passing through inter- /
ventricular foramen " J
Infundibulum
Mamillary body
Oculo-motor nerve

Pedunculus cerebri /
j

Poos

Medulla oblongat

Groove for
superior sagilt
sinus

Lingual gyrus
Cerebellum

\ Fourth ventricle
Median aperture of fourth ventricle
Central canal of spinal medulla

Medulla spinalis

FIG. 160. Medial surface of the Right Hemisphere, and the structures seen
after a sagittal section has been made through the Corpus Callosum,
the Fornix, the Diencephalon, the Mesencephalon, and the Rhomb-
encephalon, and after the Septum Pellucidum has been removed from
between the Corpus Callosum and the Fornix. The arrow passes
through the interventricular foramen from the right lateral ventricle to
the third ventricle, where it lies in the hypothalamic sulcus in the lateral
wall of the third ventricle.

When the upper parts of both hemispheres have been

removed the upper surface of the corpus callosum will be
exposed ; and it will be evident that the corpus callosum
unites into one mass the medullary centres of the two
hemispheres. The term centrum ovale is applied to the

in 27 b
424

THE BRAIN

continuous white area which consists of the corpus callosum

and the medullary centres of the two hemispheres.

Corpus Callosum. The corpus callosum is the great

transverse commissure of the cerebrum. It is placed nearer
the anterior than the posterior end of the brain, and it unites

Cingulum

Fibres of corona radiata

Intersection of C
callosal and corona I
radiata systems of|
fibres

Corpus callosum

Frontal fibres
Genu

- Cut surface

Transverse fibres
, of corpus
callosum

v Inferior longitu-
dinal fasciculus

Cingulum

Splenium
'}

'. rTapetum
P'orceps major
Stria longitudinalis medialis

FIG. 1 6 1. The Corpus Callosum exposed from above and the right half
dissected to show the course taken by the fibres.

the medial surfaces of the two cerebral hemispheres throughout

very nearly a half of their antero-posterior length (Fig. 161).

Its upper surface, which forms the floor of the central part
of the longitudinal fissure, is convex antero-posteriorly and
concave from side to side. In the posterior part of its extent
it is touched, in the median plane, by the falx cerebri ;
anteriorly, that fold of dura mater does not pass so deeply into
the fissure. On each side of the fissure the corpus callosum
is covered by the gyrus cinguli (O.T. callosal gyms). The

THE CEREBRUM

425

upper surface of the corpus callosum is coated by an exceed-

ingly thin layer of grey matter, called the indusium griseum^
which is continuous, at the bottom of the callosal sulcus, with
the grey cortex of the hemisphere. Associated with the
indusium, on each side of the median plane, are two delicate
longitudinal bands of fibres called the striae longitudinales
rnedialis and lateralis. The stria longitudinals medialis is the
more strongly marked of the two, and it is separated from
its fellow of the opposite side by a faint median furrow.
The stria longitudinalis lateralis is placed more laterally. So

Genu of

Olfactory tract-J

Optic chiasma
thrown back

Lamina terminalis
Gyrus subcallosus
FIG. 162. Anterior end of the Corpus Callosum and the Subcallosal Gyri
as seen from below when the frontal lobes of the hemispheres are
slightly separated from each other. (From Cruveilhier. )

thin is the indusium that the transverse direction of the

bundles of callosal fibres can be easily seen through it.

The strioe, with the thin layer of grey matter associated with them,
represent a gyrus called the gyrus supracallosus.

The two extremities of the corpus callosum (Fig. 160) are

greatly thickened, whilst the middle part, the truncus (O.T.
body), is considerably thinner. The thick posterior end,
which is full and rounded, lies over the mesencephalon, and
extends backwards as far as the highest point of the cerebellum.
It is called the spknium. The anterior end, which is less
thick than the posterior, is folded, downwards and backwards,
upon itself, and is called the genu. The recurved lower

426 THE BRAIN

portion of the anterior part of the corpus callosum rapidly

thins as it passes backwards, and is termed the rostrum.
The fine terminal edge of the rostrum is connected with the
lamina terminalis (Fig. 160).

Both the lateral and the medial longitudinal striae and the
indusium, which lie upon the upper surface of the corpus
callosum, turn downwards, round the splenium, and become
continuous, below it, with the attenuated posterior part of the
hippocampus, a structure which will be seen, later, in the
inferior horn of the lateral ventricle. Immediately above the
union of the indusium with the hippocampus there is a
narrow ridge of grey matter, called the fasciola cinerea, which
is the posterior, terminal part of the fascia dentata (Fig.
156). Anteriorly, the striae and the indusium pass round the
genu, and then along the under surface of the rostrum until
they terminate in the gyrus subcallosus of the corresponding
side. The gyrus subcallosus is a ridge which descends from
the rostrum of the corpus callosum and passes towards the
medial olfactory stria and the substantia perforata anterior
(Fig. 1 60).

Fibres of the Corpus Callosum. The transverse fibres of the corpus

callosum, as they enter the white medullary centre of the cerebral hemisphere,
radiate from each other towards various parts of the cerebral cortex. This
radiation is called the radiatio carports callosi. The more anterior of the
fibres which compose the genu of the corpus callosum sweep forwards,
in a series of curves, towards the frontal pole of the hemisphere. They
form the forceps minor. A large part of the splenium, forming a solid
bundle termed the forceps major, bends suddenly and abruptly backwards
into the occipital lobe. Fibres from the trunk of the corpus callosum and
also from the splenium curve round the lateral ventricle and form a very
definite stratum called the tapetum. The tapetum is a thin layer, of the
medullary centre of the hemisphere, which forms the roof and lateral wall
of the posterior horn, and the lateral wall of the posterior part of the inferior
horn of the lateral ventricle.

VENTRICULUS LATERALIS.

The lateral ventricle, in the interior of the cerebral hemi-

sphere, should now be opened up on each side. The corpus
callosum, which forms the roof of the central part (O.T. body)
and anterior horn of this cavity, must, therefore, be partially
removed.

Dissection. Make a longitudinal incision, through the

corpus callosum, about 6 mm. (a quarter of an inch) or less
from the median plane, on each side. The central portion of
the corpus callosum which lies between the incisions is to

THE CEREBRUM

427

be kept in position. The lateral portions must be turned laterally

and detached completely. As that is being done, it will become
evident that the lower part of the splenium, which is prolonged
into the forceps major, is, in reality, a portion folded forwards
in close apposition with the under surface of the posterior end
of the corpus callosum. Be careful to leave the forceps major
in its place (Fig. 163).

Anterior horn of lateral ventricle

Longitudinal fissure
Corpus callosum
Cut surface of roof of lateral ventricle

Head of caudate nucleus

Stria terminalis

Chorioid plexus
Thalamus

First frontal sulcus

Central sulcus
Chorioid plexus
Posterior horn of ventricle

Cut surface of forceps major

Fornix
Precentral sulcus

Central sulcus

Postcentral
sulcus

Lateral fissure

Corpus callosum

Chorioid plexus
Calcar avis
ulb of posterior cornu
Calcarine fissure

Longitudinal fissure

FIG. 163. Dissection of the Lateral Ventricles of the Brain. On the right
side the hemisphere was cut horizontally at the level of the junction of
the lateral wall with the roof of the ventricle. On the left side the part
of the hemisphere above the corpus callosum was torn obliquely away ;
then the corpus callosum was cut through from above.

The central part and the anterior horn of the ventricle are
now exposed ; but the cavity of the ventricle runs backwards
into the occipital lobe in the form of a posterior horn, and
downwards and forwards into the temporal lobe as the inferior
horn. The posterior horn should, at present, be opened on the
right side only. Carry the knife backwards through the medul-
lary substance which forms the roof of the cavity, and remove
a sufficient amount of the roof to give a complete view of the
interior of the cavity. Greater difficulty will be experienced

428
THE BRAIN

in opening up the inferior horn. Place the point of the knife

in the upper part of the horn, where it joins the central part
of the ventricle, and carry the blade forwards and downwards,
through the lateral part of the temporal lobe, towards the

Genu of corpus callosum

; foramen mterventnculare
Cavum septi pellucidi I | Caudate nucleus
Thalamus
Septum pellucidum Chorioid plexus

Stria terminalis

Trigonum collaterale

Hippocampus

Crus of forni

Calcar avis

Forceps major

Body of fornix

Bulb of cornu
Hippocampus

Crus of fornix

FIG. 164. Dissection to show the Lateral Ventricles. The trunk of the
corpus callosum has been detached from the genu and the splenium and
turned over to the left.

temporal pole, following the course of the cavity, which corre-

sponds, very nearly, with the course of the superior temporal
sulcus. The lateral wall of the inferior horn is thus incised,
and a sufficient amount of the lateral part of the temporal lobe
THE CEREBRUM

429

must be removed to give a view of the cavity. The dissection

necessitates the removal of the temporal operculum, but the
surface of the insula should be preserved from injury. 1

.Lateral Ventricle. When the dissection is completed,

the dissector cannot fail to note that each cerebral hemisphere
is hollow. The cavity in the interior is called the lateral
ventricle. It is lined with a thin dark -coloured layer of
epithelium which is termed the ependyma. In certain places
its walls are in apposition with each other, but in other

Central part of lateral ventricle

Pineal recess

Supra-pineal recess
Aquaeductus
cerebri

Fourth
ventricle^

Interventricular
> x foramen

Third ventricle
'Optic recess

Infundibular recess

Inferior horn
Lateral recess

FIG. 165. Cast of the Ventricles of the Brain. (From Retzius. )

localities spaces of varying capacity, and containing cerebro-

spinal fluid, are left between the boundary walls. The lateral
ventricle communicates with the third ventricle of the brain
by means of a small foramen which is termed the inter-
ventricular foramen (O.T. foramen of Monro) (Figs. 160, 165).
That aperture, which is just large enough to admit a crow-
quill, lies at the anterior end of the thalamus, and posterior to
the column of the fornix (O.T. anterior pillar). To find the
aperture, the dissector should note the rough fringe of vascular
pia mater which lies on the floor of the ventricle, and he should
follow the fringe forwards to its passage into the foramen.
The shape of the lateral ventricle is very irregular, but it

1 If the hemispheres have already been separated from one another the
dissection must be carried out on each side separately.

43

THE BRAIN

is readily understood when a cast of the cavity is examined

(Fig. 165). It is composed of a central part (O.T. body)

Caudate nucleus

Putamen \
Anterior commissure

Inferior cornu of
lateral ventricle

Pes hippocampi
Hippocampus

Chorioid / ^
plexus '

Fimbria'
Posterior collateral;
eminence
Posterior cornu

Genu of corpus
callosum

Septum
pellucidum
Cavum sep. pel!.
Caudate nucleus

Foramen
interventriculare

Stria terminalis

Thalamus
Fornix

Medial longi
""" tudinal stria

Calcartavis

Forceps major

FiG. 166. Dissection to show the Posterior and Inferior Cornua of the
Lateral Ventricle on the left side.

and three horns, viz., an anterior, a posterior, and an inferior

horn. The anterior horn is that part of the cavity which
lies anterior to the interventricular foramen. The central

THE CEREBRUM 431

part is the portion of the ventricle which extends from the

interventricular foramen to the splenium of the corpus cal-
losum. At the level of the splenium the posterior and
inferior horns diverge from the posterior end of the central
part. The posterior horn curves backwards and medially
into the occipital lobe. It is very variable in its length and
capacity. The inferior horn passes, with a bold sweep, round
the posterior end of the thalamus, and then tunnels, down-
wards and forwards, through the temporal lobe, towards
the temporal pole (Fig. 166).

Behind the anterior horn the floor of the central part of

the ventricle is fully exposed and the following parts should
be distinguished, (i) Extending backwards and laterally
from the interventricular foramen is the vascular fringe called
the chorioid plexus of the lateral ventricle. Posteriorly it
descends into the inferior horn. (2) Medial to the chorioid
plexus is the upper surface of the body of the fornix. Its
posterior extremity, on each side, becomes a crus of the fornix,
which accompanies the chorioid plexus into the inferior horn,
where it terminates in the fimbria of the hippocampus. (3)
Lateral to the chorioid plexus is a part of the upper surface
of the thalamus. (4) Running along the lateral margin of the
thalamus, in a shallow sulcus, is a white strand called the stria
terminalis. It descends posteriorly into the roof of the
inferior horn. (5) Lateral to the stria terminalis lies the
convex upper surface of the body of the caudate nucleus.

Dissection. When the parts mentioned have been identified,

the central part of the corpus callosum, which is still in position,
should be carefully raised to display the septum pellucidum, which
descends from the lower surface of the corpus callosum to the
upper aspect of the fornix, and so intervenes between the lateral
ventricles of the opposite sides, forming the medial wall of the
central part and the anterior cornu of each ventricle. Whilst
the central part of the corpus callosum is still elevated the fornix
should be followed forwards. It will be found to divide into two
rounded bundles, called the columns of the fornix, which descend,
one on each side, in front of the corresponding interventricular
foramen (Fig. 160).

Plexus Chorioideus Ventriculi Lateralis. The chorioid

plexus of each lateral ventricle is a plexus of blood vessels
enclosed in the lateral margin of a triangular fold of pia
mater called the tela chorioidea of the third "ventricle. The
body of the fold is concealed at present. It will be displayed
at a later stage of the dissection (Fig. 174).

43 2

THE BRAIN

Cornu Anterius Ventriculi Lateralis. The anterior horn

forms the anterior part of the cavity, and it extends forwards,
laterally and downwards in the frontal lobe. When seen in
frontal section it presents a triangular outline. The floor
is narrow and is formed by the white matter of the orbital
part of the frontal lobe. From it the medial and lateral
walls ascend to the roof, which is formed by the under surface
Corpus callosum

Longitudinal fissure

Lateral ventricle /
Chorioid plexus
Interventricular foramen

Claustrum

i \ Internal capsule

. r , i Lentiform nucleus

Right column of fornxx ^ Caudate nucleus

Septum pe"ucidum

FIG. 167. Frontal section through the Cerebrum through the anterior part
of the lentiform nucleus. Seen from the anterior aspect.

of the corpus callosum. The vertical medial wall is the

anterior part of the septum pellucidum, which separates the
anterior horns of the opposite sides from one another. The
in-bulging lateral wall is formed by the head of the caudate
nucleus (Fig. 167).

Pars Centralis Ventriculi Lateralis. The central part

of the ventricle likewise is roofed by the corpus callosum.
On the medial side it is bounded by the posterior part of the
septum pellucidum, and more posteriorly by the attachment

THE CEREBRUM

433

of the fornix to the under surface of the corpus callosum,

behind the posterior end of the septum pellucidum. On the
lateral side it is closed by the meeting of the roof and the
floor of the cavity.
In the floor are several important objects which have
already been referred to. Latero-medially, and, at the same
time, to some extent from before backwards, they are (i) the
caudate nucleus ; (2) a groove extending obliquely, backwards

Corpus callosum Chorioid plexus

Lateral ventricle I [ Striae on corpus callosum

Caudate nucleus I ! j Longitudinal fissure

Fronto-occipital fasciculus i l\ \ Septum pellucidum

Vena terminal

Subthalamic body I

Thalamus

3rd ventricle
Chorioid plexus
Red nucleus

FIG. 168. Frontal section showing immediate relations of Lateral and

Third Ventricles. (Part of Fig. 188 enlarged.)

and laterally, between the caudate nucleus and the thalamus, in

which are placed the vena terminalis (O.T. vein of corpus
striatum) and a white band called the stria terminalis (O.T.
tsenia semicircularis) ; (3) a portion of the upper surface
of the thalamus ; (4) the chorioid plexus ; (5) the thin, sharp
edge of the fornix.

The caudate nucleus lies in the lateral part of the floor of

the central part of the lateral ventricle, and it narrows very
rapidly as it passes backwards.

The vena terminalis is seen through the ependyma in the

groove between the caudate nucleus and the thalamus. It
joins the internal cerebral vein (O.T. vein of Galen) at the
interventricular foramen. In the same groove is placed the
stria terminalis a narrow band of white matter, which bends

VOL. in 28

434

THE BRAIN
downwards and disappears from view in the region of the
interventricular foramen. Its fibres ultimately reach the
substantia perforata anterior, in which they end.

The portion of the upper surface of the thalamus which

appears in the floor of the lateral ventricle is, in great part,
overlaid by the chorioid plexus of the lateral ventricle. The
plexus is a rich vascular fringe which appears from under
cover of the sharp edge of the fornix. It is continuous
anteriorly, through the interventricular foramen, with the
corresponding chorioid plexus of the opposite side ; whilst

Bulb of cornu

Splenium

Bulb of corni

Calcar avis

\ Tapetum
\ \
\ Optic radiation

Inferior longitudinal bundle

FIG. 169. Frontal section through the Posterior Horns of the

Lateral Ventricles.

posteriorly, it is carried into the inferior horn of the ventricle.

Although the chorioid plexus has all the appearance of lying
free within the ventricle, it is invested by an epithelial layer
of ependyma, which excludes it from the cavity and is
continuous on the one hand with the ependyma on the
sharp margin of the fornix, and on the other with the
ependyma of the upper surface of the thalamus.

Cornu Posterius Ventriculi Lateralis. The posterior

horn is a diverticulum which runs, from the posterior end of the
central part of the ventricle, into the occipital lobe. It tapers
to a point and describes a gentle curve, the convexity of
which is directed laterally. The roof and the lateral wall of

THE CEREBRUM 435

the posterior horn are formed by the tapetum of the corpus

callosum (see p. 426).

Upon the medial wall two elongated, curved elevations

may be seen. The upper of the two is termed the bulb of
the cornu, and is produced by the fibres of the forceps major
as they curve, backwards, from the lower part of the splenium
of the corpus callosum into the occipital lobe. The lower
elevation is known as the calcar avis. It varies greatly in
size, in different brains, and is caused by an infolding of the
ventricular wall which corresponds with the anterior part of
the calcarine fissure.

Dissection. If the opercula have not already been removed

to expose the insula, the dissector should now insinuate his
fingers underneath the fronto-parietal operculum of the insula
on the right side and tear that portion of the cortex away in an
upward direction. The frontal operculum (pars triangularis)
and the orbital operculum should be dealt with in the same
manner. The greater part of the temporal operculum has
already been removed in opening up the inferior horn of the
ventricle ; therefore the insula is how fully exposed to view,
and its relation to the parts in the interior of the ventricle can
be seen.

Cornu Inferius Ventriculi Lateralis (O.T. Descending

Cornu). The inferior horn must be regarded as the direct
continuation of the main ventricular cavity into the temporal
lobe. The posterior horn is merely a diverticulum from the main
cavity. At first directed backwards and laterally, the inferior
horn suddenly sinks downwards, posterior to the thalamus, into
the temporal lobe, in which it takes a curved course, forwards
and medially, to a point about 25 mm. (one inch) posterior to
the extremity of the temporal pole. In the angle between the
diverging inferior and posterior horns the cavity of the ventricle
exhibits a triangular expansion of varying capacity. It is called
the trigonum collaterale.

The lateral wall of the inferior horn is formed, for the

most part, by the tapetum of the corpus callosum. At the
extremity of the horn the roof presents a slight bulging into the
ventricular cavity. The bulging is called the amygdaloid
tubercle, and it is produced by a superjacent collection of grey
matter, termed the amygdaloid nucleus. The stria terminal's
and the greatly attenuated tail of the caudate nucleus are
both prolonged into the inferior horn, and are carried
forwards, in its roof, to the amygdaloid nucleus.

436 THE BRAIN

On the floor of the inferior horn the dissector will note

the following parts." (i) the hippocampus; (2) the chorioid
plexus; (3) the fimbria ; and (4) the eminentia collateralis.

Hippocampus (O.T. Hippocampus Major). The hippo-

campus is overlapped by the chorioid plexus, which must be
turned aside. It is a prominent elevation in the floor of the
inferior horn of the lateral ventricle, and is strongly curved
in conformity with the course taken by the horn in which it
lies. It presents, therefore, a concave medial margin and a
convex lateral margin. Narrow posteriorly, it enlarges as it
is traced forwards, and it ends, below the amygdaloid tubercle,

Optic tract

Stria terminalis | Fimbria

Chorioid plexus | ! / Subthalamic body
Caudate nucleus I j ! j ! Basis pedunculi

Inferior cornu of lateral ventricle ; ! ! ! Red nucleus

- Collateral eminence Pia mater (red)

Collateral fissure Cerebellum

FIG. 170. Frontal Section to show relations of Inferior Cornu of

Lateral Ventricle. (Part of Fig. 188 enlarged.)

in a thickened extremity, the pes hippocampi. The surface

of the pes hippocampi is marked by some faint grooves which
intervene between a number of ridges called the hippocampal
digitations. The hippocampal elevation is due to masses of
nerve cells and the nerve fibres associated with them.

Alveus. The alveus is a thin white layer formed by nerve

fibres which arise from the cells of the hippocampus, and
spread out over its ventricular surface.

Fimbria (Hippocampi). The fimbria is a narrow but very

distinct band of white matter which is attached by its lateral
margin along the concave medial border of the hippocampus,
immediately above the fascia dentata. The white matter com-

THE CEREBRUM

437

posing it is continuous with the thin white layer (alveus) which

is spread over the surface of the hippocampus. The fimbria
has two free surfaces superior and inferior \ a sharp, free medial
border, which lies immediately above the fascia dentata, and
below the chorioidal fissure ; and a lateral border, attached to
the hippocampus at its junction with the fascia dentata. It
consists of the white fibres of the alveus, which assume a
longitudinal direction at the margin of union of the hippo-
campus and the fascia dentata, and ascend to become the

Pes hippocampi
Hippocampus
Anterior collateral eminence

Trigonum collaterale \
Calcar avis

Posterior horn
Bulb of cornu

FIG. 171. Dissection to show the Posterior and Inferior Cornua of the
"Lateral Ventricle.

corresponding crus of the fornix (see p. 442). It lies between

the chorioid fissure and the fascia dentata (Fig. 171).
Anteriorly, it runs into the recurved extremity of the uncus ;
and postero- superiorly, as already stated, it becomes con-
tinuous with crus of the fornix.

Chorioid Fissure of the Cerebrum. When the pia mater

in the region of the hippocampal gyrus and the fascia dentata
is removed from the surface of the brain, the chorioid plexus
in the interior of the inferior horn of the lateral ventricle is some-
times withdrawn with it, and a fissure then appears between the
fimbria and the roof of the ventricular horn. That fissure is
III 28 a

438

THE BRAIN

part of the chorioid fissure of the cerebrum ; and it is the lateral

part of the great transverse fissure. By the withdrawal of the
chorioid plexus it is converted into an artificial gap, which

:ntral part of lateral ventricle

Grey matter of |

aqueduct
quaeductus
cerebri

Chorioid plexus
Caudate nucleus

Optic radiation

Caudate nucleus (tail)

y Optic radiation
^ Inferior longitudinal bu
Tapetum
i \ Chorioid plexus

\ Inferior horn of lateral ventricle

Alveus

Lateral lemniscus

Medial geniculate body

Hippocampal gyru

Hippocampus
Fimbria

Fascia dentata
Lateral geniculate body

Chorioid fissure

FIG. 172. Frontal section through the Cerebrum, Mid-brain, and Pons in the
plane of the geniculate bodies. It shows the relation of the chorioid
fissure to the inferior horn of the lateral ventricle.

leads directly from the exterior of the brain into the interior
of the inferior horn of the lateral ventricle.

Plexus Chorioideus. The chorioid plexus is a system of

convoluted blood vessels, enclosed within a fold of pia

THE CEREBRUM 439

mater, which is prolonged, into the inferior horn and the

central part of the lateral ventricle, through the chorioid fissure
of the cerebrum. In the inferior horn it lies on the surface
of the hippocampus and, at the posterior extremity of the
thalamus, it becomes continuous with the chorioid plexus in
the central part of the lateral ventricle (Fig. 166). But it
must not be supposed that the chorioid plexus lies free in
the ventricular cavity. It is clothed in the most intimate
manner by an epithelial ependymal layer, which represents
part of the original medial surface of the hemisphere pushed
into the cavity by the chorioid plexus. The ventricle, there-
fore, opens on the surface through the chorioid fissure only
after the thin epithelial layer is torn away by the withdrawal
of the chorioid plexus.

Eminentia Collateralis. The collateral eminence is some-

times separated into two parts, which may be distinguished
from each other as the eminentia collateralis posterior and
the eminentia collateralis anterior (Figs. 166, 171).

The posterior collateral eminence is a smooth elevation in

the floor of the trigonum collaterale, in the interval between
the calcar avis and the hippocampus as they diverge from
one another. The anterior collateral eminence is not always
present. It forms an elongated elevation in the floor of the
inferior horn of the lateral ventricle, to the lateral side of
the hippocampus. Both eminences correspond to the col-
lateral fissure on the inferior aspect of the cerebral
hemisphere.

Dissection. The dissector should now detach the remains

of the right temporal lobe and of the right occipital lobe from
the rest of the cerebrum by cutting through the forceps major
of the splenium of the corpus callosum and through the fimbria
where it passes into the crus of the fornix. The knife should
then be carried forwards from the anterior extremity of the
inferior horn, above the level of the uncus, through the temporal
pole. The temporal lobe, including the hippocampal gyrus
along its medial side, can then be separated from the remainder
of the brain, along the line of the chorioid fissure of the cerebrum.
In the detached part of the cerebrum (Fig. 171) a good view is
obtained of the floor of the inferior horn and of the parts in
relation to it. Further, by replacing it in position, the dissector
will be better able to understand the chorioid fissure, and by
turning the brain upside down he will obtain a view of the roof
of the inferior horn and the structures in relation to it. In that
way the tail of the caudate nucleus and the stria terminalis can
be traced into the amygdaloid nucleus.

The cut edge of the central part of the corpus callosum, which
ni286

440 THE BRAIN

is still in position, should now be still further pared away, so as

to bring the subjacent septum pellucidum and the fornix more
fully into view.

Upon the portion of the temporal lobe which has been separ-
ated, the dissector should examine again the fascia denlata,
which was mentioned on p. 414, and which is now much more
accessible.

Fascia Dentata Hippocampi. The fascia dentata is

the free edge of grey matter which is placed between the
fimbria and the deep part of the upper surface of the hippo-
campal gyrus. The groove between it and the fimbria
is termed \hz fimbrio-dentate sulcus. The margin of the fascia
is notched, and its surface is scored with numerous closely-
placed vertical grooves. It begins posteriorly, in the region
of the splenium of the corpus callosum, as the fasciola cinerea
(Fig. 173), and it runs forwards into the cleft of the uncus,
from which it emerges again in the form of a delicate band,
called the cauda fascia dentatce^ which crosses the recurved
part of the uncus in a transverse direction. The cauda is
not always easily seen.

SEPTUM PELLUCIDUM FORNIX TELA CHORIOIDEA

VENTRICULI TERTII.

Septum Pellucidum. The septum pellucidum is a thin

vertical partition which intervenes between the anterior
cornua and the anterior parts of the central portions of the
two lateral ventricles (Fig. 164). It occupies the triangular
interval between the corpus callosum and the body and
columns of the fornix, being attached, above and anteriorly,
to the corpus callosum, and below and posteriorly, to the fornix.
It consists of two thin laminae which form the side walls of a
median cleft called the cavum septi pellucidi (Figs. 164, 174).

Dissection. The narrow median strip of the corpus callosum,

posterior to the genu, should now be removed. Cut it trans-
versely across, and, gently raising it, separate the upper edge
of the septum pellucidum from its lower surface. Posterior to
the septum pellucidum the under surface of the median part of
the corpus callosum will be found to lie upon and to be con-
nected with the upper surface of the fornix. Sever that con-
nection also. The left half of the forceps major should be
preserved, so that its connection with the occipital lobe may be
more fully made out later. Snip off the upper edge of the
septum pellucidum with the scissors, in order to demonstrate
the two laminae with the interposed cleft.

THE CEREBRUM

441

Cavum Septi Pellucidi (O.T. Fifth Ventricle). The cavity

of the septum pellucidum is the name applied to the median
cleft between the two laminae of the septum. It varies greatly
in extent, in different brains, and it contains a little fluid. It is
completely isolated, having no communication either with the
ventricles or with the exterior.

Fornix. The fornix is an arched structure, composed of

longitudinal and transverse fibres. It consists of a central
part or body, which ends in two columns anteriorly and two
crura posteriorly.

Fasciculus mamillo-thalamicus

Corpus callosum

Taema thalami j j Rostrum of corpus callosum

Base of pineal body

Sulcus for falx

cerebri

Splenium

Median part of

transverse fissure

Fasciola cinerea

Cingulum passing
through the isthmus

Upper quadrigeminal body

Posterior commissure ]
Fimbria

Genu of corpus
callosum

Column of fornix
Anterior commissur
Subcallosal gyrus

'_ Optic recess

i Optic chiasma
Uncus
Mamillary body

FIG. 173. Dissection showing the relations of the Fornix.

Corpus Fornids. The body of the fornix is triangular in
shape. Anteriorly, where it is continuous with the columns,
it is narrow; posteriorly it broadens out, becomes flattened, and
is prolonged into the crura (Fig. 166). The posterior part of
the upper surface of the body of the fornix is in contact with
arid is adherent to the inferior surface of the posterior part
of the body of the corpus callosum. The remaining part of
the upper surface of the median portion of the fornix is
attached to the posterior part of the lower edge of the
septum pellucidum. Lateral to those attachments the upper
surface of the body of the fornix forms a part of the floor
of the lateral ventricle, on each side, and is clothed with

442 THE BRAIN

ependyma. Each lateral margin is a sharp edge, from

under which the chorioid plexus projects into the cavity of
the corresponding lateral ventricle. The lower surface of
the body of the fornix rests upon the tela chorioidea of the
third ventricle (O.T. velum interpositum), a fold of pia mater
which separates it from the third ventricle and the two
thalami (Figs. 168, 187).

Columns Fornitis (O.T. Anterior Pillars}. The two

columns of the fornix are two rounded strands which emerge
from the anterior end of the body of the fornix, and then,
diverging slightly, pass downwards, anterior to the inter-
ventricular foramina. They then sink into the grey matter
on the side walls of the third ventricle, and end at the
base of the brain in the corpora mamillaria (Figs. 160, 173).

Each mamillary body has the appearance of being a twisted loop of

the corresponding column of the fornix, in which the fibres turn upon
themselves, and are then continued upwards and backwards into the
anterior tubercle of the thalamus. The appearance, however, is decep-
tive. In the interior of the corpus mamillare there is a nucleus of grey
matter. In that nucleus the fibres of the column end ; while the other
fibres, which seem to be continuous with the fornix fibres, take origin
within the nucleus. The strand, thus formed, is called the fasciculus
mamillo-thalamicus (O.T. bundle of Vicq d'Azyr) (Fig. 173).

The connections which have just been described cannot be made out at
present, but at a later period the dissector will experience little difficulty
in tracing a column of the fornix to the corresponding corpus mamillare,
and in displaying the connection of corpus mamillare with the fasciculus
mamillo-thalamicus.

Crura Fornicis (O.T. Posterior Pillars). The crura of the

fornix are flattened bands which diverge from the posterior
part of the body of the fornix. At first they are adherent
to the under surface of the corpus callosum, but soon they
sweep downwards, round the posterior ends of the thalami,
and enter the inferior horns of the lateral ventricles. There
each cms comes into relation with the corresponding hippo-
campus, and some of its fibres spread out on the surface
of that prominence, where they form the alveus, whilst the
remainder constitute the fimbria, which has been described
already (p. 436, Fig. 171).

The transverse fibres of the fornix cross the lower surface

of the body and the anterior part of the interval between the
diverging crura. In the latter place they may be adherent
to the lower surface of the corpus callosum. On each side
they are continuous with the longitudinal fibres of the crura

THE CEREBRUM

443

and so are prolonged, in the inferior horn, into the fimbria

and the alveus. They constitute a transverse commissure
from one hippocampus to the other.

Dissection. The body of the fornix should now be divided

transversely, across its middle. Its posterior and anterior
portions may then be raised from the tela chorioidea of the third
ventricle, and thrown apart from each other. Had it been
possible to raise the corpus callosum and fornix together, the

Cavum septi pellucidi Genu of corpus callosum

Fornix (divided) .

Stria
terminalis "-/J

Septum pellucidum
.- Caudate nucleus

Column
of fornix

Tela chorioidea
of third ventricle

Internal cerebral
Cru
jralvein' / /..

V / ^

rus of fornix

Chorioid plexus

Body of fornix
reversed

FIG. 174. Dissection to show the Tela Chorioidea of the Third

Ventricle and the parts in its vicinity. The fornix has been
divided and thrown backwards.

diverging crura of the fornix would have been seen to limit a

triangular space on the under surface of the corpus callosum,
anterior to the posterior margin of the splenium. That interval
is termed the lyra ; it is traversed by a series of oblique markings
which indicate the presence of the transverse fibres passing
across from one crus of the fornix to the other.

Tela Chorioidea Ventriculi Tertii (O.T. Velum Inter-

positum). The tela chorioidea of the third ventricle consists
of two layers of pia mater which form a fold of triangular
outline. It intervenes between the body of the fornix, above,
and the roof of the third ventricle and the two thalami,

444 THE BRAIN

below. Between the two layers are blood vessels and some
subarachnoideal trabecular tissue. The narrow, anterior end
of the triangular fold lies between the interventricular
foramina. The base is situated under the splenium of the
corpus callosum, and there the upper of the two layers of pia
mater which form the tela becomes continuous with the pia
mater on the corpus callosum, and the lower layer becomes
continuous with the pia mater on the lamina quadrigemina
(Fig. 1 41).

In each of the two margins of the tela lies the chorioid

plexus of the central part of the corresponding lateral ventricle.
The plexus projects into the ventricular cavity from under
cover of the free edge of the fornix. Posteriorly, it is con-
tinuous with the part of the chorioid plexus which lies in the
inferior horn of the ventricle ; whilst anteriorly, it narrows
greatly, and becomes continuous, across the median plane,
with the corresponding plexus of the opposite side. From
the median junction two much smaller chorioid plexuses
run, backwards, in the lower surface of the tela, and project
downwards into the third ventricle. These are the chorioid
plexuses of the third ventricle (Fig. 175).

The most conspicuous blood vessels in the tela chorioidea

of the third ventricle are the two internal cerebral veins
(O.T. veins of Galen\ which run backwards one on each
side of the median plane. Each internal cerebral vein is
formed, at the apex of the fold, by the union of the vena
terminalis with a large vein issuing from the chorioid plexus ;
posteriorly, they unite to form the great cerebral vein
(O.T. vena magna Galeni), and that vein pours its blood
into the anterior end of the straight sinus (Fig. 35).

Fissura Transversa Cerebri. The name transverse fissure

is given to the continuous cleft through which the tela
chorioidea of the third ventricle and the chorioid plexuses
of the inferior horns of the lateral ventricles are introduced
into the interior of the brain. It consists of an upper or
middle part and two lateral parts. The middle part
lies between the splenium of the corpus callosum and
the body of the fornix, above, and the mid-brain, below.
The base of the tela chorioidea of the third ventricle lies
in it, and the blood vessels which enter and leave the tela
pass through it, between the layers of the tela.

The lateral parts of the transverse fissure are the inferior

THE CEREBRUM

445

parts of the chorioidal fissures, which have been studied already

in connection with the inferior horn of the lateral ventricle
(P- 437)-

Dissection. Each vena terminalis should now be divided

as it unites with the internal cerebral vein. The apex of the
tela chorioidea should then be seized with the forceps and pulled
backwards, till the whole structure is reversed. As that is
done, care must be taken to avoid injury to the attachments of
the pineal body, which is enclosed in a fold of the posterior part
of the lower layer of the tela. When the tela chorioidea has
been displaced backwards to the level of the mid-brain, the entire
upper surface of the thalamus on each side is exposed, and, between
the thalami, the cavity of the third ventricle is seen. The epithelial
roof of that ventricle, which is invaginated into the cavity by
the chorioid plexuses of the third ventricle on the under surface
of the tela, is torn away with the tela.

THE THALAMI AND THE THIRD VENTRICLE.

Thalamus. The thalamus is a large mass of grey matter
which lies obliquely across the path of the corresponding

Corpus callosum Chorioid plexus

Lateral ventricle
Caudate nucleus j
Fronto-occipital fasciculus i

Striae on corpus callosum

; Longitudinal fissure
/ 1 ! Septum pellucidum

Vena terminalis '

Hypothalamic body

3rd ventricle
Chorioid plexus

Thalamus Red nucleus

FIG. 175. Frontal section showing immediate relations of Lateral and

Third Ventricles. (Part of Fig. 188 enlarged. )

pedunculus cerebri as it ascends into the hemisphere. In

their anterior two-thirds, the two thalami lie close together,
but are separated by a deep median cleft called the third
ventricle ; the posterior thirds are further apart from one

446

THE BRAIN

another, and the corpora quadrigemina of the mid-brain lie

between them, on a lower plane. Each thalamus presents a
small anterior extremity and a large posterior extremity, and
four surfaces. The inferior and lateral surfaces are in apposi-
tion with, and, indeed, directly connected with adjacent parts.
The superior and medial surfaces are free.
The lateral surface of each thalamus is applied to a mass

Cut surface of genu

of corpus callosum

Genu of corpus callosum

Cavum septi pellucid i- -

For nix

Anterior commissure i~_

i
Massa intermedia

Groove on thalamus ,J
for fornix

Posterior commissure ,-'' M

Trochlear nerve

Brachium pontis -

Corpora quadrigemina

Brachium conjunctivum

- Septum pellucidum

- Caudate nucleus

-- Right column of fornij

__'. _ Anterior tubercle of

- \ thalamus

r ~"y Vena terminalis

& ~* "" Ventricle in.
1 Taenia thalami

" Trigonum habenulae

'Pulvinar
Stalk of pineal body
Pineal body

Lingula of cerebellum
'Medulla oblongata

FIG. "176. The two Thalami and the Third Ventricle as seen from above.

of white matter, termed the internal capsule, which is composed

largely of fibres from the basis pedunculi of the mid-brain (Fig.
1 8 8). The inferior or ventral surface of the thalamus rests
chiefly upon the subthalamic region, which is the prolongation
upwards of the tegmental part of the pedunculus cerebri. The
relation, therefore, which the thalamus presents to the upward
continuation of the pedunculus cerebri is very intimate.

The superior surface of the thalamus is free. On the

lateral side it is bounded by the groove which inter-

THE CEREBRUM 447

venes between the thalamus and the caudate nucleus and

contains the vena terminalis and the stria terminalis. On
the medial side, the superior surface of the thalamus is
separated from the medial surface, in its anterior half, by a
sharp edge, or prominent ledge, of the ependyma of the
third ventricle. The ledge is called the tcenia thalami. It
is produced by a longitudinal strand of fibres, called the stria
medullaris, which lies beneath the ependyma. A short distance
anterior to the pineal body the taenia lies upon the upper
border of a raised white band, called the habenula, which
is directly continuous with the stria medullaris.

The habenula divides posteriorly into two parts, one of which becomes
associated with the cells of the grey matter of the trigonum habenulse of
the same side (see below] ; the fibres of the other part pass through the roof
of the third ventricle immediately in front .of the upper part of the stalk
of the pineal body. They go to the trigonum habenulse of the opposite
side and, together with their fellows of the opposite side, they form the
habenular commissure (Fig. 177).

Between the habenula medially and the upper quadrigeminal body

posteriorly, lies a small triangular depressed area, the trigonum habenula.

The superior surface of the thalamus is slightly convex,

and is of a whitish colour owing to the presence of a thin
superficial coating of nerve fibres (stratum zonale). It is
divided into two areas by a faint oblique groove which
begins near the anterior extremity of the thalamus, and ex-
tends obliquely, laterally and backwards. The sulcus corre-
sponds to the free edge of the fornix. The two areas thus
mapped out are very differently related to the ventricles of
the brain. The lateral area includes the anterior extremity
of the thalamus, and forms a part of the floor of the lateral
ventricle ; it is covered with ependyma, and overlapped by
the chorioid plexus. The medial area intervenes between
the lateral and third ventricles of the brain, and takes no
part in the formation of the walls of either. It is covered
with the tela chorioidea, above which is the fornix. It
includes the posterior extremity of the thalamus.

The anterior extremity of the thalamus, called the anterior

tubercle, is rounded and prominent. It projects into the
lateral ventricle, lies postero - lateral to the corresponding
column of the fornix, and forms the posterior boundary of the
interventricular foramen.

The posterior extremity of the thalamus is very prominent,

and it projects backwards over the mesencephalon (Fig. 176).

448 THE BRAIN

The most projecting part is called the pulvinar. But the

posterior end of the thalamus shows another prominence,
which is situated below and to the lateral side of the pulvinar.
It is oval in form, and receives the name of the corpus
geniculatum laterale.

The anterior two-thirds of the medial surfaces of the two

thalami are placed very close together, and are covered not
only with the lining ependyma of the third ventricle, but also
with a moderately thick layer of grey matter continuous with
the grey matter which surrounds the aquaeductus cerebri
(Sylvius). A band of grey matter, termed the massa intermedia,
crosses the third ventricle and joins the two thalami together.

Corpus Pineale. The pineal body is a small body of a

darkish colour, and about the size of a cherry-stone, which is
placed on the dorsal aspect of the mesencephalon between
the posterior extremities of the two thalami (Figs. 176, 179).
It occupies the depression between the two superior colliculi of
the quadrigeminal lamina, and is shaped like a fir-cone. Its
base, which is directed forwards, is attached by means of a
hollow stalk or peduncle. The stalk is separated into a
dorsal and a ventral part by a continuation into it of a pointed
recess of the cavity of the third ventricle. The dorsal part
of the stalk becomes continuous, on each thalamus, with the
tsenia thalami, and through it pass the fibres of the habenular
commissure ; the ventral part is folded round a narrow but
conspicuous cord-like band of white fibres (posterior commissure}
which crosses the median plane immediately below the base of
the pineal body.

Commissura Anterior Cerebri. In the anterior part of the

cleft between the two thalami, and immediately anterior to
the columns of the fornix, a round bundle of white fibres
will be seen crossing the median plane (Figs. 177, 173). It
is the anterior commissure. It is very much larger than the
posterior commissure, and will be afterwards followed towards
the temporal lobe, in which the greater part of it ends.
Ventriculus Tertius. The third ventricle is the name
given to the deep, narrow cleft between the two thalami. It
is deeper anteriorly than posteriorly, and extends from the
pineal body posteriorly to the anterior commissure and lamina
terminalis anteriorly. Its floor is formed by the parts already
studied within the interpeduncular fossa on the base of the
brain, viz., the tuber cinereum, the corpora mamillaria, and

THE CEREBRUM

449

the grey matter of the substantia perforata posterior, and also,

more posteriorly, by the tegmenta of the cerebral peduncles.
Anteriorly, it is bounded by the lamina terminalis, the anterior
commissure, and the columns of the fornix. At the angle of
junction of the anterior boundary and the floor lies the optic

rrow passing through interventricular foramen

Caudate nucleus in right lateral ventricl
Remains of septum pellucidum
Callosal sulcus f
Sulcus cinguli

Gyrus cingul

Genu of corpus
callosum

Sub-callosal
gyrus

Paraterminal
body

Right column
of fornix

nterior commissure
Lamina terminalis

Optic recess
Optic chiasma
Infundibulum
Hypophysis

Tuber cinereum
Mamillary body /
Oculo-motor nerve

ram en
e i

i !

Fornix
Massa intermedia
' Upper surface of thalamus

1 i

, / Hypothalamic sulcus

j I

i / ' Supra-pineal recess

hi

? / / /

Splenium of corpus
callosum

Habenular commissure

Pineal body
Posterior commissure

Lamina quadrigemina
(Tectum)
Aquaeductus cerebri

Pedunculus cerebri
Anterior medullary
velum
Lingula

Fourth ventricle
Nodule

Median aperture of
fourth ventricle

Medulla oblongat

Medulla spinalis

FIG. 177. Sagittal section of Corpus Callosum, Fornix, Diencephalon, Mid-

brain, and Hind-brain. The septum pellucidum has been removed to
expose the cavity of the right lateral ventricle, from which an arrow
passes through the interventricular foramen to the third ventricle.

chiasma. Each side wall is formed by the medial surfaces

of the corresponding thalamic and hypothalamic parts of the
diencephalon. A little anterior to the middle of the ventricle
the cavity is crossed by the massa intermedia, which connects
the thalami with each other, and anterior to that the column

VOL. Ill 29

450 THE BRAIN

of the fornix will be seen, descending in the side wall. At

the anterior end of the side wall lies the interventricular
foramen which is bounded in front by the corresponding
column of the fornix. At the lower margin of the inter-
ventricular foramen the column of the fornix turns laterally
and disappears in the anterior part of the hypothalamus to
reach the mamillary body.

The roof 'of the third ventricle is formed by a thin epithelial

layer which stretches across the median plane, from the one
taenia thalami to the other. It is applied to the under
surface of the tela chorioidea, which overlies the ventricle,
and is invaginated into the cavity by the chorioid plexuses
which hang down from the under surface of that fold of pia
mater. In the removal of the tela chorioidea the thin
epithelial roof was torn away (Figs. 175, 187).

The third ventricle communicates with the lateral ven-

tricles, through the interventricular foramina, and it communi-
cates with the fourth ventricle by the aquceductus cerebri
(Sylvius], a narrow channel which tunnels the mesencephalon.
The opening of this canal will be seen in the posterior wall
of the third ventricle, immediately below the posterior com-
missure. The interventricular foramina, which put the third
into communication with the two lateral ventricles, lie at the
anterior part of the third ventricle, one on each side. Each
passes laterally and slightly upwards, between the most pro-
minent part of the corresponding column of the fornix and
the anterior tubercle of the thalamus. Through the foramina
the epithelial lining of the third ventricle becomes continuous
with that of the lateral ventricles (Figs. 177, 165, 166).

From each interventricular foramen a distinct groove passes

backwards, on the side wall of the ventricle, to the mouth of
the aquaeductus cerebri. It is termed the sulcus hypothalamicus,
and it separates the ventral part of the boundary of the third
ventricle, which is called the hypothalamus, from the more
dorsally placed thalamus.

The outline of the third ventricle is seen to be very irregular when

it is viewed from the side in a median section through the brain (Fig. 177),
or .as it is exhibited in a plaster cast of the ventricular system of the brain
(Fig. 165). It presents several diverticula or recesses. Thus, in the anterior
part of the floor there is a deep funnel-shaped recess, recessus infundilndi ,
leading down, through the tuber cinereum, into the infundibulum of the
hypophysis. Another recess, recessus opticus, lies above the optic chiasma.
Posteriorly, two additional recesses are present. One, the recessus pinealis,

THE CEREBRUM 451

passes backwards, above the posterior commissure and the entrance of the
aquaeductus cerebri, into the stalk of the pineal body. The second is
placed still higher, and is carried backwards for a greater distance. Its
walls are epithelial, and therefore it cannot be seen in an ordinary dissection.
It is termed the recessus suprapinealis (Fig. 177).

Dissection. The further study of the cerebral hemispheres

should be postponed until the examination of the mid-brain
or mesencephalon is completed. The membranes should be
removed from the upper surface of the cerebellum, and the
prominent anterior part of that organ may then be pulled back-
wards to expose, as far as possible, the corpora quadrigemina,
i.e. the four rounded eminences or colliculi on the dorsal aspect
of the mesencephalon. As the cerebellum is displaced back-
wards, care should be taken to secure and preserve the slender
trochlear nerves. They wind round the lateral sides of the
pedunculi cerebri, after they have issued from a lamina, called
the anterior medullary velum, which lies immediately below
the inferior pair of colliculi.

THE MESENCEPHALON.

The mesencephalon or mid-brain is the stalk which occupies

the aperture of the tentorium cerebelli, and connects the
cerebral hemispheres with the parts in the posterior cranial
fossa. 1 It is about three-quarters of an inch long, and it consists
of a dorsal part, the lamina quadrigemina, and a much larger
ventral part, which is formed by the two large pedunculi cerebri.
In the undissected brain the lamina quadrigemina is com-
pletely hidden from view by the splenium of the corpus
callosum, which projects backwards over it, and also by the
superimposed cerebral hemispheres. The pedunculi cerebri,
however, can be seen, to some extent, at the base of the brain,
where they bound the posterior part of the interpeduncular
fossa. The mesencephalon is tunnelled from end to end
by a narrow passage called the aqu&ductus cerebri (Sylvius).
The aqueduct lies much nearer the dorsal than the ventral
surface of the mid-brain, and it connects the third ventricle
with the fourth ventricle.

Lamina Quadrigemina. The dorsal surface of the lamina

quadrigemina is raised into four eminences or colliculi, two
superior and two inferior, which are called the corpora quadri-
gemina. Each colliculus is composed, for the most part,

1 If the mesencephalon was divided, when the brain was removed, the
divided parts must be fixed together with pins while the superficial characters
are being studied,
ill 29 a

452 THE BRAIN

of grey matter, but each has also a superficial coating of

white fibres. The superior colliculi are larger and broader
than the inferior, but they are not so well defined nor yet so
prominent.

A longitudinal and a transverse groove separate the quadri-

geminal bodies from one another. The longitudinal groove
occupies the median plane, and extends upwards as far as the
posterior commissure. From its lower end a short but well-
defined narrow band of white fibres, called the frenulum veli,
passes to the anterior medullary velum, a lamina which lies
immediately below the inferior pair of quadrigeminal promi-
nences, in the roof of the fourth ventricle. The upper part
of the longitudinal groove is occupied by the pineal body.
The transverse groove curves round below each of the two
superior colliculi and separates them from the inferior pair.

Brachia of the Corpora Quadrigemina. The corpora

quadrigemina form the dorsal part of the mid-brain, but each
body is connected also with the corresponding lateral aspect
of the mesencephalon by a prominent white strand, which
is prolonged upwards and forwards under the projecting
pulvinar. The strands are called the brachia of the corpora
quadrigemina, and they are separated from each other by a
continuation, on the side of the mesencephalon, of the trans-
verse groove which separates the superior colliculi from the
inferior.

Corpus Geniculatum Mediale. Closely connected with

the brachium of the inferior quadrigeminate body will be seen

the medial geniculate body. It

CORP:GEN:LAT. is a little oval eminence, very

sharply defined, which lies on the

side of the upper part of the
mesencephalon under shelter of
MEDIAL ROOT. the pulvinar of the thalamus.

Connections of the Brachia

and the Termination of the Optic
Tract. There are two superior

. . ....

and two inferior brachia, right

F1G ' ' R OIS ^d left, connected respectively

with the corresponding superior

and inferior colliculi, and two optic tracts, right and left, which
pass backwards from the optic chiasma at the base of the brain.
Each inferior brachium runs upwards and forwards from the

PULVINAR

LATERAL ROOT.

OPTIC TRACT

THE MESENCEPHALON 453

corresponding inferior colliculus and disappears from view,

under cover of the medial geniculate body. Many of the
fibres of which it is composed pass upwards towards the higher
parts of the brain in the tegmental portion of the corresponding
pedunculus cerebri, but some terminate amidst the cells of the
medial geniculate body.

Each superior brachium passes from the side of the corre-

sponding superior colliculus upwards, forwards, and laterally
between the medial geniculate body and the pulvinar. A
superficial examination of it is sufficient to show that it is
connected with the lateral root of the optic tract of the same
side by fibres which pass through the interval between the two
geniculate bodies ; and with the corresponding lateral genicu-
late body. It is important to remember, however, that the
fibres of which it is formed are connected with other regions
in addition to those indicated by superficial appearances. By
means of the fibres which it receives from the optic tract it
connects the superior colliculus with the retinae of both sides.
Other fibres of the superior brachium connect the superior
colliculus with the lateral geniculate body ; and a third series
of fibres passes through the superior brachium on its way
from the visual region of the occipital part of the cortex to
the superior colliculus.
Tractus Optici. The optic tracts are two relatively broad
white strands, right and left, which issue from the correspond-
ing postero-lateral angles of the optic chiasma. Each tract
consists of fibres derived from the corresponding parts of the
retinae of the two sides and of fibres which connect the
inferior colliculus of one side with the medial geniculate body
of the opposite side. After it issues from the chiasma the
tract runs backwards, first round the side of the tuber cinereum
and then round the lateral side of the pedunculus cerebri, and,
whilst at the side of the pedunculus cerebri, it is in relation,
laterally, with the bippocampal gyrus of the cerebrum. When
the tract reaches the dorsal part of the lateral aspect of the
pedunculus it divides into two portions, which are called its
medial and lateral roots.

The medial root ends in the medial geniculate body and it

consists largely, if not entirely, of fibres which connect the
medial geniculate body of one side with the inferior colliculus
of the opposite side, and which are known as Gudden's
commissure.

454 THE BRAIN

The lateral root of the optic tract consists of fibres derived

from the retinae of both sides. They terminate partly in the
lateral geniculate body ; partly in the pulvinar ; and partly in
the superior colliculus of the same side, to which they pass
through the superior brachium.

Pedunculi Cerebri (O.T. crura cerebri). The cerebral

peduncles constitute the chief bulk of the mesencephalon.
When the brain is viewed from below, they appear as two
large rope -like strands, which emerge, close together, from
the upper aspect of the pons, and diverge as they proceed
upwards and forwards to the cerebral hemispheres At the

Corpus geniculatum mediale Superior brachium

Pulvinar \ 1 Inferior brachium

Superior quadrigeminal body

Inferior
Stria terminalis fffi/^*' " AJ^LJ-/ / quadrigeminal body

Corpus geniculatum tmi _. _ ; ^

laterale if~ ^Er "iT^"^ Aquaeductus cerebri

Posterior perforated
substance

Corpus mamillare
Tuber cinereum
.
Anterior perforated

^~9~ p ticchiasnia

Optic nerve

FIG. 179. The Origin arid Relations of the Optic Tract.

(Professor Thane, from Quain's Anatomy.}

point where each peduncle disappears into the corresponding

hemisphere, it is embraced, on its lateral side, by the optic
tract and the gyrus hippocampi.

Each pedunculus cerebri consists of two parts, viz., a

dorsal part, called the tegmentum, which is prolonged upwards
to the region below the thalamus ; and a ventral part, called
the basis (O.T. crusta\ which is carried upwards into a layer
of white fibres called the internal capsule, situated on the
lateral side of the thalamus. When the brain is examined
from below the bases of the peduncles are seen. They are
white in colour and streaked in the longitudinal direction.
On the exterior of the mesencephalon, the separation between
the two parts of the pedunculus cerebri (i.e. the tegmentum

THE MESENCEPHALON 455

and the basis pedunculi) is indicated by a medial and a

lateral groove or sulcus. The medial sulcus is the deeper
and more distinct. It looks into the interpedtmcular fossa,
and from it emerge the fila of the oculo - motor nerve.
It consequently receives the name of the sulcus oculomotorius.
The lateral groove is termed the sulcus lateralis.

Cut Surface of the Mesencephalon. When the cut

surface of a mesencephalon, which has been divided trans-
versely, is examined, the first point which should be noted is
the position of the aquaductus cerebri (Figs. 180, 181). It is
a narrow passage which lies nearer the dorsal surface than
the ventral surface of the mesencephalon, and it leads from
the fourth ventricle, below, to the third ventricle, above. It
is surrounded by a thick layer of grey matter, called the
central grey matter of the aqueduct. In a fresh brain the
central grey matter is always very conspicuous, and in its
midst are situated the nuclei of the oculo-motor and trochlear
nerves, and the upper nucleus of the trigeminal nerve,
but, except in very favourable circumstances, the positions
of the nuclei cannot be detected by the naked eye. The
grey matter of the aqueduct is continuous, below, with the
grey matter spread out on the anterior wall of the fourth
ventricle ; whilst, above, it is continuous with the grey matter
on the floor and sides of the third ventricle.
The division between the tegmentum and the basis
pedunculi, on each side, is rendered very evident by a con-
spicuous lamina of dark pigmented matter, termed the sub-
stantia m'gra, which intervenes between them.

Substantia Nigra. As seen in transverse section, the sub-

stantia nigra presents a somewhat crescentic outline. It is
a thick band interposed between the basal and tegmental
parts of each pedunculus cerebri, and it consists of grey
matter many of the cells of which are deeply pigmented.
It begins, below, at the upper border of the pons, and it
extends upwards into the subthalamic region. Its margins
come to the surface at the oculo-motor and lateral sulci,
and its medial part is traversed by the merging fibres of
the oculo - motor nerve. The surface turned towards the
tegmentum is concave and uniform ; the opposite surface is
convex, and is rendered highly irregular by the presence of
numerous slender prolongations of its substance into the
basis pedunculi.

456

THE BRAIN

Basis Pedunculi (O.T. cnista). The basis pedunculi is

somewhat crescentic when seen in section, and stands quite
apart from its fellow of the opposite side. It is composed of
a compact mass of longitudinally directed nerve fibres which
are carried upwards into the internal capsule. The inter-
mediate three-fifths of each basis pedunculi is formed, almost
entirely, by the important cerebro-spinal fasciculus (O.T. pyra-

Inferior quadrigeminal body

Grey matter of _
aqueduct

Aquaeductusj__
cerehri \ "

^Mesencephalic root of trigeminal nerve

^'Nucleus of trochlear nerve

- Inferior brachium
v ,,-- Medial longitudinal fasciculus
Raph

Brachium conjunct! vum

Substantia nigra

Basis pedunculi

FIG. 1 80. Transverse section through the Mesencephalon at the level of the
inferior quadrigeminal body : the right side only is reproduced. The
drawing is taken from a Weigert-Pal specimen, and therefore the grey
matter is pale and the strands of white matter are dark. The dark colour
of the substantia nigra is not evident owing to the thinness of the section.

midal tract) as it descends from the motor area of the cerebral

cortex, but the cerebro-spinal fasciculus is quite indistinguish-
able, under ordinary circumstances, from the fronto-pontine
fibres on its medial side and the temporo-pontine fibres on its
lateral side.

Tegmentum. Unlike the bases pedunculi, the tegmentum

is undivided, a faint line in the median plane, termed the
median raphe, alone indicating that it consists of a right and

THE MESENCEPHALON

457

a left half. Towards the dorsum of the mesencephalon it is

fused with the deep surface of the lamina quadrigemina, and
only its lateral surfaces are free.

The tegmentum is composed of an admixture of grey and white matter,

constituting what is termed a formatio reticularis. The white matter
consists of fibres running both transversely and longitudinally. Certain
of the longitudinal fibres are grouped together and form well-marked
tracts, which, in a section through the mesencephalon of a fresh brain, can
be detected by the naked eye. The tracts are: (i) the medial longi-
tudinal bundles ; (2) the brachia conjunctiva ; (3) the lemnisci.
Superior quadrigeminal body

Tegmentum

Inferior brachium i

Medial geniculate body

Lateral geni- \

culate bodyv ^__^_J.

Optic tract

Basis peduncul

Medial lemniscus

Grey matter of aqueduct

Aquaeductus cerebri

"^__| Nucleus of oculo-

.' : motor nerve
f;iLj. Medial longi-
"ff, # tudinal fasciculus

r-Red nucleus

4- Fibres of brachium
. .' conjunctivum

.Fila of
oculo-motor nerve

Substantia nigra

Corpus mamillare
FIG. 1 8 1. Section through upper part of Mesencephalon at level of superior
quadrigeminal body. The drawing is taken from a Weigert-Pal specimen.
The dark colour of the substantia nigra is not evident owing to the
thinness of the section.

Fascicuhts Longitudinalis Medialis. The medial longitudinal fasciculus

(Figs. 180 and 181) is a small, compact bundle which is placed upon the
corresponding lateral aspect of the ventral portion of the central grey
matter of the aqueduct.

The brachia conjunctiva (O.T. superior cerebellar peduncles} are two

large strands which are continued upwards from the cerebellum into the
mesencephalon. By pulling away the margin of the cerebellum, where it
overlaps the inferior colliculi of the quadrigeminal lamina, the dissector
will see the brachia on the surface as they converge in an upward direction.

458 THE BRAIN

Stretching across the interval between them, and bringing them into
continuity with one another, is a thin lamina called the anterior medullary
velum. When the brachia conjunctiva reach the bases of the inferior
quadrigeminal bodies, they sink into the substance of the mesencephalon,
and, in a transverse section through the lower part of that portion of the
brain, they may be seen as two white strands, semilunar in outline and
plaqed one on each side of the grey matter of the aqueduct. As they
ascend, they gradually assume a deeper (i.e. a more ventral) position in
the tegmental part of the mesencephalon, and they decussate with each
other across the median plane and proceed upwards to the red nuclei.

The term lemniscus (O.T. fillet] is given to two tracts which have
different connections. The medial lemniscus (Figs. 180 and 181) is a
sensory tract passing upwards to the thalamus. The lateral lemniscus
belongs to the acoustic apparatus, and is a part of a chain through which
the cochlear. nuclei of one side establish connection with the inferior
quadrigeminal body and the medial geniculate body of the opposite side.
The lateral lemniscus can be readily detected as it emerges from the
upper part of the lateral sulcus of the mid-brain, and passes, backwards
and upwards, to the lower border of the inferior quadrigeminate body and
inferior brachium. It has the form of a raised triangular band which
encircles the lateral surface of the upper end of the brachium conjunctivum
(Fig. 194).

Within the upper part of the tegmentum there is a collection of nuclear

matter which is termed the nucleus ruber, from its ruddy appearance
when seen in section. It is rod-like in form, and extends upwards into the
tegmental region below the thalamus (Fig. 188). In transverse section it
presents a circular outline, and it is closely associated with the upward
prolongations of the majority of the fibres of the brachium conjunctivum
of the opposite side. The brachium conjunctivum cerebelli is an efferent
tract from the nucleus dentatus of the hemisphere of the cerebellum, and
its fibres end in the red nucleus and the pulvinar of the thalamus of the
opposite side. The tegmentum of each pedunculus cerebri may be con-
sidered to consist of two parts : viz., a lower part, which is subjacent to
the inferior quadrigeminal bodies, and is largely occupied by the decussation
of the brachia conjunctiva cerebelli ; and an tipper part, subjacent to the
superior quadrigeminal bodies, which is traversed by the emerging bundles
of the third nerve, and contains the nucleus ruber.

BASAL GANGLIA OF THE CEREBRAL

HEMISPHERES.

The basal ganglia of the cerebral hemispheres must now

be examined. They are (i) the caudate and lentiform nuclei,
which, together, form the corpus striatum, (2) the claustrum,
and (3) the amygdaloid nucleus. At the same time the com-
position of the thalamus and the external and internal
capsules should be studied.

Dissection. The right and left portions of what remains of

the cerebrum must be separated from one another, if that has
not already been done, by a median sagittal incision. Anteriorly,
the incision must pass between the columns of the fornix, and

BASAL GANGLIA

459

it will divide the anterior part of the corpus callosum, the lamina
terminalis, the anterior commissure and the optic chiasma.
In the interval between the columns of the fornix and the corpus
callosum the knife should pass through the cavity between the
layers of the septum pellucidum. Posteriorly, the incision will
bisect the pineal body and its peduncle, and the upper part of
the lamina quadrigemina, which is still attached to the cerebrum ;
then it will pass through the upper part of the aquaeductus cerebri,

Genu of corpus callosum

Anterior horn of lateral ventricle

Head of caudate nucleus

Anterior limb of internal capsule

Cavum septi pellucidi

Genu of internal capsule

Globus pallidus

Fasciculus mamillo-thalamicus
Posterior limb of internal capsule

Thalamus
Retrolenticular part

of internal capsule

Tail of caudate nucleus

Hippocampus

Splenium

Posterior horn of lateral ventricle

Stria gennari -

Calcarine fissure .--

Tapetum

Optic radiation

Inferior longitudinal bundle

FIG. 182. Horizontal section through the Right Cerebral Hemisphere at the
level of the widest part of the lentiform nucleus.

and, ventral to the aqueduct, it will separate the cerebral

peduncles of opposite sides from one another. As the knife
passes through the base of the brain, that is, through the floor
of the third ventricle, from before backwards, it will divide the
tuber cinereum ; then it will pass between the mamillary bodies,
and, posteriorly, it will bisect the posterior perforated substance.
The massa intermedia, which unites the adjacent surfaces of
the thalami, will be divided as the knife passes through the
cavity of the third ventricle. After the division has been made
the dissector should note the positions and relations of the

460 THE BRAIN

divided parts, and he should compare the cut surfaces with

Figs. 177, 159.

When the study of the cut surfaces is completed, a horizontal

incision must be made through the remains of the right half of
the cerebrum, at the level of the upper part of the interventricular
foramen, in order to display the relative positions of the basal
ganglia. And through the left part of the cerebrum a number
of frontal or vertical transverse incisions must be made, the
first, immediately in front of the posterior end of the olfactory
tract, the second, through the anterior perforated substance ;
the third, immediately anterior to the mamillary bodies, and the
fourth, through the cerebrum and then through the front part
of that portion of the cerebral peduncle which is still attached
to it.

After the sections have been made, examine the horizontal

section first(Figs. 182, 183), and note the following points, using
the upper surface of the lower segment : (i) The peripheral
grey and the central white matter of the hemisphere. (2)
Close to the median plane, from before backwards (a) the
divided anterior part of the corpus callosum and the fibres of
the forceps minor passing forwards and laterally from it into
the white matter of the frontal lobe ; (<) the right layer of
the septum pellucidum ; (c) the divided right column of the
fornix ; (d) the medial surface of the thalamus, separated
from the column of the fornix by the interventricular foramen ;
(e) medial to the posterior part of the thalamus, the upper
surface of the anterior part of the lamina quadrigemina and
a part of the pineal body. (3) Lateral to the anterior divided
part of the corpus callosum is the cavity of the anterior horn
of the lateral ventricle. (4) In the lateral wall of the floor of
the anterior horn the divided head of the caudate nucleus of
the corpus striatum. (5) Bounded medially by the head of the
caudate nucleus and the thalamus, a broad band of the white
matter called the internal capsule. (6) Lateral to the internal
capsule, a triangular mass of grey matter called the lentiform
nucleus. It is divided into three parts by two thin white
laminae called the medial and lateral medullary laminae.
The most lateral of the three parts is called the putamen ; it
is larger and darker than the medial two portions, which
form, together, the globus pallidus, which is paler than the
putamen. (7) Lateral to the lentiform nucleus, a thin lamina
of white matter called the external capsule. It is continuous,
anteriorly and posteriorly, round the anterior and posterior
margins of the lentiform nucleus, with the anterior and
posterior borders of the internal capsule, and it is bounded,

BASAL GANGLIA

461

laterally, by (8) A thin lamina of grey matter called the

claustrum, which has a smooth medial surface and a scalloped
lateral surface. (9) The insula, which lies lateral to the
claustrum and consists of a layer of white and a layer of grey
matter. It forms the medial wall of (10) A space called
the lateral fossa of the hemisphere. The lateral fossa is
Fibres of forceps minor -

Genu of corpus callosum

Subcallosal gyru?

Paraterminal body

Ant. horn of lateral ventricle

Lamina terminali. 1 -

Anterior commissure

Right column of fornix

Stria terminalis

Thalamus

Trigonum habenulae
Pineal body

Grey matter of frontal lobe

White matter of frontal lobe

f Caudate nucleus

Anterior limb of internal capsule

Putamen ~l Lentiform

Globus pallidus / nucleus

Genu of internal capsule

Medullary laminae

Posterior limb of internal capsule

Retro-lentiform part of
internal capsule
-Optic radiation

Pulvinar
Stria terminalis ,'
Caudate nucleus

FIG. 183. Horizontal section of Corpus Striatum and adjacent parts on the
right side, after the dissection represented in Fig. 182 had been made.
The line to the anterior horn of the lateral ventricle crosses the right
lamina of the septum pellu'cidum.

bounded on the lateral side by (n) The frontal operculum,

anteriorly, and (12) the temporal operculum, posteriorly, and
it opens to the exterior by (13) The lateral fissure which
passes between the two opercula. (14) At the postero-lateral
angle of the thalamus, note a small grey mass (see Fig. 182) ;
it is the tail of the caudate nucleus, descending into the roof of
the inferior horn of the lateral ventricle. Place the upper

462 THE BRAIN

segment of the divided brain on the lower segment, and trace

the continuity of the caudate nucleus, along the floor of
the central part of the lateral ventricle, from the divided tail,
posteriorly, to the divided head, anteriorly. Then turn the
lower segment of the section upside down and trace the tail
of the caudate nucleus, along the roof of the inferior horn of
the lateral ventricle, to the amygdaloid tubercle at the
anterior end of the roof. (15) Immediately to the medial
side of the divided tail of the caudate nucleus is the thin

Longitudinal fissure

Genu of corpus callosum

Corpus callosum (genu)' / Caudate nucleus

Longitudinal fissure, ; Caudate nucleus (in section)

Anterior horn of lateral ventricle

FIG. 184. Frontal section through the Frontal Lobes of the Cerebrum. The
posterior surface of the anterior part of the cerebrum is depicted so that
the reader is looking into the anterior horns of the lateral ventricles from
behind.

strand of white fibres, called the stria terminalis, which was

noted previously in the floor of the central part of the
lateral ventricle (see p. 431). Trace it also along the roof
of the inferior horn to the amygdaloid tubercle.
Examine next the series of vertical transverse sections and
note (i) That, in the first section, which passes through the
posterior part of the frontal lobe, the head of the caudate
nucleus and the anterior part of the lentiform nucleus are
fusing together, ventro-lateral to the anterior horn of the
lateral ventricle (see Fig. 185). Note also that, as they
blend, a striate appearance is produced by the intermingling

BASAL GANGLIA

463

of a large number of grey and white striae which pass

between the two grey masses. It is because of the union
and because of the striate appearance in the region of
the union that the caudate nucleus and the lentiform nucleus
are spoken of, together, as the corpus striatum. (2) That,
in the second section, which passes through the region of the
anterior perforated substance (Fig. 1 86), the lower surface of the

Longitudinal fissure

Corpus callosum

Lateral ventricle

Chorioid plexus '

Interventricular foramen

Right column of fornix

Claustrum

Internal capsule

Lentiform nucleus ~ Corpus

Caudate nucleus /striatum

Septum pellucidum
FIG. 185. Frontal section through the Cerebral Hemisphere cutting through
the anterior part of the lentiform nucleus. Seen from the anterior end.

anterior parts of the lentiform and caudate nuclei are blending

with the anterior perforated substance. (3) That, in the third
section, which passes between the tuber cinereum and the
mamillary bodies, the main features referred to in the account
of the horizontal section are again visible, but that there are
some modifications due to the different plane of section (Fig.
187). The points of difference to be noted are (a) That
the caudate nucleus, the stria terminalis and the lateral part
of the upper surface of the thalamus lie, in this section, in the

464

THE BRAIN

floor of the central part of the lateral ventricle, (b) That in

the substance of the thalamus two divided white bundles are
seen. The lower of the two bundles is the divided column
of the fornix on its way to the mamillary body ; and the higher
is the fasciculus mamillo-thalamicus on its way from the
mamillary body to the upper and anterior part of the thalamus.
(c) That, lateral to the thalamus is the lentiform nucleus,
clearly divided in this position into three parts by the two
medullary laminae, (d) That, between the lentiform nucleus,
laterally, and the thalamus and the caudate nucleus, medially,
is the internal capsule, (e) That, as the internal capsule passes

Ventricular surface of
caudate nucleus
Caudate nucleus

Anterior horn of lateral

ventricle

Paraterminal body
(grey matter)
White matter of para-
terminal body

Gyrus subcallosum -

Supra-optic recess
Optic chiasn
ar Corona radiata

Internal capsule

Lentiform nucleus

Anterior perforated substance

Optic tract

FIG. 1 86. Frontal section through anterior Perforated Substance and the
anterior part of Corpus Striatum, after the dissection represented in Fig.
183 had been made on the left hemisphere.

between the caudate nucleus and the upper part of the

lentiform nucleus, its fibres begin to diverge towards all the
adjacent parts of the cortex, forming the corona radiata.
(/) That the lower end of the internal capsule is continuous
with the upper and most anterior part of the pedunculus
cerebri. (g) That, from the pedunculus cerebri fibres are
passing laterally, below the lentiform nucleus, to the medullary
striae and the external capsule, (ti) That, immediately below
and lateral to the section of the pedunculus is the divided
optic tract. (/) That, lateral to the lentiform nucleus is the
external capsule, and still more laterally lie the claustrum and
the insula.

BASAL GANGLIA

465

Note further, that the plane of the section under con-

sideration is anterior to the anterior end of the inferior cornu
of the lateral ventricle (see Fig. 187). (4) That in the fourth
section (a) The fibres of the internal capsule are directly
continuous, below, with the fibres of the basal or anterior
part of the peduncle of the cerebrum, and, above, with the
corona radiata, to which fibres converge from the adjacent
parts of the grey matter of the cortex, (b) In the region

Longitudinal fissure
Chorioid plexus
Lateral ventricle

Claustrum

Corpus callosum
,-Fornix

Tela chorioidea of
'third ventricle

-Caudate nucleus
-Vena terminalis

-Thalamus

-Ventricle in.
Chorioid plexus
'Internal capsule

For. interventriculare
Column of
fornix
Optic tract

Anterior commissure
Optic nerve

Globus pallidus'

Amygdaloid nucleus
Fasciculus mamillo thalamicus

Substantia perforata anterior

' Olfactory tract

i Optic chiasma

Infundibulum
Column of fornix

FIG. 187. Frontal section through the Cerebral Hemisphere in such a plane
as to cut the three parts of the lentiform nucleus ; the posterior cut
surface of the anterior part of the hemisphere is depicted.
now under consideration, the thalamus rests upon the sub-
thalamic region which is directly continuous with the teg-
mental or dorsal part of the corresponding pedunculus
cerebri. (c) In the subthalamic region two additional nodules
of grey matter are easily recognisable. The medial and
more rounded of the two is the upper part of the red nucleus,
which extends downwards, through the upper half of the
tegmental portion of the mid-brain. The more lateral is the
VOL. in 30

466

THE BRAIN

hypothalamic body, which is limited to the posterior part of

the subthalamic region, (tf) The lentiform nucleus now lies
above the roof of the inferior horn of the lateral ventricle,
from which it is separated by a layer of transversely directed
white fibres (Fig. 188). (e) The lentiform nucleus is not

"Caudate nucleus

Occipito-frontal fasciculus t Tbalamus

Superior longitudinal fasciculus

External cap;

Claustrum

lusula

Putamen of lenti-
form nucleus

Globus pallidus of lr.

lentiform nucleus I

Stria terminalis f?
Upper tempor
" ./. sulci
Caudate nucl<
Inferior cornu of
lateral ventricle

Corpus callosum

Chorioid plexus

Septum pellucklum

Fornix

Chorioid plexuses

of third ventricle

Third ventricle
Red nucleus
Subthalamic body
Optic tract

Fimbria

Pyramidal fibres
(cerebro-spinal)

Chorioid plexus

1 Hippocampal fissure

Collateral fissure

Cerebellum

Brachium pontis
Pyramid of medulla oblongata

FIG. 1 88. Oblique frontal section of Brain to show the course of the cerebro-
spinal fibres. The internal capsule lies between the lentiform nucleus
laterally and the caudate nucleus and thalamus medially.

now so distinctly divided into three segments by the medullary

laminae.

When the examination of the surface appearances of the

sections is completed the .dissector should study, in more
detail, the parts- which he has seen in various portions of their
extent in the series of sections. He should replace the
1 This fissure is-an artifact (Elliot Smith).

BASAL GANGLIA 467

sections in their proper relations to each other at one time,

and separate them from each other again, when necessary,
and so confirm the majority of the statements contained in
the following accounts of the individual- structures.

Corpus Striatum. The corpus striatum is a mass of grey

matter embedded in the base of the hemisphere. It consists
of two parts a supero-medial part, the caudate nucleus, and
an infero-lateral part, the lentiform nucleus. The anterior
portions of the two nuclei are blended together, but the
remaining portions are separated from one another by a thick
layer of white substance of the hemisphere, called the internal
capsule.

Nucleus Caudatus. The caudate nucleus is a comma-

shaped mass. The head of the comma lies in tKe lateral
wall of the anterior horn of the lateral ventricle. The
body runs backwards, in the lateral part of the floor of the
central portion of the cavity of the lateral ventricle and the
tail turns downwards and forwards in the roof of the inferior
horn. The lower and anterior part of the head is fused with
the anterior part of the lentiform nucleus (Fig. 185). One*
surface of the caudate nucleus is intravehtricular, that is, it is
in direct relation with the cavity of the lateral ventricle and is
covered with the 'ependyma. The opposite surface is extra-
ventricular. The extraventricular surface of that part of the
nucleus which lies in the anterior horn, and in the central
part of the lateral ventricle, is in relation with the internal
capsule, but the extraventricular surface of the portion of the
tail which lies in the roof of the inferior horn of the ventricle
is separated from the lower surface of the lentiform nucleus
by fibres passing, more or less transversely, between the
cortex of the temporal lobe and the upper part of the corre-
sponding peduncle of the brain and the subthalamic region.
The medial border of the caudate nucleus is separated from
the thalamus by the stria terminalis ; and the lateral border,
in the region of the anterior horn and the central part of the
lateral ventricle, is in relation- with the medial surface of the
upper part of the internal capsule, and with a bundle of
longitudinal fibres of the white matter of the cerebrum called
the occipito-frontal fasciculus (Fig. 1 88).

Nucleus Lentiformis. The lentiform 'nucleus is an

irregular triangular pyramid of grey matter. It possesses an
inferior surface or base (Figs, i&y, 188); a lateral surface;

468 THE BRAIN

and an antero-medial and a postero-medial surface (Figs.

182, 191).
The posterior part of the inferior surface lies above the
inferior horn of the lateral ventricle, from which it is separated
by some white matter and by the tail of the caudate nucleus
and the stria terminalis (Fig. 188). More anteriorly the
inferior surface rests upon the white matter of the temporal
lobe of the hemisphere, and still more anteriorly it fuses with
the grey matter of the anterior perforated substance (Fig. 186).
Curving backwards and laterally in a groove on the lower
surface of the lentiform nucleus lies the twisted bundle of
fibres of the anterior commissure, on its way to the temporal
lobe (Fig. 189).

The lateral surface is convex and is in relation, in the

whole of its extent, with a layer of white matter, called the
external capsule, which separates it from the claustrum.

The antero-medial and the postero-medial surfaces are in

relation with the internal capsule, and the medial angle which
separates the two surfaces lies in a bend of the capsule which
is called the genu (Figs. 182, 191).

Passing vertically through the lentiform nucleus and

dividing it into three parts are two white layers called the
medullary laminae. As already stated, the medial two parts
are lighter in colour than the lateral part; they constitute the
globus pallidus. The lateral part is the putamen.

The antero -inferior part of the lentiform nucleus is

continuous with the head of the caudate nucleus and the
anterior perforated substance (Fig. 186), but in the remainder
of its extent the lentiform nucleus is surrounded by the white
matter of the hemisphere.

The lentiform nucleus is associated with the cortex of

the hemisphere, with the thalamus, and with other adjacent
parts, by white nerve fibres which pass to and from the
nucleus.

Claustrum. The claustrum is a thin plate of grey matter

which lies between the external capsule and the white matter
of the insula. Its medial surface, which is relatively smooth,
is separated from the lateral surface of the lentiform nucleus
by the external capsule. Its lateral surface is scalloped, the
elevations and depressions corresponding with the gyri and
sulci of the insula. Its lower border, which is its broadest
part, is fused, anteriorly, with the anterior perforated substance

BASAL GANGLIA 469

and the amygdaloid nucleus. In extent the claustrum corre-

sponds closely with the length and height of the insula.

Nucleus Amygdalae. The amygdaloid nucleus lies partly

in the anteripji_jaU^pXjh^_antenor end ^of the inferior horn
of the lateral ventricle and partly in the adjacent portion of
the roof of the inferior horn. It is continuous with the tail
of the caudate nucleus ; with the antero-inferior part of the
putamen of the lentiform nucleus ; with the anterior perforated
substance, and with the grey matter of the piriform area of
the hippocampal gyrus.

Nuclei of the Thalamus. When sections of the thalamus

are examined it will be noticed that it is surrounded, except
on its medial surface, by white matter.

The thin layer of white matter on the superior surface is

termed the stratum zonale. It consists of fibres derived partly
from the optic tract and partly from the optic radiation of
the internal capsule. The white lamina on the lateral surface,
which separates the grey matter from the internal capsule, is
the external medullary lamina. The lower surface rests,
anteriorly, on the hypothalamus and the temporal peduncle
of the thalamus (p. 470) and posteriorly on the upper part of
the tegmentum of the cerebral peduncle.

The grey matter of the thalamus is divided into three portions or nuclei
by the internal medullary lamina, which consists of a posterior stem and
two anterior branches. The portion of the thalamus which lies between
the two branches of the internal medullary lamina is the anterior nucletis.
It is connected with the mamillary body of the same side by the fasciculus
mamillo-thalamicus. The part of the thalamus lateral to the stem and the
lateral branch of the internal medullary lamina is the lateral nucleus. It
is longer than the medial nucleus and includes the whole of the posterior
end of the thalamus. The remaining part of the thalamus is the medial
nucleus ; it lies between the internal medullary lamina and the grey matter
of wall of the third ventricle, but extends, backwards, only as far as- the
trigonum habenube.

The thalamus is connected with the cortex of the hemi-

sphere by bundles of fibres which are called the stalks or
peduncles of the thalamus ; they are the frontal, the parietal,
the temporal and the occipital.

The frontal peduncle consists of fibres which emerge from

the antero-lateral part of the thalamus and pass, in the anterior
part of the internal capsule, to the frontal area of the cortex
of the hemisphere. The parietal peduncle springs from the
lateral part of the thalamus and passes partly through the
internal and external capsules, and partly, through the lentiform
in 30 a

47

THE BRAIN

nucleus, to the parietal lobe and the posterior part of the

frontal lobe. The temporal peduncle or ventral stalk is
formed by fibres which spring from the cells of the medial
and lateral nuclei. They issue from the lower surface of the
anterior part of the thalamus and pass, below the lentiform
nucleus, to the temporal lobe and the insula. The occipital
peduncle springs from the lateral side of the posterior end of
the thalamus, in the region of the pulvinar, and its fibres
form the optic radiations. They pass through the posterior

White matter of frontal lobe

Groove for lenticulo-striate artery
Coron-t radiata

Fibres of optic -%-*

radiations
Fibres of acoustic -

ra tiations
Lateral geniculate "

body
Medial geniculate

body"

Lentiform nua
Roof of inferior horn of /
lateral ventricle '
Pedunculus cerebri
Anterior commissure /
Mamillary bodv

Orbital surface of frontal lobe

[factory tract
I Optic nerve
Anterior perforated substance

Optic tract Tuber cinereum

FIG. 189. Dissection of the right Lentiform Nucleus and the right Corona
Radiata from the lateral side.

or retro-lentiform part of the internal capsule and are dis-

tributed to the cortex of the occipital lobe, especially in the
region of the calcarine fissure (Figs. 182, 191).
Dissection. Take the lower part of the remains of the right
hemisphere and from its lateral side tear away the grey and
white matter of the insula, then the claustrum, and, finally, the
external capsule, to expose the lateral surface of the lentiform
nucleus. As this is being done note the fibres which pass through
the region of the limen insulae and connect together the frontal
and the temporal lobes ; they constitute the fasciculus uncinatus.
Note also that the white layer which lies below the lentiform
nucleus contains (i) In its posterior part, the fibres of the
acoustic radiations ; (2) In its anterior part the fibres of the
temporal peduncle of the thalamus ; and in addition the fibres of

BASAL GANGLIA 471

the anterior commissure pass through it on their way to the

temporal lobe. Define the fibres of the anterior commissure
(Fig. 189) and trace them forward and medially, to the medial
face of the section, by removing the anterior perforated substance,
which lies below them.

The fibres which lie anterior and posterior to the lentiform

nucleus are fibres of the internal capsule. The anterior fibres
can be traced downwards to the basis pedunculi, but those of
the posterior part, which are fibres of the acoustic and optic
radiations, turn medially towards the posterior part of the
thalamus and the medial geniculate body.

Make a similar dissection on the upper segment of the right

hemisphere to expose the upper part of the lateral surface and
the upper border of the lentiform nucleus. Note that the white
matter which appears at the upper border of the lentiform
nucieus consists of fibres of the internal capsule, which are
passing vertically into the corona radiata, and of some longi-
tudinally directed fibres which form the superior longitudinal
fasciculus (Fig. 188). Now remove the lentiform nucleus and
expose the remainder of the lateral surface of the internal
capsule. Finally, trace the main mass of the capsule downwards
into the basis pedunculi of which they form the middle three-
fifths ; the lateral and medial fifths being formed by fibres
passing from the temporal and frontal lobes to the pons. Pre-
serve the pieces of the right hemisphere so that the continuity
of the motor fibres of the anterior two-thirds of the posterior
division of the capsule with the cerebro-spinal fibres of the pons
and medulla can be demonstrated at a later stage.

When the dissection of the right hemisphere is completed

turn to the posterior vertical section of the left hemisphere and
expose the internal capsule from the lateral side by removing,
in turn, the remains of the insula, the claustrum, the external
capsule, and the lentiform nucleus ; then trace the fibres of
the internal capsule of the left side downwards into the basis
pedunculi.

Complete the dissection of the right hemisphere by tracing

the fasciculus mamillo-thalamicus upwards from the mamillary
body into the anterior nucleus of the thalamus.
Capsula Interna. -The internal capsule is a relatively
thick lamina of white substance by means of which associa-
tions are established between the cortex of the hemisphere,
its basal nuclei, the lower parts of the brain, and the medulla
spinalis, It lies between the caudate nucleus and the thalamus,
on the medial side, and the lentiform nucleus on the lateral
side, but it extends both anterior and posterior to the lentiform
nucleus, and therefore consists of lentiform, pre-lentiform, and
retro-lentiform portions. It is continuous, below, with the
basis pedunculi and above with the corona radiata, and the
lentiform part is bent upon itself, round the medial angle
of the lentiform nucleus. The bend, which is known as the
genu, lies between, and unites together, the anterior and
in 30 b

472

THE BRAIN

posterior divisions of the lentiform portion of the capsule.

Through the anterior division, which lies between the lentiform
and caudate nuclei, pass the fibres of the anterior peduncle
of the thalamus, and fronto-pontine fibres which associate the
cells of the frontal part of the cortex of the hemisphere with
the nerve cells of the ventral part of the pons. The genu
consists of fibres which convey motor impulses from the
motor area of the cortex of the hemisphere to the nuclei of
the nerves which supply the muscles of the face and tongue
of the opposite side. The posterior division of the lentiform

Fibres of medullary laminae oroi

Upper limit of int. capsule
Area in relation |

to putamen
Frontal fibres of
corona radiata

Area in relation to globus pallidus

Basis peclunculi

jk Lateral
Afe geniculate body
,-'^V Optic radiations

Medial geni-
culate body
Olfactory bulb
Anterior commissure .

Optic tract .ft

Corpus mamillare / / ,

Oculo-motor nerve / /

Pyramidal fibres /

Cut surface of pons /

Pyramid

Olive

VVl

Trochlear nerv<

Lateral lemniscus
dial lemniscus
Brr.chium pontis

flr

FIG. 190. Dissection of Internal Capsule and Pyramidal Fibres.

portion of the capsule, which lies between the lentiform

nucleus and the thalamus, is separable into (i) an anterior
two -thirds, which consists principally of fibres conveying
motor impulses to the nuclei of the nerves which supply
the muscles of the upper limb, trunk, and lower limb of
the opposite side, in that order from before backwards,
together with some sensory fibres ; and (2) a posterior third,
which contains sensory fibres, that is, fibres conveying ordinary
sensory impulses to the cortex of the hemisphere. The
majority, if not all, of the sensory fibres spring from the
thalamus, and they pass to the parietal, occipital, and temporal
lobes. The fibres which spring from the posterior part
of the thalamus and pass through the posterior or retro-

BASAL GANGLIA
473

Lower limb a

Trunk a

Upper limb area

Face area

Putanien, globus pallidus,

and medullary laminae of

lentiform nucleu;

Irisula

Acoustic area'

Acoustic radiations'
Claustrum'

Optic radiations

Calcar avis

^Anterior horn
of lateral ventricle

.Caudate nucleus

Anterior segment of
'internal capsule

Face fibres in genu

of internal capsule

Upper limb "\ Anterior

fibres of posterior
-Trunk fibres ^division of
Lower limb internal
fibres J capsule

Sensory fibres

Thalamus
Crus of fornix

Hippocampus
Splenium of corpus cal-
losum (horizontal section)
Cuneus (ver-
tical section)
Calcarine fissure

Lingual gyrus

(horizontal

section)

Visual
area

FIG. 191. Diagram showing the Motor and the Acoustic and Visual Areas
of Left Hemisphere and their relations to the Internal Capsule.

The internal capsule and the auditory and visual areas are seen in
horizontal section. The motor areas, in red, are supposed to be in vertical
section and to be placed at right angles to the horizontal section.

The area of ordinary sensation is not shown, but the fibres from it lie
mainly in the posterior third of the posterior division of the internal capsule.

474 THE BRAIN

lentiform part of the capsule, and then along the lateral

wall of the posterior horn of the lateral ventricle to their
distribution in the visual area of the occipital cortex, are called
the optic radiations (Fig. 191).

Through the posterior part of the internal capsule in the

retro-lentiform area, but at a lower level than the optic
radiations, there passes a series of fibres, from the medial
geniculate body to the temporal lobe, which constitute the
acoustic radiations (Fig. 191).

Capsula Externa. The external capsule is a relatively

thin lamina of white matter which intervenes between the
lentiform nucleus and the claustrum. It is continuous,
anteriorly and posteriorly, with the internal capsule, and,
above, with the corona radiata. It blends, below, with the
sheet of white fibres which separates the lentiform nucleus
from the roof of the inferior horn of the lateral ventricle.

THE PARTS OF THE BRAIN WHICH LIE IN

THE POSTERIOR CRANIAL FOSSA.

The parts of the brain which lie below the tentorium

cerebelli in the posterior cranial fossa are the lower part of the
mid-brain, the pons, the medulla oblongata, and the cerebellum.
The mid-brain has been considered already. The cerebellum,
the medulla oblongata, and the pons constitute collectively
the rhombencephalon or hind brain, and they are grouped
around the fourth ventricle of the brain. The fourth ventricle
is a cavity which communicates below with the central canal of
the medulla spinalis, and above with the aquaeductus cerebri.

Medulla Oblongata. The medulla oblongata is the con-

tinuation of the spinal medulla into the brain. It is nearly
30 mm. long (rather more than one inch), and may be
reckoned as beginning at the level of the foramen magnum.
Thence it proceeds upwards, in an almost vertical direction
(Fig. 1 88), and it ends at the lower border of the pons. At
first, its girth is similar to that of the spinal medulla, but it
rapidly expands as it approaches the pons, and consequently
it presents a more or less conical appearance. Its anterior
surface lies in the groove on the basilar portion of the occi-
pital bone, and its posterior surface is sunk into the vallecula
of the cerebellum.

MEDULLA OBLONGATA

475

The bilateral construction of the medulla oblongata is

indicated by the appearance of its exterior, for the antero-
median and postero-median sulci on the surface of the spinal
medulla are prolonged upwards on the anterior and posterior
surfaces of the medulla oblongata.

The antero-median fissure, as it passes from the spinal

medulla on to the medulla oblongata, is interrupted, at the
level of the foramen magnum, by several strands of fibres

Optic chiasma
Optic tract

Corpus geniculatum
laterale
Corpus geniculatum
mediale

Substantia perlorata
posterior

Junction of pons and

brachium pontis

Restiform body
Olive

Decussation of
pyramids

Optic nerve
Infundibulum
Tuber cinereum
Corpus mamillare

Oculo-motor nerve

(m.)

Trochlear nerve (iv.)

winding round

cerebral peduncle

Trigeminal nerve (v.)

Abducent nerve (vi.)
Facial nerve (VH.)
Acoustic nerve (vin.)

Vagus and Glosso-

pharyngeal nerves
(ix. andx.)
Fila of hypo-
glossal nerve (xn.)
cut short
Accessory
nerve (xi.)

nterior root of
first cervical nerve
FIG. 192. Anterior aspect of the Medulla Oblongata, Pons,
and Mesencephalon of a full-time Foetus.

which cross the median plane from one side to the other.
This intercrossing is termed the decussation of the pyramids.
Above the level of the decussation the furrow passes upwards
to the lower border of the pons. There it expands slightly,
and ends in a blind pit, termed the foramen ccecum.

The postero-median fissure runs upwards for only half the

length of the medulla oblongata. Then the central canal,
continued upwards from the medulla spinalis, becomes the
fourth ventricle of the brain. As the canal expands dorsally
it pushes aside the Hps of the posterior median fissure till

476 THE BRAIN

the epithelium of the posterior wall of the central canal

appears on the surface, and forms the posterior wall or roof
of the lower part of the fourth ventricle in the triangular
interval between the diverging posterior funiculi of the
medulla oblongata.

The surface of each half of the medulla oblongata should

now be studied. It is well, however, to defer the examina-
tion of the medullary part of the floor of the fourth ventricle
till a later period. The dissector has already noticed two
linear rows of nerve fila issuing from and entering the medulla
oblongata on each side. The anterior row consists of the
fila of the hypoglossal nerve and the uppermost fila of the
anterior root of the first cervical nerve. They continue along
the side on the medulla oblongata in the line of the anterior
nerve roots of the spinal medulla, and they emerge along the
bottom of a more or less distinct groove. The posterior row
is formed of the nerve fila of the accessory, vagus, and glosso-
pharyngeal nerves. As they enter they lie in series with the
posterior roots of the spinal nerves.

By these two rows of nerve fila, each side of the

medulla oblongata is divided into three districts, viz., an
anterior, a lateral, and a posterior, similar to the surface areas
of the three funiculi of each half of the medulla spinalis.
At first sight, indeed, they appear to be direct continuations
upwards of the funiculi of the spinal medulla ; it is easily
demonstrated, however, that that is not the case, and that the
fibres in the three funiculi of the medulla spinalis undergo a
rearrangement as they are traced into the medulla oblongata.

Anterior Area of the Medulla Oblongata Pyramis. The

district between the antero-median fissure and the row of
hypoglossal nerve fila issuing from the medulla receives the
name of the pyramid. An inspection of the surface is almost
sufficient to show that the pyramid is formed by a compact
mass of longitudinally directed fibres. It expands somewhat,
and assumes a more prominent appearance as it passes
upwards, and, finally, as it reaches the lower border of the
pons, it becomes slightly constricted and disappears from
view by plunging into the pons. The pyramids are the great
motor strands of the medulla oblongata.

The pyramid, at first sight, appears to be the continua-

tion upwards of the anterior funiculus of the spinal medulla,
but it contains also a large number of fibres which, at a lower

MEDULLA OBLONGATA

477

level, lie in the lateral funiculus. That will be realised

if the decussation of the pyramids is examined. For that
purpose introduce the back of the knife-blade into the antero-
median fissure below the decussation, and on one side push
in a lateral direction the anterior funiculus of the medulla
spinalis. The pyramid will then be seen to divide into two

N.H. Nucleus hypoglossi.

N.V. Yago-glosso-pharyngeal

nucleus.

F.S. Tractus solitarius.

N.A. Nucleus ambiguus.

CROSSED PYR.TR.
DIR.PYR.TR.

FIG. 193. Diagram of the Decussation of the Pyramids.

(Modified from Van Gehuchten. )

portions, viz., a small strand termed the fasciculus cerebro-

spinalis anterior (O.T. direct pyramidal tract], which proceeds
downwards into the anterior funiculus of the spinal medulla
close to the antero - median fissure, and a much larger
strand called the fasciculus cerebrospinalis later alis (O.T.
crossed pyramidal tract\ which, at the level of the decussation,
is broken up into three or more coarse bundles which sink
backwards and, at the same time, cross the median plane to

478
THE BRAIN

take up a position in the opposite lateral funiculus of the

spinal medulla, close to the posterior column of grey matter.
It is the intercrossing of the corresponding bundles of the
lateral cerebro-spinal fasciculi of opposite sides which pro-
duces the characteristic decussation.

But whilst the fasciculus cerebrospinalis anterior of the

anterior funiculus and the fasciculus cerebrospinalis lateralis
of the opposite lateral funiculus of the spinal medulla are

Optic tract

Pedunculus cerebri

orpus geniculatum laterale

Pulvinar

Corpus geniculatum mediale

Superior brachium
Inferior brachium
Inferior quadrigeminal body
Lateral lemniscus
Brachium conjunctivum
Taenia pontis

Brachium pontis

Restiform body

Ligula

~~~ Olive

Arcuate fibres
Clava

Funiculus cuneatus

Tuberculum cinereum

Lateral district of medulla oblongata

Anterior funiculus of spinal medulla

FIG. 194. Lateral view of the Medulla Oblongata, Pons,

and Mesencephalon of a full-time Fcetus.

both represented in one district of the medulla oblongata,

it may be asked : What becomes of the larger lateral
part of the anterior funiculus of the spinal medulla in
the medulla oblongata ? It is thrust backwards by the
decussating bundles of the lateral cerebro-spinal fasciculus,
and occupies a deep position in the medulla oblongata.

Lateral Area of the Medulla Oblongata. The lateral area

is the district on the surface of the medulla oblongata which
is included between the two rows of nerve fila, viz., the hypo-
glossal fila anteriorly, and the fila of the accessory, vagus, and

MEDULLA OBLONGATA 479

glosso-pharyngeal posteriorly. It presents a very different

appearance in its upper and lower parts. In its lower
portion it appears to the eye as a continuation upwards
of the lateral funiculus of the spinal medulla ; in its upper
part the striking oval prominence, named the olive, is seen.

The lower part of the district, however, is very far from

being an exact counterpart of the lateral funiculus of the spinal
medulla. It has been noted already that the large fasciculus
cerebrospinalis lateralis, which in the spinal medulla lies
in the lateral funiculus, is not present in that district of the
medulla oblongata; above the decussation of the pyramids
it forms the chief part of the pyramid of the opposite side.
Another small strand of fibres, the dorsal spino-cerebellar
fasciculus (O.T. direct cerebellar tract), prolonged upwards in
the lateral funiculus of the spinal medulla, gradually leaves
the lateral portion of the medulla oblongata. The tract of
fibres in question lies on the surface, and it is often visible
to the naked eye as a white streak inclining obliquely into
the posterior district of the medulla oblongata to join its
upper part, which is called the restiform body. The great
majority of the remainder of the fibres which are prolonged
upwards from the lateral funiculus of the spinal medulla dis-
appear from the surface at the lower border of the olive, by
dipping into, the substance of the medulla oblongata under
cover of that projection. A narrow band, however, passes
upwards to the pons, in the interval between the posterior
border of the olive and the fila of the vagus and glosso-
pharyngeal nerves.

The olive is a smooth, oval prominence, which occupies

the upper part of the lateral area of the medulla oblongata.
Its long axis, which is vertical, is about 12.5 mm. (half an
inch) long, and its upper end is separated from the lower
border of the pons by an interval or groove.

Posterior Area of the Medulla Oblongata. The constituent

parts of the lower half of the posterior region are the cuneate
and gracile funiculi ; in its upper half they are the ependymal
roof of the fourth ventricle, medially, and the diverging funi-
culi, laterally. 1 It is separated from the lateral area on each

1 The dissector should note that the lower part of the cavity of the hind-
brain, i.e. the fourth ventricle, is not behind but in the upper part of the
medulla, which it separates into dorsal and ventral parts ; the dorsal part forms
a portion of the roof of the ventricle, whilst the ventral part forms a portion of
the floor.

480

THE BRAIN

side by the row of fila belonging to the accessory, vagus, and

glosso-pharyngeal nerves.

The lower part of the posterior area corresponds more or

less closely with the posterior funiculus of the spinal medulla.
It will be remembered that in the cervical part of the spinal
medulla the posterior funiculus, on each side, is divided, by
a distinct septum of pia mater, into a postero-median strand,
the fasciculus gracilis, and a postero-lateral strand, the fasci-
culus cuneatus. The two strands are prolonged upwards into

Pineal body

Frenulum veli

Anterior
medullary velum

Brachium
conjunctivum

Brachium pontis

Striae medullares

Area acustica

Ala cinerea

Funiculus cuneatus

Funiculus gracilis

Superior
quadrigeminal body
Inferior
quadrigeminal body

- Cerebral peduncle

Pontine part of floor

- of ventricle iv.

Colliculus facialis
Area acustica
Restiform body
Trigonum hypoglossi
Clava

Tuberculum
cinereum

Funiculus cuneatus

FIG. 195. Posterior view of the Medulla Oblongata, Pons, and Mesen-
cephalon of a full-time Foetus. The greater part of the roof of the
fourth ventricle is removed.

the medulla oblongata. In the lower part of the posterior

area they stand out distinctly, and are separated from one
another by the postero-intermediate sulcus, which is continued
upwards from the medulla spinalis. Each strand, when
it reaches the lower part of the fourth ventricle, ends in a
slightly expanded prominence. The swollen extremity of the
fasciculus gracilis is called the dava ; it is thrust aside from
its fellow of the opposite side by the opening up of the
central canal to form the fourth ventricle.

In sections at the level of the lower part of the fourth

MEDULLA OBLONGATA 481

ventricle, it is seen that the prominences produced by the

two strands and their enlarged extremities are in a great
measure due to the presence of two elongated nuclei, which
lie subjacent to them and gradually increase as they are traced
upwards. These are termed the gracile and the cuneate nuclei^
and as the grey matter increases in quantity the fibres of the
two corresponding strands diminish in number. Indeed, it is
doubtful if any of the fibres are prolonged upwards beyond
the level of the nuclei.

But a third longitudinal elevation also is apparent in the

lower part of the posterior area of the medulla oblongata. It
is placed on the lateral side of the fasciculus cuneatus between
it and the posterior row of nerve fila and it has no counter-
part in the posterior funiculus of the spinal medulla. It is
called the funiculus of Rolando, because it is produced by
the substantia gelatinosa (Rolandi) approaching the surface.
Extremely narrow below, the funiculus of Rolando widens
somewhat as it is traced upwards, and it, finally, ends in an
expanded extremity called the tuberculum cinereum. The thin
layer of fibres which appear on the surface of the tuberculum
cinereum, and cover the substantia gelatinosa (Rolandi), in
that position, belong to the tractus spinalis (O.T. spinal root)
of the trigeminal nerve.

The restiform body forms the upper part of the posterior

area on each side. It lies between the lower part of the
floor of the fourth ventricle and the fila of the vagus and
glosso-pharyngeal nerves, and is thrust laterally by the enlarge-
ment of the fourth ventricle. It is a relatively large rope-like
strand, which inclines upwards and laterally, and then, finally,
it takes a turn backwards, and enters the cerebellum, of which
it constitutes the inferior peduncle. The restiform body, there-
fore, is to be regarded as the main connection between the
cerebellum, above, and the medulla oblongata and medulla
spinalis, below. At the same time, it must be understood
that it is not formed of fibres which are prolonged into it
from the fasciculus gracilis and fasciculus cuneatus of its
own side, although a surface inspection of the medulla
oblongata might lead very naturally to that supposition,
because there is no sharp line marking it off from the
ends of those strands.

The fibres which build up the restiform bodies come from several differ-
ent sources. It will be sufficient to indicate the more important of them
VOL. Ill 31

482 THE BRAIN

(i) fibres from the lateral funiculus of the spinal medulla, through the
dorsal spino-cerebellar fasciculus ; (2) olivo-cerebellar fibres from the opposite
inferior olivary nucleus to the cerebellum ; (3) fibres from the cuneate and
gracile nuclei of both sides in the form of the arcuate fibres.

Fibrae Arcuatse Externae. On the surface of the medulla

oblongata, more particularly in the neighbourhood of the
lower border of the olive, a number of curved bundles of fibres,
termed the external arcuate fibres, may be noticed. They
vary greatly in number and in distinctness, and are some-
times so numerous as to cover the olive almost entirely.
An attentive examination will show that they come to the
surface (i) in the antero-median fissure between the pyramids,
(2) in the groove between the pyramid and the olive, and (3)
sometimes also through the substance of the pyramids. But
at whatever point they reach the surface, the majority have one
destination, viz., the restiform body a considerable part of
which they form. They are derived from the cuneate and
gracile nuclei of the opposite side, and end in the cerebellum.

At the inferior end of the olive there is not uncommonly a curved

bundle of fibres, called the circum-olivary fascictclus, which follows the
line of the external arcuate fibres but has a different commencement and
termination. It consists of fibres descending from the cerebrum, and corre-
sponds with the fibres of the pons which end round the pontine nuclei.

Dissection. The pyramidal fibres of one side should now be

carefully raised. When dislodged from their bed they should
be gently pulled upwards towards the pons. In that way their
entrance into the pons will be brought very clearly into view.
Further, numerous arcuate fibres will be seen running forwards
upon the medial aspect of the opposite pyramid to reach the
surface, and the ventral edge of the medial lemniscus will be
exposed also.

Pons. The pons is the marked prominence, on the base

of the brain, which lies anterior to the cerebellum and is
interposed between the medulla oblongata and the pedunculi
cerebri (Figs. 160, 194). It is convex from side to side,
as well as from above downwards, and the transverse streaks
on its surface show that, superficially, it is composed of
transverse bundles of nerve fibres. On each side the trans-
verse fibres collect themselves together to form a large
compact strand which sinks, postero-laterally, into the corre-
sponding hemisphere of the cerebellum. The strand is
termed the brachium pontis (O.T. middle cerebellar peduncle).

When the brain is in situ the ventral surface of the pons is

in relation to the basilar portion of the occipital bone, the

PONS 483

dorsum sellas of the sphenoid bone, and the medial parts of

the posterior surfaces of the petrous portions of the temporal
bones. It presents a median groove which gradually widens
as it is traced upwards (Fig. 192). The groove lodges the
basilar artery, but is not caused by that vessel ; it is due to
the prominence produced, on each side, by the passage
downwards, through the pons, of the bundles of fibres which
form the pyramids of the medulla oblongata. Where the
pons becomes the brachium pontis the large trigeminal
nerve is attached to its ventral surface, nearer its upper than
its lower border.

With the exception of the restiform bodies, which pass

backwards into the cerebellum, most of the constituent parts
of the medulla oblongata are continued into the pons. The
pedunculi cerebri emerge from the upper aspect of the pons.

The dorsal surface of the pons cannot be studied at present.

It is turned towards the cerebellum, which hides it from view,
and it forms the upper part of the anterior boundary or floor
of the fourth ventricle.

Cerebellum. The cerebellum is distinguished by the

numerous parallel and more or less curved sulci which
traverse its surface and give it a foliated appearance. As in
the case of the cerebral hemispheres, the grey matter is
spread over the entire surface, whilst the white matter forms
a central core in the interior.
The cerebellum consists of a median portion, the vernris,
and two hemispheres, but the distinction between those main
subdivisions of the organ is not very evident on its superior
surface. Anteriorly and posteriorly there is a marked de
ficiency or notch in the median plane (Fig. 197). The
posterior notch is smaller and narrower than the anterior
notch. It is bounded on each side by the posterior parts of
the cerebellar hemispheres, and anteriorly by the vermis, and
it is occupied by the falx cerebelli. The anterior notch is
much wider and, when viewed from above, it is seen to be
occupied by the inferior colliculi of the quadrigeminal lamina
and the brachia conjunctiva cerebelli. Its sides are formed
by the hemispheres, and the posterior end is bounded by the
vermis.

On the superior surface of the cerebellum there are, as

already stated, no definite lines of demarcation between the
vermis and the upper surfaces of the hemispheres. The upper

484 THE BRAIN

part of the vermis forms a median ridge, from which the

surface slopes gradually downwards, on each side, to the margin
of the corresponding hemisphere. On the upper part of the
vermis four regions are recognised. Anteriorly, at the posterior
end of the anterior notch, lies the central lobe, and prolonged
upwards from it on the dorsal surface of the anterior medullary
velum, between the brachia conjunctiva, are a few folia which
constitute the lingula. Posterior to the central lobe is the
monticulus, separable into two parts an anterior, more elevated
portion, the culmen, and a posterior, sloping ridge, the declive.
Posterior to the declive, in the anterior boundary of the
posterior notch, lies a single folium called the folium vermis.

On the inferior surface of the cerebellum, the distinction

between the three constituent parts of the organ is much
better marked. On that aspect the hemispheres are full,
prominent and convex, and they are separated by a deep,
median hollow which is continued forwards from the posterior
notch. The hollow is termed the vallecula cerebelli, and in its
anterior part the medulla oblongata is lodged. If the medulla
is forced away from the cerebellum, and the hemispheres
are pulled apart so as to expose the upper boundary of the
vallecula, it will be seen that that boundary is formed by the
inferior surface of the vermis, and, further, that the vermis is
separated, on eajch side, from the corresponding hemisphere
by a distinct furrow, termed the sulcus valleculcel

If the margin of the vermis, where it forms the posterior

boundary of the anterior notch on the superior aspect of
the cerebellum, is gently raised, and at the same time the
mesencephalon is pulled forwards, two strands lying upon
the dorsal aspect of the pons will be seen. These are
the brachia conjunctiva cerebelli (O.T. superior peduncles].
They emerge from the white matter of the cerebellum,
converge as they proceed upwards, and, finally, they dis-
appear under the inferior quadrigeminal bodies. The thin
lamina which is stretched across between them is the anterior
medullary velum. It is continuous below with the white core
of the vermis, and it helps to form the roof of the upper
part of the fourth ventricle. From its dorsal surface, close

1 As the medulla oblongata is displaced forwards, and the hemispheres of

the cerebellum are pulled apart, the epithelial roof of the fourth ventricle and
its covering of pia mater will be torn away, and the lower part of the floor
or anterior boundary of the fourth ventricle will be displayed.

CEREBELLUM

485

to the inferior quadrigeminal body, the small trochlear nerves

emerge.

Certain of the sulci which traverse the surface of the

cerebellum, deeper and longer than the others, map out
districts which are termed lobes. The most conspicuous of
all the clefts is the horizontal sulcus.

Sulcus Horizontalis Cerebelli. The horizontal sulcus

begins anteriorly, where its lips separate from one another
to enclose the large brachia pontis, and it passes round the

Pons

Mesencephalon

Central lobule

Culmen monticuli

Anterior crescentic lobule

Posterior crescentic lobule

Superior semilunar
lobule
Declive monticuli

Folium vermis

Inferior semilunar lobule

Tuber vermis
Posterior notch

FIG. 196. Upper surface of the Cerebellum.

circumference of the cerebellum, cutting deeply into its lateral

and posterior margins. By means of the horizontal sulcus
the cerebellum is divided into an upper and a lower part,
which may be studied separately.

Lobes on the Upper Surface of the Cerebellum. It has been noted

already that the upper surface of the vermis superior is subdivided. The
divisions, commencing at the anterior end, are: (i) the lingula ; (2) the
central lobule ; (3) the culmen monticuli ; (4) the declive monticuli ; (5) the
folium vermis. With the exception of the lingula, each part is continuous
on each side with a corresponding district on the upper surface of the hemi-
sphere, and forms with those districts a cerebellar lobe. Thus, the central
lobule is prolonged laterally on each side in an expansion called the ala

486

THE BRAIN

the culmen constitutes a median connecting piece between the two anterior
crescent ic lobules of the hemispheres ; the declive stands in the same relation
to the posterior crescentic lobules ; and the folium vermis is the connecting
band between the superior se/nilunar lobules of the hemispheres.

Lingula. The lingula can be seen only when the posterior boundary of
the anterior notch is pushed backwards. It consists of four or five small
folia, continuous with the grey matter of the vermis, prolonged upwards
on the surface of the anterior medullary velum, in the interval between
the brachia conjunctiva.

Lobus Centralis with its Alae. The central lobule lies at the posterior

Central lobule
Brachium conjunctivum

Anterior medullary velum

Brachium pontis
Posterior medullary^ j

velum v

Nodule

Flocculus

Horizontal sulcus

Inferior semilunar lobule

Lobulus gracilis \

Biventral lobule

Pyramid

Horizontal sulcus

Lobulus gracilis
Biventral lobule

Uvula Tonsil
Tuber vermis

FlG. 197. Lower surface of the Cerebellum. The tonsil of the right side
has been removed so as to display the posterior medullary velum and
the furrowed band.

end of the anterior notch, and is largely hidden by the culmen. It is a

little median mass which is prolonged laterally for a short distance round
the semilunar notch in the form of two expansions, termed the alee,

Lobus Culminis. The cnlinen monticnli constitutes the summit or

highest part of the monticulus of the vermis. It is prolonged laterally on
each side into the corresponding hemisphere as the anterior crescentic
lobule. This is the most anterior subdivision on the upper surface of the
hemisphere. The two anterior crescentic lobules, with the culmen
monticuli, form the lohiis culininis cerebelli,

Lobus Declivis. The decline monticuli\\o& posterior to the culmen, from

which it is separated by a distinct fissure, and it forms the sloping part or
descent of the monticulus of the vermis. On each side it is continuous

CEREBELLUM

487

with the posterior crescentic lobule of the hemisphere, and the three parts
are included under the one name of lobus declivis.

The two crescentic lobules on the upper surface of the hemisphere are
frequently described together as the quadrate lobule.

Lobus Semilunaris Superior (O.T. Lobus Cacuminis). The folium

vermis forms the most posterior part of the superior portion of the
vermis, and it bounds the horizontal fissure, superiorly, at the posterior
notch. It is a single folium, the surface of which may be smooth
or notched with rudimentary secondary folia, and it is the connecting
link between the two superior semilunar lobules of the hemispheres
the three parts constituting the lobus semilunaris superior. As the folium
vermis is traced laterally into the semilunar lobule of the hemisphere,
it is found to expand greatly. The result is that the lobus semilunaris
superior, on each side, forms an extensive foliated district bounding the
posterior part of the horizontal sulcus superiorly.

Lobes on the Lower Surface of the Cerebellum. The connection

between the several portions of the inferior part of the vermis, and the

Culmen Central lobule

Declive

Tuber vermis

Py

Lingula on the
anterior medul-
lary velum
Nodule

FIG. 198. Median section through the Vermis of the Cerebellum.

(From Gegenbaur. )

corresponding districts on the inferior surface of the two hemispheres is not

nearly so distinct as in the case of the superior part of the vermis and the
lobules on the upper surface of the hemispheres.

The following subdivisions of the inferior part of the vermis are

recognised, from behind forwards (i) the tuber vermis, (2) the pyramid,
(3) the uvula, and (4) the nodule.

On the inferior surface of the hemisphere there are five lobules mapped
out by intervening sulci. They are (i) \hzflocculus, a little lobule lying
on the brachium pontis ; (2) the biventral lobule, which lies immediately
posterior to the flocculus, and is partially divided into two parts by a fissure
which traverses its surface ; (3) the tonsil, a rounded lobule, which bounds
the vallecula on the medial side of the biventral lobule ; (4) the inferior
semilunar lobule, placed posterior to the biventral lobule, and bounding the
horizontal sulcus inferiorly.

The lobules of the inferior parts of the hemispheres, with the corre-
sponding portions of the inferior part of the vermis, constitute the lobes
on the inferior aspect of the cerebellum.

Lobus Noduli. The lobus noduli comprises the nodule and the flocculus,
of each side, with an exceedingly delicate connecting lamina of white
matter, termed the posterior medullary velum.

488 THE BRAIN

The velum cannot be properly seen at present, but it will be exposed at

a later stage of the dissection.

Lobus Uvulse. The uvula is a triangular elevation placed between the

two tonsils. It is connected, across the sulcus valleculee, with each tonsil
by a low-lying ridge of grey matter which is scored by a few shallow
furrows, and in consequence termed \hz furrowed band. The two tonsils
and the uvula form the lobus uvula.

To see the furrowed band it will be necessary to remove the tonsil on

one side, when the posterior medullary velum also will be exposed.

Lobus Pyramidis. The pyramid is connected with the biventral

lobule on each side by a faint ridge which crosses the sulcus vallecul<K.
The term lobus pyramidis is given to the three lobules which are thus
associated with each other.

Lobus Tuberis. The tuber vermis, which forms the most posterior part
of the inferior vermis, is composed of several folia, which run directly into the
inferior semilunar lobule on each side. The three parts of the lobus tuberis
are thus linked together. The inferior semilunar lobule is traversed by
two, or it may be three, curved fissures. The most anterior of these cuts
off a narrow, curved strip of cerebellar surface called the lobulus gracilis.

Dissection. A median section should now be made through

the vermis of the cerebellum and the two medullary vela into
the cavity of the fourth ventricle. When the two parts of the
cerebellum are drawn slightly asunder, a view of the fourth
ventiicle is obtained ; further, the connections of the two
medullary vela and the arrangement of the peduncles of the
cerebellum can be more clearly understood.

Arbor Vitse Cerebelli. The cut surface of the cerebellum

presents a very characteristic appearance. The grey matter
on the surface stands out distinctly from the white matter in
the interior. Further, the complete manner in which the
surface is cut up by the sulci into secondary and tertiary folia
is seen. The central mass of white matter in the vermis is
termed the corpus medullare. From the corpus medullare,
prolongations pass into the various lobules, and they give off
branches to supply each folium with a central white stem or
core. The term arbor vita is applied to the appearance
which consequently results when a section is made through
the cerebellum (Fig. 198).

Cerebellar Peduncles. The cerebellar peduncles are the

structures which connect the cerebellum with the medulla
oblongata, the pons and the mid-brain. They are three in
number on each side viz., the inferior, the middle, and
the superior. They are all directly connected with the white
medullary centre of the cerebellum, and are composed of
fibres which emerge from or enter the white central sub-
stance of the organ.

The middle peduncle or brachium pontis is much the

CEREBELLUM 489

largest of the three. It is formed by the transverse fibres of

the pons, and it enters the cerebellar hemisphere on the
lateral side of the other two. The lips of the anterior part
of the horizontal sulcus are separated widely from each other
to give it admission (Fig. 195).

The inferior peduncle is the restiform body of the medulla

oblongata. As it leaves the dorsum of the medulla oblongata
it turns sharply backwards and enters the cerebellum between
the other two peduncles.

The superior peduncles are the brachia conjunctiva of the

cerebellum. They are composed of fibres which come, for
the most part, from the nucleus dentatus of the cerebellar
hemisphere. As they issue from the cerebellum, the
peduncles lie close to the medial sides of the corresponding
middle peduncles. They then proceed upwards towards the
inferior pair of quadrigeminal bodies. At first, they form the
lateral boundaries of the upper part of the fourth ventricle,
but they converge, as they ascend on the dorsal aspect of the
pons, so that ultimately they overhang the fourth ventricle
and enter into the formation of its roof. They disappear
under cover of the inferior colliculi of the quadrigeminal
lamina, and their course in the mesencephalon has been
described already (Figs. 180, 181, 194, 195) (p. 45?)-

Medullary Vela. The medullary vela are closely associated

with the peduncles. They consist of two thin laminae of
white matter which are projected out from the white central
core of the cerebellum. The anterior medullary velum stretches
across the interval between the two brachia conjunctiva
(superior peduncles), with the medial margins of which it is
directly continuous. " It is triangular in form, and is con-
tinuous below with the white matter of the cerebellum.
Spread out on its dorsal surface is the tongue-shaped prolonga-
tion of grey matter from the cortex of the cerebellum which
is termed the lingula, and issuing from its substance, close
to the inferior colliculi of the quadrigeminal lamina, are the
two trochlear nerves.

*\}\e posterior medullary velum is somewhat more complicated

in its connections. It presents the same relation to the
nodule that the anterior velum presents to the lingula. It is
a wide thin lamina of white matter so thin that it is
translucent which is prolonged out from the white centre
of the cerebellum above the nodule. From the nodule it

490 THE BRAIN

stretches laterally to the flocculus, thereby bringing those

two small portions of the cerebellum into association with
each other. Where it issues from the white matter of the
cerebellum it might almost be said to be in contact with the
anterior medullary velum, but as the two laminae are traced
forwards they diverge from each other : the anterior velum is
carried upwards between the brachia conjunctiva of the cere-
bellum, whilst the posterior medullary velum turns downwards,
round the nodule, and ends in a slightly thickened free
crescentic edge. The cavity of the fourth ventricle passes
backwards between the two vela, which form a tent-like roof
for it.

Isthmus Ehombencephali. If the dissector examines the

rhombencephalon from the side he will recognise that there
is a region below the lamina quadrigemina and above the
cerebellum which is bounded dorsally by the anterior
medullary velum, laterally by the brachia conjunctiva, and
ventrally by the upper part of the pons : it is to that region
that the term isthmus rhombencephali is applied. It contains
the upper part of the fourth ventricle.

Ventriculus Quartus. The fourth ventricle is somewhat

rhomboidal in form. Below, it tapers to a point and becomes
continuous with the central canal of the lower part of the
medulla oblongata ; above, it narrows, in a similar manner,
and is continued into the aquaeductus cerebri of the mid-
brain. The anterior wall is termed the floor^ and is formed
by the dorsal surface of the pons and the ventral part of the
upper portion of the medulla oblongata. The posterior wall
is called the roof. On each side a narrow pointed prolonga-
tion of the widest part of the ventricular cavity passes laterally
round the upper part of the corresponding restiform body.
The prolongations are termed the lateral recesses and are seen
to the greatest advantage when the cerebellum is divided
in the median plane and the halves are turned aside.

The lateral boundary of the fourth ventricle, on each side,

is formed, from below upwards, by the clava, the upper part
of the fasciculus cuneatus, the restiform body or inferior
peduncle of the cerebellum, the brachium pontis or middle
peduncle of the cerebellum, and the brachium conjunctivum
or superior peduncle of the cerebellum.

Dissection. On one side cut through the brachium con-

junctivum, the brachium pontis and the restiform body, and so

FOURTH VENTRICLE 491

separate one half of the cerebellum, which must be laid aside

for the present, but must be preserved for future use.

When the dissection is completed the dissectors will be

able to recognise that the anterior part of the cavity of the
fourth ventricle is rhomboidal in form. It constitutes the
so-called rhomboid fossa, which is surrounded by the lateral
boundaries of the ventricle and closed anteriorly by the pons
and the dorsal surface of the ventral part of the upper
half of the medulla oblongata. Only the lower part of
the rhomboid fossa lies in the medulla oblongata ; the
middle part is in the metencephalon, that is, it lies anterior
to the cerebellum and posterior to the lower part of the pons ;
and the upper part is in the isthmus rhombencephali.

The lower part of the rhomboid fossa is triangular in out-

line, and its inferior angle is continuous with the central canal
of the lower part of the medulla oblongata. The anterior
boundary or floor of this part of the fossa is marked by a
number of converging sulci, and is called the calamus
scriptorius. Along the lateral margins of the lower part of
the fossa will be seen the remains of the torn epithelial roof
of the lower part of the fourth ventricle. The torn margins
are the tcenice of the fourth ventricle. The middle part
of the rhomboid fossa is separable into a lower wider part,
which is prolonged laterally, on each side, below and posterior
to the restiform body, as the lateral recess of the fourth
ventricle. The upper section of the intermediate part of
the fossa is bounded laterally by the brachia pontis and is
much narrower than the lower part. The upper part of the
rhomboid fossa lies posterior to the pons and between the
brachia conjunctiva. At its upper end it becomes continuous
with the aquaeductus cerebri of the mid-brain.

The floor, or anterior boundary, of the fossa rhomboidea is

the floor, or anterior boundary, of the fourth ventricle. In
the upper part of its extent it is formed by the posterior
surface of the pons, and in the lower part by the posterior
surface of the ventral part of the upper portion of the medulla
oblongata. It is divided into lateral portions by a median
sulcus which is deeper below, in the region of the calamus
scriptorius, and shallower above. On each side of the median
sulcus is the emhientia medialis. In the upper part of the
fossa the eminentia medialis occupies practically the whole
of each half of the floor ; in the upper part of the middle

492 THE BRAIN

portion of the fossa a rounded eminence, the colliculus facialis,

appears on its surface ; below the colliculus the eminentia
medialis narrows rapidly, and its terminal, tapering portion
is called the trigonum hypoglossi. The medial eminence is
bounded laterally by a sulcus, the sulcus limitans. In the
upper region, along the lateral border of the sulcus limitans,
is a narrow bluish-tinted area called the locus cceruleus ;
the colour of that area is due to a subjacent collection of
pigmented cells which constitute the substantia ferruginea.
Opposite the colliculus facialis the sulcus limitans expands
into a shallow fossa, the superior fovea. The lower end of
the sulcus limitans terminates, in the upper part of the in-
ferior section of the rhomboidal fossa, in a definite depression,
the inferior fovea. To the lateral side of the superior and
inferior foveae and the middle part of the sulcus limitans is
the area acustica, which is prolonged laterally towards the lateral
recess, and, in rare cases, a prominence, the tuberculum acusti-
cum, appears on its surface. Below the inferior fovea, be-
tween the trigonum hypoglossi medially and the area acustica
laterally, lies a depressed, grey-coloured, triangular area called
the ala cinerea, which is separated from the lower part of the
floor, the area postrema, by a raised bundle, the funiculus
separans. Immediately above the inferior fovea a number of
ridges, the medullary striae, (O.T. strice. acusticcz], cross the floor
of the fossa transversely. Laterally, they cross the restiform
body, at the lateral border of the fossa, and become con-
tinuous with the cochlear root of the acoustic nerve ; and,
medially, they disappear into the median sulcus (Fig. 195).

The roof of the fourth ventricle is formed, in the upper area,

by the medial parts of the brachia conjunctiva and the inter-
vening anterior medullary velum. Descending upon the
velum, from above, is the frenulum veli ; issuing from it, in
the same region, are the rootlets of the trochlear nerves.
The lower part of the upper portion of the roof is covered
by the lingula of the cerebellum. The roof of the inter-
mediate section of the ventricle is the white matter of the
vermis of the cerebellum, and the roof of the lower part is
reduced to the- lining epithelial ependyma with the posterior
medullary velum, and the obex (see p. 493).

The tela chorioidea of the fourth ventricle is the layer of

pia mater which covers and strengthens the epithelial roof of
the lower part of the cavity. Between it and the epithe-
FOURTH VENTRICLE 493

Hum, at the lower end of the roof, is a thin layer of grey

matter, called the obex. Above, at the posterior medullary
velum, the tela becomes continuous with the pia mater on
the lower surface of the vermis of the cerebellum. Laterally
the tela is prolonged, on each side, posterior to the restiform
body, over the lateral recess, and it forms the stronger part
of the wall of that expansion. Between the median part of
the tela chorioidea of the fourth ventricle and the pia mater
on the lower surface of the vermis of the cerebellum lies the
cisterna cerebello-medullaris (O.T. cisterna magna) (Fig. 141).

Apertures in the Tela Chorioidea of the Fourth Ventricle.

In the early stages of development the tela chorioidea and
ependyma form an unbroken layer, but at a later period
three apertures appear in them. One of the apertures, the
apettura medialis ventriculi quarti (O.T. foramen of Magendie\
lies immediately above the obex, at the lower angle of the
ventricle, and through it the cavity of the fourth ventricle
communicates with the cerebello- medullary portion of the
subarachnoid space. The other two apertures lie at the
apices of the lateral recesses, immediately posterior to the
fila of the glossopharyngeal nerves.

Chorioid Plexuses of the Fourth Ventricle. The chorioid

plexuses are invaginations of the ependyma caused by vascular
prolongations of the tela chorioidea. In the lower part of
the ventricle they form two parallel bands, one on each side
of the median plane, and their lower ends project through
the median aperture. At the upper part of the tela chorioidea
they communicate together, and then each passes laterally
into the corresponding lateral recess and their lateral ex-
tremities project through the lateral apertures.

Dissection. The dissector should now introduce his fingers

into the horizontal sulcus of that half of the cerebellum which
is still connected with the medulla oblongata and the pons, and
tear the upper part of the cerebellum away from the lower part.
By that proceeding the manner in which the peduncles enter
the white medullary centre, and also, to some extent, the general
distribution of their fibres, will be seen.

Next, separate the remains of the cerebellum from the isthmus,

the pons, and the medulla oblongata by cutting through the
peduncles at the points where they enter the central white matter.
A horizontal section may then be made through the other half
of the organ, rather nearer its upper surface than its lower
surface. The section will reveal the nucleus dentatus.

Nucleus Dentatus. The dentate nucleus is a collection

494 THE BRAIN

of grey matter embedded in the white medullary centre of
the hemisphere of the cerebellum. Its appearance is very
similar to that of a nucleus which lies in the olive of the
medulla oblongata. It is a thin lamina of grey matter,
which appears, on section, as a wavy line folded upon itself
so as to form a crumpled grey capsule with a mouth open
towards the median plane. The greater number of the fibres
which build up the brachium conjunctivum issue from its
mouth.

There are other smaller isolated nuclei of grey matter in the white
medullary centre of the cerebellum. They are : the nucleus emboliforniis,
which lies close to the hilum of the dentate nucleus ; the nucleus globosus,
medial to the nucleus emb'oliformis ; and the mtcletts fastigiJ, or roof
nucleus, which is situated in the white matter above the cavity of the fourth
ventricle. As a rule, those nuclei cannot be demonstrated in a specimen
obtained in the dissecting-room.

Dissection. Place the lower part of the mid-brain in relation

with the upper part, in which the position of the motor fibres,
descending from the cortex of the hemisphere, through the
anterior part of the posterior division of the internal capsule,
has already been defined. Note the position of the motor fibres
in the basis pedunculi of the lower part of the mid-brain. They
lie, for the main part, in the intermediate three-fifths. On one
side trace the motor tract downwards to the upper border of the
pons. Then remove the superficial transverse fibres of the pons
and trace the motor tract downwards, through the pons. At
the lower border of the pons it will be found to become continuous
with the ventral (anterior) part of the pyramid of the medulla
oblongata. The dissector should note that the tract diminishes
somewhat in size as it is followed downwards through the pons. 1
The diminution is due to some of the fibres leaving the tract and
passing across the median plane to the nuclei of the cerebral
motor nerves of the opposite side. Note that, when the motor
tract reaches the lower end of the medulla oblongata, the majority
of its fibres cross to the opposite side, to form the lateral cerebro-
spinal fasciculus of the lateral funiculus of the spinal medulla
of that side, and that the smaller number continue to descend
on the same side, to form the anterior cerebro-spinal fasciculus
of the anterior funiculus of the same side of the spinal medulla.

Remove the motor tract in the lower part of the mid-brain

and in the pons and medulla oblongata, and note the following
structures which lie dorsal to it (i) In the mid-brain a dark
pigmented layer, the substantia nigra. (2) In the pons a deep
layer of transverse fibres which constitute the corpus trapezoi-
deum. (3^ In the medulla oblongata a band of longitudinal
white fibres which form part of a long strand called the medial
lemniscus.

Lemniscus Medialis. In the lower part of the medulla

1 The dissector should note also that other fibres which end in the pons,
round the pontine nuclei, are associated with the motor fibres.

LEMNISCUS MEDIALIS
495

oblongata the medial lemniscus consists of fibres which have

ascended from the lateral and the anterior funiculi of the
spinal medulla, where they form tracts called the lateral and
the anterior spino-thalamic fasciculi. In the upper part of
the medulla oblongata the spino-thalamic fasciculi are joined

Median ra
Cerebral peduncle
Upper border

Oculo-motor nerve

| Cerebro-pontine fibres ending in pons

; Others are seen passing; to pyramid of
s^^^^,'i medulla oblongata

Trigeminal nerve

Glossopharyngeal
nerve

s- / Flocculus
4

Vagus nerve / t
Accessory nerve /
Olive

Accessory nerve /

Lemniscus
Pyramidal fibres (cut) Pyramidal decuss

FIG. 199. Dissection of Pons and Medulla Oblongata to show Pyramidal

Fibres and Lemniscus.

by fibres derived from the nucleus gracilis and the nucleus

cuneatus of the opposite side. The nucleus gracilis and the
nucleus cuneatus lie in the upper ends of the fasciculi of
the same names, and the fibres which pass from them to the
lemniscus of the opposite side decussate with similar fibres
derived from the opposite gracile and cuneate nuclei, in the

496 THE BRAIN

region between the olivary bodies, and as they decussate

they form the decussation of the lemnisri or interolivary
decussation (Fig. 201).

In addition to the fibres derived from the spino-thalamic

fasciculi and the nucleus gracilis and nucleus cuneatus of the
opposite side, the lemniscus, whilst it is still in the medulla
oblongata, receives fibres from the sensory nuclei of the
cerebral nerves of the opposite side.

The portion of the lemniscus found in the medulla oblongata

is known as the medial lemniscus. It ascends through the pons
into the mid-brain, where many of its fibres end in the superior
colliculus, but some ascend still higher and terminate in the
thalamus of the same side. As the medial lemniscus ascends
through the pons it receives additional fibres from the nuclei
of the sensory cerebral nerves of the opposite side. The
majority of the additional fibres pass to the lemniscus through
the corpus trapezoideum, and those derived from the nuclei of
the cochlear division of the opposite acoustic nerve attain a
position at the lateral border of the medial lemniscus, and they
form a more or less separate bundle termed the lateral lemniscus.
In the region of the upper part of the pons the fibres of the
lateral lemniscus turn dorsally, and, after emerging from the
upper border of the pons, they cross superficial to the lateral
surface of the upper part of the brachium conjunctivum of the
cerebellum (Fig. 194), and disappear under cover of the
inferior colliculus of the quadrigeminal lamina, and also under
the inferior brachium and the medial geniculate body. They
terminate in association with the cells of the inferior col-
liculus, and with those of the medial geniculate body, whence
the acoustic radiations already noted (p. 474) pass to the
superior temporal gyms.

Dissection. To trace the lemniscus upwards it is necessary

to remove the deep transverse fibres of the pons, and the sub-
stantia nigra of the mid-brain. As the dissector makes the
dissection, he should note (i) That the lemniscus increases in
width in the lower part of the pons on account of the accession
of fibres from the nuclei of the sensory cerebral nerves of the
opposite side. (2) That in the upper part of the pons the lem-
niscus decreases in width as the lateral portion leaves it to pass
to the inferior colliculus.

After the dissector has displayed, as far as possible, the

position and connections of the lemniscus he should turn to
the brachium conjunctivum of the cerebellum and attempt to
demonstrate its associations. It is quite easily recognisable,
as it lies behind the upper part of the pons, in the dorso-lateral
LEMNISCUS MEDIALIS 497

boundary of the upper part of the fourth ventricle. There, it

should be located, and thence it should be traced backwards into
the hemisphere of the cerebellum, of the same side, to the
dentate nucleus, and forwards, medial to the lateral lemniscus
and ventral to the inferior colliculus, into the tegmental part
of the cerebral peduncle. As the fibres are traced into the mid-
brain they will be found to approach the corresponding fibres
of the opposite side, with which they decussate, in the lower part
of the mid-brain, dorso-medial to the medial lemniscus. After
decussating they pass upwards to the red nucleus of the opposite
side, where the majority terminate.

When the dissections described are completed the dissector

should make a series of transverse sections through the opposite
half of the medulla oblongata and the pons, or, better still,
through the whole of another specimen, if it can be obtained.
In such a series of sections he will be able to note some of the
points now to be mentioned, but the majority of the details noted
are well seen only on specially prepared and stained sections.

Internal Structure of the Medulla Oblongata. When transverse

sections are made through the upper part of the medulla oblongata, a faint
line, called the median raphe, is seen in the median plane. It divides
the medulla oblongata into two exactly similar halves. The raphe is
formed by the close intersection of fibres running in opposite directions.

Each half of the medulla oblongata is composed of (a) strands of white

matter ; () grey matter, which is present both in the form of direct con-
tinuations into the medulla oblongata of portions of the grey matter of
the spinal medulla, and in the form of isolated masses, which are not
represented in the spinal medulla ; (c] the formatio reticularis, a substance
which is composed of grey matter coarsely broken up by fibres which
traverse it in different directions ; and (d) neuroglia. The white matter, as
in the spinal medulla, is disposed, for the most part, on the surface and the
grey matter in the interior, but in the open part of the medulla oblongata
the grey matter comes to the surface on its dorsal aspect, and forms the
obex (p. 496).

When the grey matter of the spinal medulla is traced up into the medulla
oblongata, many striking changes in its arrangement become apparent.
Owing to the increase in size of the large wedge-shaped gracile and cuneate
fasciculi, the posterior columns of grey matter are pressed laterally, so that
they soon assume a position at right angles to the median plane. At the
same time, the cuneate and gracile nuclear columns of grey matter, which
grow out from the basal portion of the posterior column and underlie the
strands of the same name, begin to make their appearance. From the
deep aspects of those nuclei, fibres, which take origin within them, stream
antero-medially through the neck of the posterior grey column to reach the
ventral median raphe. And as they pass ventrally they separate the head
from the basal part of the posterior grey column. The basal part of the
grey column remains close to the central canal, but the head and the
substantia gelatinosa remain near the surface, and, towards the upper part
of the lower half of the medulla oblongata, the head enlarges and forms a
prominence on the surface which has already been noticed as the tuberculum
cinereum (p. 481).
The fibres which spring from the cells of the nucleus gracilis and the

nucleus cuneatus and break through the neck of the posterior grey column

are called the internal arcuate fibres. They reach the raphe on the deep

or dorsal aspect of the pyramidal fasciculus and, in the median plane at the

VOL. Ill 32

498

THE BRAIN

level of the olives, where they form a very complete decussation with the
corresponding fibres of the opposite side, termed the decussation of the
lemniscus or sensory decussation. As soon as they reach the opposite side

Gracile nucleus
Cuneate nucleus.

,-Cuneate nucleus
Tractus spinalis of fifth
nerve

Substantia gelatinosa
Rolancli

Dorsal spino-cerebellar
fasciculus

Lateral cerebro-spinal
fasciculus

Detached anterior
column of grey matter

Decussation of pyramids

Fasciculus anterior proprius

FIG. 200. - Section through the lower part of the Medulla Oblongata
of the Orang.

Funiculus gracilis
Funiculus
cuneatus

Tractus
spinalis of
fifth

Gracile nucleus

Cuneate
nucleus

Substantia
gelatinosa
Rolandi

Decussation
of the lemnisci

Medial
accessory
olivary nucleu
Fila of the
ypoglossal
nerve

;' *" 'X Pyramid

FIG. 201. Transverse section through the lower part of the Medulla
Oblongata of a full-time Foetus, above the Decussation of the Pyramids,
treated by the Weigert-Pal method. The grey matter is white, and the
medullated strands of nerve fibres are black.

of the medulla oblongata the internal arcuate fibres turn upwards, and,
together with the fibres of the spino-thalamic fasciculi, which are ascending
from the lateral and anterior funiculi of the spinal medulla, they form a
well-marked longitudinal tract caUed.the.w^/z'a/ lemniscus.

STRUCTURE OF MEDULLA OBLONGATA 499

The medial lemniscus or fillet is placed close to the raphe, on the dorsal
aspect of the pyramidal motor fasciculus.
The anterior column of grey matter is divided in a similar manner, by
the fibres of the lateral cerebro - spinal fasciculus as it passes from the
pyramid to the lateral funiculus of the opposite side of the medulla spinalis.
The basal part of the divided anterior grey column remains near the central
canal, but the head is displaced and forced dorso-laterally into the lateral
area of the medulla oblongata, where it becomes continuous with strands
of grey matter called the nucleus ambigiius and the nucleus laterahs.

Half- way up the medulla oblongata the central canal> which has been
gradually approaching the dorsal surface, opens out into the cavity of the.
fourth ventricle, and the remains of the posterior grey columns, which
surrounded it at lower levels, are spread out on the floor of the ventricle in
such a manner that the portion which corresponds with the basal part of

Gracile nucleus

Funiculus
gracilis

Decussation
of pyramids

Funiculus

cuneatus

.Tractus spinalis
of fifth nerve

Substantia
gelatinosa
Rolandi

Dorsal spino-

cerebellar

fasciculus

Detached head of
anterior column
of grey matter
Fasciculus proprius
anterior pushed aside
by the decussation

Antero-median furrow
FIG. 202. Transverse section through lower end of the Medulla Oblongata of
a full-time Foetus, treated by the Weigert-Pal method. The grey matter
is therefore bleached white ; whilst the medullated tracts are black.

the anterior grey column of the spinal medulla is situated close to the
median plane, whilst the part which represents the base of the posterior
grey column of the spinal medulla occupies a more lateral position ; therefore
the hypoglossal nerve, which is a motor nerve, springs from the grey matter
near the median plane which is an upward prolongation of the motor or
anterior grey column, and the fibres of the glosso-pharyngeal and vagus
nerves, which are mainly sensory nerves, terminate in association with the
more laterally situated grey matter of the medulla oblongata which is
continued upwards from the base of the posterior grey column of the spinal
medulla.

As the central canal opens out into the cavity of the fourth ventricle and
the basal parts of the posterior grey columns are forced laterally, the
ependymal epithelium of the dorsal wall of the canal is expanded into the
extensive epithelial membrane, which forms the roof of the lower part of
the fourth ventricle.

Every section of the upper portion rfjfrthfe InftduHa oblongata is divided

into medial, lateral, and dorsa^r^tsWVhV9Jofcii|cf trfJfrBQglossal nerve
in 32 a

GU MIC CAigS

and the roots of the vagus and glosso-pharyngcal nerves. The medial
part lies between the root fibres of the hypoglossal nerve and the median
raphe. It consists mainly of white matter, but on its ventral aspect, close
to the anterior median fissure, lies the nucleus of the external arcuate fibres,
embedded amongst those fibres ; and on the lateral part of the dorsal aspect
of the pyramidal fasciculus, there is a tract of nerve cells which is called the
medial accessory olive.

The nerve fibres of the medial area are longitudinal, transverse and
oblique. The longitudinal fibres form four main strands. Ventrally they
form the pyramidal fasciculus ; immediately dorsal to the pyramidal fasci-
culus they constitute the medial lemniscus ; behind the lemniscus are the
tecto-spinal fibres, and still more dorsally, immediately subjacent to the
grey matter of the floor of the fourth ventricle, is the medial longitudinal
fasciculus. The medial lemniscus consists of the fibres of the spino-thalamic
fasciculi, prolonged upwards from the lateral and anterior funiculi of the
spinal medulla, and of internal arcuate fibres derived from the gracile and
cuneate nuclei of the opposite side. The tecto-spinal fibres are descending
from the lamina quadrigemina to the spinal medulla. The medial longi-
tudinal fasciculus is continuous, below, with the fasciculus anterior proprius
of the spinal medulla. It ascends through the medulla, pons, and mid-brain
to the subthalamic region, forming intimate associations with the motor
nuclei of the cerebral nerves.
The oblique and transverse fibres of the medial area are internal and
external arcuate fibres.

The most striking feature in transverse sections of the upper part of the
lateral area of the medulla oblongata is the olivary nucletts, which lies sub-
jacent to the olivary eminence. It presents the appearance of a thick
undulating layer of grey matter, folded on itself so as to enclose a space
filled with white matter and open towards the median plane. It is in
reality a grey lamina arranged in a purse-like manner with the open mouth
directed towards the raphe. Dorsal to the olivary nucleus lies the dorsal
accessory olivary mtcleus. More dorsally there are columns of nerve cells
which form the nucleus lateralis and the nucleus ambiguus, and which
are continuous, below, with the head of the anterior grey column of the
spinal medulla. Still more dorsally is the ventral part of the nucleus of
the spinal tract of the trigeminal nerve.

The white matter of the lateral area consists of longitudinal and oblique
fibres, and that portion of it which lies dorsal to the olivary nucleus is
sometimes spoken of as \h&formatio reticularis grisea, because it contains a
certain amount of grey matter, whilst the corresponding part of the medial
area, which is practically devoid of grey matter, is called the form otto
reticularis alba.

Some of the longitudinal white fibres of the lateral area of the medulla
oblongata form definite fasciculi which associate together different grey
masses. Close to the surface, below the level of the olive, and immediately
dorso-lateral to the issuing fila of the hypoglossal nerve lies the bulbo-
spinal fasciculus. On the superficial aspect of the olivary nucleus and
along its dorso-lateral border is the thalamo-olivary fasciculus, and dorsal
to the thalamo-olivary fasciculus are the ventral and the dorsal spino-
cerebellar fasciculi. More medially lie the rubro-spinal fasciculus and fibres
of the spino-thalamic fasciculi ; the oblique fibres are internal and external
arcuate fibres. Some of the internal arcuate fibres are passing between the
gracile and cuneate nuclei and the restiform body of the opposite side, and
some are connecting the cerebellar hemisphere of one side with the olivary
nucleus of the opposite side.

The dorsal area of each half of the medulla oblongata also consists

STRUCTURE OF MEDULLA OBLONGATA 501

of intermingled grey and white matter. The upward prolongation of the

separated head of the posterior grey column forms the nucleus of the spina*
tract of the trigeminal nerve, which lies partly in the dorsal and partly in the
lateral area. Medial to it lie the upward prolongations of the nucleus
gracilis and the nucleus cuneatus, and at a higher level the nuclei of the
vestibular portion of the acoustic nerve. Medial to the nucleus gracilis,
on the margin of the grey matter of the floor of the fourth ventricle, is the
fasciculus solitarius, a strand of nerve fibres and nerve cells ; the fibres
being fibres of the glosso-pharyngeal and the vagus nerves passing to the
cells of the strand which forms one of their nuclei.

The white fibres of the posterior area are longitudinal and oblique. The
most important longitudinal fibres are (i) the fibres of the spinal root
of the trigeminal nerve which descend, close to the surface, and superficial

Anterior medullary velum

,. . . Grey matter on floor

Ventricle iv. v of ventr i c le iv.

Mesencephahc root of ^sr^^^rsfe^^^a^ Brachium

trigeminal nerve ^T^g^ ~~ t&L^*'' conjunctivum

Medial longitudinal V^Sgl ' ^ s ^^\

bundle "jHp?l ^P*^*-' Lateral lemniscus

Formatio reticularis -

Nucleus of 'M conjunctivum

lateral lemniscus ^ Mi Medial lemniscus

Pyramidal bundles (cerebro-spinal

fasciculi)

FIG. 203. Transverse section through the upper part of the Pons
- of the Orang.

to the nucleus, which is formed by the upward prolongation of the head of

the posterior column of grey matter ; and (2) the fibres of the fasciculus
solitarius (see above). The oblique fibres consist of fibres of the restiform
body, fibres passing from the nucleus gracilis and nucleus cuneatus, and of
fibres passing to the olivary nucleus of the opposite side.

Internal Structure of the Pons. When transverse sections are made

through the pons, it is seen to consist of two well-defined parts, viz., a
ventral and a dorsal. Broadly speaking, the ventral part, pars basalts,
corresponds to the pyramidal parts of the medulla oblongata, and the basal
parts of the pedunculi cerebri ; whilst the dorsal part corresponds to the
formatio reticularis of the medulla oblongata and the tegmental parts of the
pedunculi cerebri.

The basilar part of the pons is 'the larger of the two subdivisions. It
is composed of a large number of transverse bundles of fibres, through
the midst of which coarse longitudinal bundles of fibres proceed down-

5 02 THE BRAIN

wards from the bases of the pedunculi cerebri ; some of the longitudinal
fibres are cerebro-spinal fibres, passing to the medulla oblongata where
they form the bundles of the pyramids. Others are C( rebro-pontine fibres ;
they terminate round the cells of the nuclei pont is, which are the small
masses of grey matter which occupy the interstices between the transverse
and longitudinal bundles of fibres. Of the transverse fibres two distinct
sets may be recognised, viz., the superficial transverse fibres, through
the midst of which the bundles of cerebro-spinal fibres are prolonged,
and a deeper set termed the corpus trapezoidum. The superficial transverse
fibres traverse the entire thickness of the ventral part of the pons, and
on each side, pass into the corresponding brachium pontis. The trapezial
fibres lie posterior to the cerebro-spinal bundles in the boundary area
between the dorsal and ventral parts of the pons, but encroach con-
siderably into the ground of the former. They are seen only in the lower
part of the pons, and they pass into the lateral lemniscus. They take origin
in the terminal nucleus of the cochlear division of the acoustic nerve.

The dorsal or tegmental part of the pons is, for the most part, formed
of a prolongation upwards of the formatio reticularis of the medulla.
Superiorly, it is carried into the tegmental parts of the pedunculi cerebri.
It is divided into two halves by a median raphe, which is continuous,
below, with the raphe of the medulla oblongata, and, above, with the raphe
of the tegmental part of the mesencephalon, whilst over its dorsal surface is
spread a thick layer of grey matter which belongs to the upper part of the
floor of the fourth ventricle. In transverse sections through the upper
part of the pons 'a dark spot in the lateral part of the floor indicates the
position of a small mass of pigmented cells called the substantia ferruginca.
It underlies the locus cceruleus.

Four strands of longitudinal fibres are seen on each side in transverse

sections through the dorsal part of the pons. These are (i) the medial
lemniscus, (2) the lateral lemniscus, (3) the medial longitudinal bundle, and
(4) the brachium conjunctivum.

The medial lemniscus assumes, in the pons, a ribbon-shaped form. It is

placed between the ventral part of the pons and the formatio reticularis
of the dorsal part.

The lateral lemniscus, largely composed of fibres derived directly or in-

directly from the corpus trapezoidum, is seen in the upper part of the pons.
It sweeps round the lateral side of trie brachium conjunctivum to gain the
surface.

The medial longitudinal bundle is much more distinct than it is in

the medulla oblongata. It has separated itself more completely from
the longitudinal fibres of the formatio reticularis, and it is now seen,
close to the median plane, immediately subjacent to the grey matter of
the floor of the fourth ventricle.

The brachium conjunctivum, in transverse sections, presents a semi-

lunar outline. It occupies a lateral position in the dorsal part of the
pons, and gradually sinks deeply into its substance, although it does not
become completely submerged until it reaches the mesencephalon.

The superior olive is a small isolated clump of grey matter which is

embedded in the dorsal part of the pons in the path of the fibres of the
corpus trapezoidum.

CRANIAL TOPOGRAPHY

After the gyri and sulci of the hemispheres and the various parts of the
mid-brain and the hind-brain have been carefully studied the dissectors

CRANIAL TOPOGRAPHY
53

should obtain a skull which has been divided in the median sagittal plane,
and should study the relationships of the various gyri and sulci of the

FIG. 204. Diagram of Left Lateral Aspect of the Skull, showing the relations
of the Cerebral Sulci and the Branches of the Middle Meningeal Artery to
the Bones of the Cranium.

BLACK.

1. Bregma.

2. Line of lateral fissure and lateral

part of parieto-occipital fissure.

3. Artificial line of separation between

occipital lobe behind and the

parietal and temporal lobes in front.

4. Lambda.

5. Base line.

6. Horizontal, 30 mm. long, parallel with

base line.

7. Lower end of vertical line.

8. Vertical line 10 mm. long.

9. Sylvian point in region of the pterion.

10. Spheno-frontal suture.

11. Squamo-parietal suture.

12. Above aster ion, where the parietal,

the occipital and the mastoid portion

of the temporal bone meet.

13. Artificial line of separation between

the posterior parts of the parietal

and temporal lobes.
BLUE.

1. Central sulcus.

2. Post central sulcus.

3. Posterior part of posterior branch of

lateral fissure.

4. Superior temporal sulcus.

5. Middle temporal sulcus.

6. Posterior end of calcarine fissure.

7. Anterior horizontal branch of lateral

fissure.

8. Ascending branch of lateral fissure.

9. Precentral sulcus.

10. Inferior frontal sulcus.

11. Superior frontal sulcus.

RED.

1. Stem of middle meningeal artery.

2. Anterior branch of middle meningeal

artery.

3. Posterior branch of middle meningeal

artery.

supero-lateral surface of each hemisphere to the bones of the cranial vault,

and to the grooves for the main branches of the middle meningeal arteries,
HI 32,&

504 THE BRAIN

which are situated on the inner surface of the skull wall. They should
note especially, in relation to the bones and the arterial grooves, the
situations of the posterior horizontal limb of the lateral fissure, the central
sulcus and the occipital pole of each hemisphere, because : (i) in the lower
lip of the posterior horizontal limb of the lateral fissure lies the acoustic
area ;
(2) the anterior central gyrus, which lies in front of the central sulcus, is the
general motor area of the brain; (3) the posterior central gyrus, which
lies behind the central sulcus, is the general sensory area ; and (4) the
occipital pole is in the region of the visual area (Figs. 153, 204).

The anterior branch of the middle meningeal artery lies, as a rule, over
the region of the anterior central gyrus (Fig. 204), and the posterior branch,
which is, however, more irregular in position, frequently runs along the
ine of the first temporal gyrus, which is immediately below the posterior
horizontal limb of the lateral fissure, and consequently it crosses or lies
close to the acoustic area (Fig. 204).

The general positions of the sulci and gyri are shown, in Figs. 135, 152,
and in Fig. 38, which is a reproduction of a radiograph of a head in which
metallic rods and pieces of metallic paste had been introduced, other
important areas have also been made visible.

The exact positions of the various cerebral sulci vary, to a certain extent,
in heads of different shapes and sizes, but a sufficiently accurate estimation,
for practical purposes, can be made on any head or skull by the use of a
few easily remembered points and lines (Fig. 204). They are :

(1) A base line extending from the lower margin of the orbit to the
upper border of the external acoustic meatus (5-5, black, Fig. 204).

(2) A line, 30 mm. long, extending backwards from the lower end of
the zygomatic process of the frontal bone, parallel with the base line
(6, black, Fig. 204).

(3) A line, 10 mm. long, projected upwards at right angles to (2) from its
posterior end (8, black, Fig. 204). The upper end of (3) marks the " Sylvian
point," which lies at or near the pterion, and it marks the position where
the lateral end of the stem of the lateral fissure divides into its three
terminal branches (9, black, Fig. 204).

(4) A line projected from the lower end of the zygomatic process of the
frontal bone, through the " Sylvian point : ," to the median plane (2-2, black,
Fig. 204). This line usually strikes the median plane a short distance in
front of the lambda ; the first 75 mm. '(three inches) of it, behind the
" Sylvian point," mark the position of the straight part of the posterior
horizontal limb of the lateral fissure, and the last 18 mm. (about three-
quarters of an inch) indicate the position of the upper and lateral part of
the parieto-occipital fissure.

(5) A line marking the general position of the central sulcus. It com-
mences 25 mm. (one inch) behind the " Sylvian point," immediately above
the lateral fissure, and extends upwards and backwards to a point in the
median plane situated 12.5 mm. (half an inch) behind the central point on
a line extending from the root of the nose (nasion) to the external occipital
protuberance (inion) (i, blue, Fig. 204).

The occipital pole of the hemisphere lies immediately above and lateral
to the external occipital protuberance.

THE AUDITORY APPARATUS

505

THE AUDITORY APPARATUS.

THE organ of hearing admits of a very natural subdivision

into three parts, viz., the external, the middle, and the
internal ear.

Auricle

Epitympanic recess

Aditus of tympanic antrum

Lateral semi-circular canal '

Superior semi-circular canal

Vestibule .'

Internal acoustic

meatus

. Concha

External acoustic meatus

Mastoid process

Styloid process
Auditory tube Canal for facial nerve (cut above)

FIG. 205. The parts of the Ear (semi-diagrammatic). The purple colour
indicates the mucous lining of the tympanic cavity, which is continuous,
through the auditory tube, with the mucous lining of the pharynx, and,
through the aditus, with the mucous lining of the tympanic antrum.

The external ear consists of the auricle and the ex-

ternal acoustic meatus. The auricle collects the waves
of sound, and is, comparatively speaking, of subsidiary im-
portance in man, although it is of considerable service in

506 THE AUDITORY APPARATUS

some of the lower animals. The external acoustic meatus

is a passage leading inwards, from the bottom of the concha
of the auricle, to the membrana tympani, which separates
the external ear from the middle ear. The middle ear is
a narrow chamber termed the tympanic cavity. It is inter-
posed between the external acoustic passage and the internal
ear or labyrinth, and the main part of its lateral wall is formed
by the membrana tympani. Stretching across the cavity of
the tympanum, from its lateral to its medial wall, there is a
chain of three small bones, called the auditory ossicles. The
internal ear, or labyrinth, is the most essential part of the organ.
It consists of a complicated system of cavities situated in the
densest part of the petrous portion of the temporal bone. The
cavities contain fluid called perilymph, and also a membranous
counterpart of the bony chambers, called the membranous
labyrinth. Within the latter there is fluid termed endolymph.

EXTERNAL EAR.

Dissection. The dissection of the ear should be conducted

differently on opposite sides.

On one side remove the lateral pterygoid lamina and the

remains of the external and internal pterygoid muscles, if that
has not been done already. Then clear away the tensor veli
palatini muscle and expose the lateral surface of the auditory
tube. Dissect on the postero-medial aspect of the tube and
expose the levator veli palatini muscle, from the lateral side.
Follow the muscle downwards and medially, below the lower
orifice of the tube, into the soft palate. Then detach the auditory
tube from the posterior border of the medial pterygoid lamina ;
cut the levator veli palatini at the point where it enters the soft
palate, and separate the cartilaginous part of the auditory tube
from any parts of the wall of the pharynx which may still be
connected with it. When that has been done turn to the temporal
bone ; place the saw at right angles to the external surface of
the squamous part and saw through the bone, along the line of
the petro-tympanic fissure, to the posterior border of the spine
of the sphenoid. Turn next to the medial surface and saw
through the body of the sphenoid at the level of the anterior
boundary of the foramen lacerum ; then, with the aid of the
chisel and bone forceps, detach the posterior border of the great
wing of the sphenoid from the anterior border of the petrous part
of the temporal bone. When the dissection is properly done
the greater part of the temporal bone is removed from the
remainder of the skull, with the cartilaginous part of the auditory
tube attached to the anterior margin of its petrous portion, and
a small part of the body of the sphenoid bone attached to its
apex. The anterior wall of the mandibular fossa was separated
by the first saw-cut, but the posterior wall is still present, with the
cartilaginous part of the auditory tube attached to its medial

EXTERNAL EAR

507
end and the cartilaginous part of the external acoustic meatus
to its lateral border. The dissector should now cut away the
tragus of the auricle, to expose the orifice of the external meatus
which lies at the bottom of the concha ; then, with knife or
scissors, he must remove the anterior wall of the cartilaginous
part of the external meatus. Next pass a probe into the bony
part of the meatus to gauge its length, and, whilst the probe is
kept in position as a guide, cut away the anterior wall of the
bony part of the meatus, taking care not to injure the tympanic
membrane which closes the medial end of the meatus. When
the dissection is completed the boundaries of the meatus
and the lateral surface of the tympanic membrane should be
examined.

Tympanic antrum Canalis facialis

Apertura tympanica
canaliculi chordae

=- Cochlea

Canal for tympanic nerve

FIG. 206. Frontal section of the Right Temporal Bone passing through the
external and the internal acoustic meatuses.

Meatus Acusticus Externus. The external acoustic meatus

runs forwards and medially, from its lateral orifice to its
medial boundary, and, during its course, it forms a slight curve
with the convexity upwards. Its total length, measured from
the bottom of the concha to the tympanic membrane, is about
24 mm., of which 8 mm. corresponds with the cartilaginous
part, and 16 mm. with the bony part of the canal : but, as the
membrana tympani is placed obliquely, the anterior wall and

508

THE AUDITORY APPARATUS

the floor are longer than the posterior wall and the roof,
respectively. Moreover, the diameter of the canal is not
uniform. It is narrowest at the isthmus, which lies about
5 mm. from the tympanic membrane ; and its vertical diameter
is greatest at the lateral end, whilst its antero-posterior
diameter is greatest at its medial end. These facts must
be borne in mind during the removal of foreign bodies which
have made their way into the canal. As the tube passes from
the surface, medially, it describes a gentle sigmoid curve, but
its general direction is towards the median plane with a

Osseous part of meatus

Recessus

epitympanicus

Malleu

Cochlea

Tympanum

Membrana

tympani

Internal carotid
artery

.Crus antihelicis
inferior

Cyraba conchae
rus helicis

Cartilaginous
part of meatus
'Cavum concha;

Lower boundary
of incisura
intertragica

FIG. 207. Vertical transverse section through the Right Ear : anterior half
of section viewed from behind. (Howden.)

slight inclination forwards. The skin lining the cartilaginous

portion is abundantly furnished with ceruminous glands and
is provided also with laterally directed hairs, which tend to
prevent the entrance of dust. The cutaneous lining of the
osseous part, which is thin and tightly adherent to the
subjacent periosteum, is destitute of hairs, and glands are for
the most part absent. The cutaneous lining of the meatus is
continued, in the form of an exceedingly delicate layer, over
the lateral surface of the membrana tympani.

When the direction, the length, and the diameters of the

external meatus have been noted, the dissectors should
examine the lateral surface of the tympanic membrane,

TYMPANIC MEMBRANE 509

Membrana Tympani. The slope of the tympanic mem-

brane has already been referred to. It slopes very obliquely
downwards, forwards and medially, and its lateral surface is
deeply concave. The deepest point of the concavity is the
umbo, 1 which corresponds with the lower end of a bar of bone,
the handle of the malleus, which is embedded in the membrane
and can be seen through the thin layer of tissue covering
it. The handle of the malleus extends upwards, and
slightly backwards, from the umbo towards the roof of the
meatus ; and a short distance from the upper margin of
the membrane it becomes continuous with a small laterally
directed process, the lateral process of the malleus, which bulges
the membrane towards the meatus. Above the lateral process
of the malleus there is a portion of the membrane which is
less tense than the remainder. It is the membrana flaccida
(ShrapnelPs membrane). It is bounded anteriorly and
posteriorly by relatively thickened borders, called the anterior
and posterior malleolar folds. The whole of the peripheral
margin of the membrane, except that which corresponds with
the membrana flaccida, is lodged in a ring-like sulcus of bone,
the sulcus tympanicus, which is formed by the tympanic
element of the temporal bone.

Dissection. After the examination of the external meatus

is completed the dissector must secure the tensor tympani
muscle, which springs from the petrous part of the temporal
bone, close to the apex and above the level of the cartilaginous
part of the auditory tube. Having secured it, he must trace
it laterally, above the auditory tube, to the point where
it passes into the bony canal through which it enters the
tympanum. Then he must cut away the antero-lateral wall of
the cartilaginous part of the auditory tube, from the pharyngeal
orifice to the upper -extremity, and pass a probe through the
bony part of the tube into the tympanum. He should next turn
to the anterior surface of the petrous part of the temporal bone
and, with chisel and bone forceps, carefully remove the tegmen
tympani and expose the tympanic cavity from above. The
dissection must be carried forwards into the auditory tube and
backwards into the tympanic antrum. As the dissection is
carried forwards a narrow margin of bone must be left along
the anterior border of the tympanic membrane, and care must
be taken to avoid injury to the tendon of the tensor tympani,
which emerges from the extremity of its bony canal, near the
medial wall of the tympanum, and crosses the cavity to be
inserted into the malleus. The chorda tympani nerve, which

1 The term " umbo" refers to a prominence and would be more properly
used in association with the convexity on the inner side of the membrana
tympani than with the concavity on its outer aspect.

5io THE AUDITORY APPARATUS

passes forwards, close to the tympanic membrane and above

the tendon of the tensor tympani, must also be preserved, if
possible.

MIDDLE EAR, TYMPANIC ANTRUM, AND AUDITORY TUBE

Cavum Tympani or Middle Ear. The tympanic cavity

is a small chamber, containing air, which is placed between
the bottom of the meatus externus and the internal ear or
labyrinth (Fig. 209). Posteriorly, it communicates, by a
relatively large orifice, called the aditus, with the tympanic
antrum and the mastoid air-cells ; whilst, anteriorly, the
auditory tube opens into it and puts it into connection with
the cavity of the pharynx. It contains the chain of auditory
ossicles, which crosses from its lateral to its medial wall ; and
it is lined with delicate mucous membrane.

The vertical depth and the antero-posterior length of the

tympanic cavity are each about 12.5 mm. (half an inch]. Its
width, from side to side, is about
4.5 mm. (a sixth of an inch); and,
as both its lateral and medial walls
bulge into the cavity, its width in
the centre is still further reduced.
The tympanic cavity consists of
(i) an upper part, which extends
upwards beyond the level of the
membrana tympani, and to which
FIG. 208. Schematic vertical the term recessus epitympanicus is

the tympanum proper, which lies im-

. mediate 'y to the medial side of the

is in the recessus epi- membrana tympani. The tympanic

tympanicus). cavity presents for examination a

3. Promontory on medial wall. r j n -i r n

4 . Membrana tympani. TOOf and a floor, and four Walls, VIZ.,

anterior, posterior, lateral, and medial.

The roof is composed of a thin plate of bone, termed the
tegmen tympani, which separates the cavity from the middle
fossa of the cranium. In chronic inflammatory conditions
of the middle ear, an extension of the inflammatory process,
through the tegmen, to the meninges of the brain is always to
be feared.

The floor or jugular wall is narrow, and it also is formed

by a thin osseous lamina, which is interposed between the

TYMPANIC CAVITY

5 11

tympanum and the jugular fossa. It separates the tympanum

from the bulb of the internal jugular vein, and an exten-
sion of an inflammatory condition of the middle ear, through
the bone to the vein, may lead to thrombosis (clotting).

Ampulla of lateral semi-circular canal

Ampulla of superior semi-circular canal

Utricle
Saccule

Facial nerve

Aditus to tympanic antrum

Facial nerve

Acoustic nerve
(upper division)
Acoustic nerve
(lower division)

Cochlea

Auditory tube
External acoustic
mea.tus

Head of malleus

\ Remains of anterior
\ process of malleus'

Handle of malleus

cus (long crus of)

! I

Air cell I

Membrana tympani

Styloid process Facial nerve

FIG. 209. The Tympanic Cavity and adjacent parts (semi-diagrammatic).

The posterior or mastoid wall presents, in its upper part,

the opening or aditus which leads from the recessus epi-
tympanicus into the tympanic antrum, and below that, close
to the medial wall, is a small hollow conical projection termed
the pyramid (Fig. 213). The pyramid is perforated on its
summit, and the aperture leads into a canal which curves
backwards and then downwards until it opens into the lower

THE AUDITORY APPARATUS

part of the last stage of the canalis facialis. The curved

canal of the pyramid lodges the stapedius muscle, the delicate
tendon of which enters the tympanic cavity through the
aperture on the summit of the pyramid. Lateral to the
pyramid is the aperture on the posterior wall called the
apertura tympanica canaliculi chorda through which the chorda
tympani nerve enters the tympanum.

The anterior wall is narrow, because the medial and lateral

walls converge anteriorly. The upper part of the anterior wall
Recessus epitympanicus

Membrana
flaccida

Anterior and pos-

terior malleolar
folds

'endon of tensor
tympani (cut)
Handle of
malleus

Membrana
tympani

Tympanic sulcus

FIG. 210. Left Membrana Tympani and Recessus Epitympanicus viewed

from within. The neck and head of the malleus have been removed to
show the membrana flaccida. (Howden. )

is occupied by the opening of the tensor tympani canal ; the

intermediate part by the tympanic orifice of the auditory tube ;
and the lowest part is a lamina of bone which separates the
tympanic cavity from the carotid canal. The tympanic end
of the septum between the auditory tube and the tensor
tympani canal is called the processus cochkariformis ; it serves
as a pulley round which the tendon of the tensor tympani
muscle turns abruptly, in a lateral direction, towards the
malleus.

On the medial wall, which intervenes between the

tympanum and the labyrinth, there are eminences, depressions,

MEMBRANA TYMPANI

5*3

and apertures which require notice. The anterior, and

larger, part of the wall bulges laterally, into the cavity (Figs.
209, 213), and forms a very evident elevation, termed the
promontory. Above the posterior part of the promontory
there is a depression called the fossa of the fenestra vestibuli ;
and at the bottom of the fossa is an oval aperture called the
fenestra vestibuli (Fig. 213). The long axis of the fenestra
is directed antero -posteriorly, and, in the macerated bone,
the aperture opens into the vestibular part of the labyrinth,

Recessus
epitympanicus -

Body of incus

Short crus ;

of incus ~ ~

Ligament j .'':

" "

w --

att* **>*

' " a x' E '

f^p^TX. Superior ligament of malleus

^^ - Head of malleus

Anterior ligament
of malleus

Handle of malleus
Tensor tympani

Foot of stapes

Septum tubae
auditiva;
Osseous part c
the auditory
tube
FIG. 211. Left Membrana Tympani and Chain of Tympanic Ossicles
seen from the medial aspect. (Howden. )

but, in the recent state, it is closed by the footpiece of the

stapes (Fig. 209), the most medial of the auditory ossicles,
which is implanted in the fenestra. The pyramid, on the
posterior wall, is immediately posterior to the fenestra vesti-
buli. Above the fenestra vestibuli, in the angle formed by
the meeting of the roof and medial wall of the tympanum,
and therefore in the recessus epitympanicus, is an antero-
posterior ridge. It is produced by the canalis facialis
bulging into the tympanum (Fig. 213). The wall of the
canal is very thin, and allows the white facial nerve, which
is contained within the canal, to be readily seen. Below
and behind the promontory is the fossula fenestrae cochleae,
VOL. in 33

5M

THE AUDITORY APPARATUS

and at the bottom of the fossa there is an aperture called

the fenestra cochlea', in the macerated bone the aperture
leads into the cavity of the cochlea, but, in the recent state,
it is closed by a membrane called the secondary membrane of
the tympanum.

The lateral wall of the tympanic cavity is formed, for the

most part, by the membrana tympani, but, above the tympanip
membrane, the lateral wall of the recessus epitympanicus is
formed by a portion of the squamous part of the temporal
bone (Figs. 209, 210).

Membrana Tympani. The membrana tympani is an

elliptical disc of membrane which is stretched across the

Membrana flaccida

Anterior

malleolar fold

Handle of malleus

Antero-superior
quadrant
Antero-inferior quadrant

Posterior
malleolar fold
Lateral process
of malleus
Long crus of incus

Postero-superior
quadrant

Postero-inferior
quadrant

i - Cone of light

FIG. 212. Left Tympanic Membrane as viewed from the external meatus
during an otoscopic examination. The dotted lines indicate the manner
in which the tympanic membrane is subdivided arbitrarily into four areas
or quadrants. (Howden.)

medial end of the meatus acusticus externus, and it forms the

greater part of the lateral wall of the tympanum. It is placed
very obliquely ; its lower and its anterior borders both inclining
medially.

The mode of attachment of the membrane deserves some

attention. At the medial end of the meatus a ring-like ridge
of bone, very distinctly grooved, forms a frame in which the
membrane is set (Fig. 210). But the ridge is deficient above,
where its extremities are separated by a deep notch called the
incisura tympanica. The notch is occupied by a portion of
the membrane which is not so dense in its texture (seeing
that the fibrous layer is absent), and not so tightly stretched
as the remainder ; consequently it receives the name of the

MEMBRANA TYMPANI 515

membrana flaccida (ShrapnelPs membrane). The circular

groove in the bony ridge is called the sulcus tympanicus. The
edge of that part of the membrane which is fixed in the sulcus
tympanicus is thickened, and at the incisura tympanica, the
thickened part, it is carried down, anterior and posterior to
the membrana flaccida, in the form of two bands, called
respectively the anterior 2X\& posterior malleolar folds.

The membrana tympani is composed of three layers viz.,

a lateral cuticular layer, an intermediate fibrous lamina, and

Tympanic antrum
Recessus epitympanicus

Canalis facialis

Tegmen tympani

Fenestra vestibuli

Canal for
Lensor tympani

Septum tubae
auditivae

Promontory

Auditory tube

Foramen for
ympanic nerve

Fenestra cochleae

Course of canalis facialis

FIG. 213. Vertical section through the Left Ear : postero-medial half
of section viewed from the front. (Howden. )

a medial mucous layer. The handle of the malleus is in-

timately connected with the fibrous layer, and is covered
medially by the mucous layer. It draws the membrane
towards the tympanic cavity, and is the cause of the concavity
on the lateral surface. The deepest point of that concavity
corresponds with the flattened extremity of the handle of
the malleus, and is termed the umbo.

When the living ear is examined, with a speculum, the surface of the
membrane appears highly polished, and a cone of light extends downwards
and forwards from the tip of the handle of the malleus. A pair of striae
(Prussak's striae), which correspond to the anterior and posterior malleolar
folds, extend from the processus lateralis of the malleus to the margins
ill 33 a

THE AUDITORY APPARATUS

of the incisura tympanica, and thus map out the membrana flaccida. The
long crus of the incus can be faintly seen through the membrana tympani,
parallel with and posterior to the handle of the malleus.

Antrum Tympanicum. The tympanic antrum is a recess

or air-chamber, in the temporal bone. It lies immediately
behind the epitympanic portion of the tympanic cavity and,
in the adult, it is 14 mm. (about half an inch] from the
surface of the skull, medial to the suprameatal triangle. In
the child it is much more superficial.

The cavity of the tympanic antrum is lined with mucous

membrane which is continuous,
anteriorly, through a relatively
wide aperture called the adittts,
with the mucous membrane of
the tympanic cavity, and it is
6 also continuous, posteriorly and
below, with the mucous mem-
brane of the air-cells in the
mastoid portion of the temporal
bone.

The roof of the tympanic

antrum is formed by a thin plate
of the petrous part of the tem-
poral bone, called the tegmen
FIG. 214. Left Malleus and Incus. *

(After Heimhoitz. ) tympani. It separates the tym-

1. Tendon of tensor tympani. panic antrum from the cavity of

2. Handle of the malleus. tVp mirlr11<a -Friccn r\f tVip> clrnll

3. Long crus of the incus. tnG Diddle lOSSa Ol the SkUll

4 . Short crus of the incus. and from the membranes cover-

s' Incus. . . .

6. Anterior process of the malleus. The ing the inferior Surface OI the

ne The "two" ^ th" temporal lobe of the brain. The

of the lateral wall is formed by that

portion of the squamous part

of the temporal bone which lies immediately above and
behind the aperture of the external acoustic meatus. The
posterior wall and \ktfloor are formed by the mastoid portion
of the temporal bone, and it is through apertures in those
boundaries that the cavity of the tympanic antrum communi-
cates with the mastoid air-cells. On the medial wall^ which
is formed by the petrous part of the temporal bone, is a
horizontal bulging, caused by the lateral semicircular canal
of the internal ear ; the bulging extends forwards into the
aditus (Fig. 205). Immediately anterior to the medial margin

TYMPANIC MUCOUS MEMBRANE 517

of the aditus the canalis facialis descends along the posterior

border of the medial wall of the tympanum.

The antero-posterior diameter of the tympanic antrum is

about 14 mm., the vertical diameter, about 9 mm., and the
transverse diameter, about 7 mm.

Tympanic Mucous Membrane. The tympanum is lined,

throughout, with a thin mucous membrane which is continuous
with the mucous membrane of the pharynx, through the
auditory tube. As already mentioned, it forms the medial
layer of the membrana tympani, and it is prolonged posteriorly
into the tympanic antrum and mastoid air-cells. It covers
the ossicles also, and it invests the tendons of the stapedius
and tensor tympani muscles.

Facet for Head

incus | Processus
anterior

Manubrium Manubrium

A B

FIG. 215. The Left Malleus. (Howden. )

A. Posterior aspect. B. Medial aspect.

Ossicula Auditus. The auditory ossicles are the malleus, the incus,
and the stapes.

The malleus presents a head, a neck, a manubrium, and two processes

termed the processus lateralis and the processus anterior. The head is
large and rounded. It is directed upwards, and lies above the level of the
membrana tympani, in the recessus epitympanicus, close to the roof and
the lateral wall of the tympanum (Figs. 209, 211). On its posterior aspect
there is a notch-like articular surface, for articulation with the body of the
incus. The manubrium is attached to the fibrous layer of the membrana
tympani. The processus lateralis (O.T. brevis} is a stunted projection
which springs from the root of the manubrium. It is directed laterally, and
abuts against the membrana tympani immediately below the membrana
flaccida. The processus anterior (O.T. gracilis} is a slender spicule of bone
which passes forwards and downwards into the petro-tym panic fissure.
It almost invariably breaks when the malleus is detached from the adult
skull, but it can be easily preserved in the skull of an infant.

The incus is shaped somewhat like a prsemolar tooth in which the roots
are very divergent, It presents a body and a long and a short crus, The
ill 33 6

THE AUDITORY APPARATUS

body is provided with an articular surface, which looks forwards and

articulates with the head of the malleus. The short cms is directed
backwards, and its extremity is attached, by ligaments, to the posterior
wall of the tympanum, below the opening into the tympanic antrum. The
long crus proceeds downwards and medially, in a direction nearly parallel

Articular surface for

head of malleus

Crus breve

Body

Crus_
longum

Processus
lenticularis

FIG. 216. The Left Incus. (Howden. )

A. Anterior aspect. B. Medial aspect.

to that of the manubrium of the malleus, but more medial, and on a plane
posterior to the manubrium. On its inferior extremity, which is bent
medially, there is a small knob of bone, called the processus lenticularis,
which articulates with the head of the stapes.

The malleus and incus move together on an axis which is formed by

the processus anterior of the malleus 'and the crus breve of the incus.
The articular surfaces of the two bones are provided with peculiar catch-
teeth which interlock when the bones are performing their ordinary
movements. When, however, force is applied to the medial surface of
the membrana tympani, as, for instance, when
the tympanum is inflated through the auditory
tube, the incudo-malleolar joint gapes and the
malleus moves by itself. Traction upon the
-Cms posterior attachments of the stapes, through the incus, is
thus avoided.

The stapes is shaped like a stirrup, and

presents a head or lateral extremity separated
by a slightly constricted neck from two crura

FIG. 217. Left Stapes, which join a medial plate called the basis
(Howden.) stapedis. The head is excavated by an articular

cup for the processus lenticularis of the incus.

The crura are grooved longitudinally on their concave sides (sulcus

stapedis). The posterior crus is more sharply curved than the anterior
crus. The base fits into the fenestra vestibuli and corresponds in its
outline with that aperture. Its lower border is straight, whilst its upper
border is curved.

Ligaments of the Auditory Ossicles. In addition to the delicate

articular capsules, which surround the joints between the auditory ossicles,
there are certain bands which connect the bones to the walls of the tym-
panum and serve to restrain their movements.

In connection with the malleus there are (i) an anterior ligament >

Head

Neck
rus anterior

Foot-plate

TYMPANIC MUSCLES

which passes forwards, from the root of the processus anterior, to the
anterior wall of the tympanum in the neighbourhood of the petro-
tympanic fissure ; (2) a lateral ligament, which extends from its lateral
process to the margin of the incisura tympanica ; and (3) a superior
ligament, which connects the head with the roof of the tympanum.

The ligament of the incus binds the extremity of its short crus to the
posterior wall of the tympanum, whilst the annular ligament of the stapes
connects the margin of its base to the circumference of the fenestra vestibuli.
Tympanic Muscles. Two muscles are associated with
the tympanum, viz., the stapedius and the tensor tympani.

Membrana tympani

Epitympanic recess \

Malleus ' .'

Cochlea
Internal meatus

Internal carotid
Osseous part of auditory tu
Base of spine of sphenoid

Cartilaginous part of
auditory tube
Otic ganglion

Nerve to internal pterygoid

Levator veli palatini

Pharyngeal recess

Cartilage of auditory tube

Middle concha -
Anterior lip of auditory tu

Tensor veli palatini

inferior concha

Hamulus

Palate

External meatus
Tympanic plate

Condyle of mandible
Middle meningeal artery

Mandibular nerve
External pterygoid
-- Cavity of auditory tube

Internal maxillary artery

Internal pterygoid
.Ramus of mandible

Masseter

FIG. 2 1 8. Oblique section of a part of the Head showing the relations

of the Auditory Tube.

The stapedius occupies the interior of the pyramid and the

canal which curves downwards from it. The delicate tendon
of the stapedius enters the tympanum, through the aperture
on the summit of the pyramid, and is inserted into the
posterior aspect of the neck of the stapes. The stapedius
muscle is supplied by a branch from the facial nerve.

The tensor tympani arises from the upper part of the cartilage
of the auditory tube and from the contiguous parts of the
great wing of the sphenoid and the petrous part of the temporal
in 33 c

520 THE AUDITORY APPARATUS

bone. From its origin it passes backwards and laterally, above

the osseous part of the auditory tube. In the tympanic cavity
the tendon turns at right angles, round the extremity of the
processus cochleariformis (p. 512), and passes laterally, towards
the lateral wall of the tympanum, to its insertion into the upper
part of the medial surface of the manubrium of the malleus.
The tensor tympani receives its nerve of supply through the
otic ganglion from the mandibular division of the trigeminal
nerve. The name of the muscle indicates its action.

Chorda Tympani Nerve. The chorda tympani, which

traverses the tympanic cavity in close relation to the upper
part of the membrana tympani, is described on p. 182.

External meatus

Tympanic antrum

Temporal line

Mastoid notch (O,T.

Digastric fossa)

Styloid Air-cells in mastoid part

process of temporal bone

FIG. 219. Dissection of the Tympanic Antrum and the mastoid part of
the temporal bone from the outer side.

Tympanic Plexus. This has been described previously

on p. 220.

Tuba Auditiva (O.T. Eustachian). The auditory tube is

the passage which places the tympanic cavity in communica-
tion with the pharynx. Through it air reaches the tympanic
cavity and antrum and the mastoid cells. It consists of an
osseous and a cartilaginous portion. The osseous portion is
about 12.5 mm. (half an inch] in length. It is widest at its
entrance into the tympanum, and narrowest at its other end.
The cartilaginous portion is about an inch in length, and has
been already described on p. 298.

Dissection : Second Method. On the opposite side the bony

part of the external meatus, the tympanic antrum, and the

TYMPANIC CAVITY 521

tympanic cavity should be approached from the postero-lateral

aspect. The dissection of the bone should be carried out after
the manner adopted by the surgeon when operating for the cure
of extensive mastoid and middle ear disease, but, to facilitate
the dissection, and to gain better access to the bone, the auricle
may be removed by cutting through the cartilaginous part of
the external meatus.

After the auricle has been cut away take all the soft parts,
including the periosteum, from the outer surface of the mastoid
part of the temporal bone, and identify (i) the supra-meatal
triangle and the supra-meatal spine, which lie at the junction
of the superior with the posterior border of the bony part of the
external meatus, and (2) the temporal line, which passes,
backwards and upwards, above the supra-meatal triangle. The

Lateral semicircular canal Posterior semicircular canal

Remains of posterior | Temporal line

wall of external meatus , r

; / / Wall of groove for

sigmoid part of

Tympanic plate
Styloid process Wall of canalis

facialis

FIG. 220. Dissection of the Tympanic Antrum and the petro-mastoid part of
the temporal bone from the outer side. The arrow is passing through
the aditus from the tympanic antrum into the tympanic cavity.

objects of the first stage of the dissection are (i) the removal
of the outer compact layer of bone ; (2) the opening up of the
spongy tissue of the mastoid part of the temporal bone, and
the exposure of the mastoid air-cells and the cavity of the
tympanic antrum, whilst, at the same time, injury to the posterior
wall of the bony part of the external meatus and to the sigmoid
part of the transverse sinus, which lies in a groove on the inner
aspect of the posterior part of the mastoid portion of the temporal
bone, is avoided. The tympanic antrum lies at the level of the
supra-meatal triangle, that is, above and posterior to the external
meatus, and about 14 mm. (a little more than half an inch) from
the superficial surface of the temporal bone. The dissection
should be commenced in the supra-meatal triangle, and should
be carried, forwards and medially, into the bone, parallel with
the posterior wall of the external meatus, until the tympanic
antrum is opened into. After the tympanic antrum has been
identified, the spongy tissue of the anterior part of the mastoid
area must be gradually removed till the more medially situated

522 THE AUDITORY APPARATUS

and more compact bone is exposed. When that stage of the

dissection is completed, the dissector should note the following
points : (i) In the anterior boundary of the exposed area is
the compact posterior wall of the bony part of the external
meatus. (2) Posteriorly is a broad projecting ridge indicating
the position of the groove which lodges the sigmoid part of the
transverse sinus. (3) At the upper and deeper part of the area
are the medial wall of the tympanic antrum and the aditus
leading into ] the tympanic cavity. (4) The intervening area is
occupied by the remains of the mastoid air-cells, which may
extend downwards to the tip of the mastoid process. They are
continuous above with the cavity of the , tympanic antrum.
(5) On the medial wall of the aditus and the anterior part of the
medial wall of the tympanic antrum is a horizontal ridge which

Lateral semicircular canal

Superior semicircular canal I

Fenestra vestibuli | Temporal line

Canalis facialis (posterior ! ^, ^ f > Posterior semicircular canal

horizontal part)

End of canal for

tensor tympani

End of auditory tube

Styloid process

Vertical part of canalis facialis

Remains of posterior wall of external meatus

FIG. 221. Dissection of the Tympanic Cavity and the semicircular

canals from the outer side.

indicates the position of the lateral semicircular canal of the

labyrinth, and, below it, on the medial wall of the mouth of the
aditus, is a vertical ridge indicating the position of the 'canalis
facialis, which lodges the important facial nerve.

The next stage of the dissection consists in the removal of

the posterior wall of the external meatus, and the exposure of
the lateral surface of the tympanic membrane (p. 514). After
the tympanic membrane has been examined, a seeker should
be passed through the aditus into the tympanic cavity, and its
handle should be allowed to rest on the lower part of the exposed
area ; then, whilst the seeker remains in position, the remainder
of the posterior wall and the upper boundary of the external
meatus, from the level of the seeker to the level of the roof of
the tympanic antrum, can be cut away without fear of injury
to any important structure. The dissection should be com-
pleted by the removal of the tympanic membrane and ossicles,
and when this has been done a very complete view wiJJ be
obtained of the medial walls of the tympanic cavity, the aditus

TYMPANIC CAVITY 523

and the tympanic antrum. Anteriorly, on the medial wall of

the tympanic cavity, is the promontory, which marks the position
of the first turn of the cochlea. Above and posterior to the
promontory is the fenestra vestibuli. The fenestra cochleae lies
at the lower and posterior part of the promontory, in the anterior
part of a recess called the fossula fenestrae cochleae. Above
the fenestra vestibuli is a ridge caused by the posterior horizontal
part of the canalis facialis ; this becomes continuous, on the
medial wall of the aditus, with the vertical ridge which indicates
the position of the vertical part of the canal. Above the latter
is the horizontal ridge due to the lateral semicircular canal.
The dissector should open the canalis facialis to expose the
facial nerve ; then he should open the lateral semicircular canal,
and afterwards remove the bone above and posterior to it to
expose the walls of the superior and posterior semicircular
canals (Figs. 219, 220, 221).

INTRAPETROUS PART OF THE FACIAL NERVE AND THE

ACOUSTIC NERVE.

The facial and acoustic nerves have already been traced

into the internal acoustic meatus (p. 112). The dissector
should now open up the meatus and follow the facial nerve
in its course through the petrous portion of the temporal bone.
The canal which it occupies is termed the canalis facialis
(O.T. aqueduct of Fallopius). It begins at the bottom of
the internal acoustic meatus, and opens on the exterior of
the skull at the stylo-mastoid foramen. Between its com-
mencement and termination it pursues a curved course, and
that, combined with the density of the bone, renders the dis-
section difficult.

Dissection. On the side on which the middle ear has been

opened from the lateral aspect and the canalis facialis has already
been partially opened up, the dissector should complete the
dissection of the intrapetrous part of the facial nerve and should
examine the acoustic nerve.

Separate the temporal bone from the other cranial bones

which still adhere to it, and fix it in the natural position (in a
vice if possible). Remove the squamous portion by a horizontal
saw cut at the level of the anterior surface of the petrous portion.
Make a second horizontal saw cut, immediately above the roof
of the internal acoustic meatus, and carry it laterally into the
tympanum, in which it should emerge immediately above the
already opened canalis facialis where the latter lies above the
fenestra vestibuli. Then, with the bone forceps or chisel, remove
the remains of the roof of the internal meatus and follow the
facial nerve along the canalis facialis to the hiatus canalis
facialis, and so expose the ganglion geniculi. Secure the

524 THE AUDITORY APPARATUS

branches which arise from the ganglion and then follow the
nerve backwards above the fenestra vestibuli. The greater part
of the vertical portion of the canal has already been opened from
the lateral aspect ; the remainder can now be displayed by
means of two saw cuts (i) a frontal section (vertical transverse)
carried medially from the lateral surface of the bone to the
posterior border of the stylo-mastoid foramen ; (2) a sagittal
cut (vertical antero-posterior) carried from the posterior surface
of the bone to meet cut (i). The portion of bone between the
two cuts must then be removed, and the dissection must be
completed with bone forceps. Three branches are given off
from the facial nerve in the terminal part of the canal.

Intrapetrous Portion of the Facial Nerve. As the facial

nerve traverses the petrous bone, it may be looked upon as
consisting of four parts, which differ from one another in the
relations they present and in the direction which they take.
They are :

1. A part within the internal acoustic meatus.

2. A very short part which extends from the bottom of the internal
acoustic meatus to the ganglion geniculi.

3. A part which occupies that portion of the canalis facialis which runs

along the medial wall of the tympanic cavity.

4. A part which extends vertically downwards to the stylo-mastoid

foramen.

First Part. In the internal acoustic meatus, the facial

nerve runs almost directly laterally, in company with the
acoustic nerve. In that stage of its course it lies in relation
to the upper and anterior part of the acoustic nerve, and
its motor and sensory roots join. At the bottom of the
internal acoustic meatus it enters the canalis facialis.

Second Part. The second part of the facial nerve is very

short. It runs laterally, with a slight inclination forwards
between the vestibule and cochlea, and very soon ends in
the swelling termed the ganglion geniculi.

Third Part. At the ganglion geniculi, the facial nerve

bends suddenly and proceeds backwards and slightly
downwards, in that portion of the canal which runs along
the upper part of the medial wall of the tympanic cavity,
immediately above the fenestra vestibuli (O.T. ovalis).

The first three portions of the facial nerve are nearly

horizontal, and pursue a somewhat V-shaped course. The
apex of the V is directed forwards, and corresponds to the
ganglion geniculi.

Fourth Part, The fourth part is vertical, and passes down-

INTRAPETROUS PART OF FACIAL NERVE 525

wards, posterior to the pyramid, to gain the stylo-mastoid

foramen.

FIG.

38 37 36 35 34

222. Diagram of Intrapetrous part of facial nerve and its connections.

(Prof. A. M. Paterson.)
Nerve to stapedius.

Chorda tympani.

Tympanic plexus.

Communication to lesser superficial

petrosal nerve.
Ganglion geniculi.
Motor part of facial nerve.
Sensory part of facial nerve.
Acoustic nerve.
External petrosal nerve.
Greater superficial petrosal nerve.
Carotid canal.
Carotico-tympanic branch.
Carotid plexus.
Great deep petrosal.
Nerve of pterygoid canal,
ind 18. Spheno-palatine branches.
Maxillary nerve.
Spheno-palatine ganglion.
External petrosal nerve.
Middle meningeal artery.

22. Otic ganglion.

23 and 24. Branches to auriculo- tem-

poral nerve.

25. Communication to chorda tympani.

26. Posterior division of mandibular

nerve.

27. Anterior division of mandibular

nerve.

28. Lingual nerve.

29. Inferior alveolar nerve.

30. Auricula-temporal nerve.

31. Tympanic branch of glosso-pharyn-

geal.

32. Glosso-pharyngeal nerve.

33. Vagus.

34. Auricular branch of vagus.

35. Communication from facial to auricu-

lar branch of vagus.

36. Nerve to digastric (post, belly).

37. Nerve to stylp-hyoid muscle.

38. Posterior auricular nerve. -

The branches which spring from or join the facial nerve

during its passage through the temporal bone are :

1. The greater superficial petrosal nerve, "|

2. Communicating twig to the lesser superficial I from ganglion

petrosal, | geniculi.

3. External superficial petrosal nerve, J

4. Nerve to stapedius.

5. Chorda tympani.

6. Communicating twigs to the auricular branch of vagus.

The greater superficial petrosal nerve has been examined

526 THE AUDITORY APPARATUS

already (p. 241). Its origin from the ganglion geniculi of

the facial nerve can now be seen.

The communicating branch to the lesser superficial petrosal

arises from the ganglion geniculi, and unites with the fibres
of the tympanic nerve which issue from the tympanic plexus.

The external petrosal nerve is not always present. It

joins the sympathetic plexus which accompanies the middle
meningeal artery.

The nerve to the stapedius muscle arises from the facial as

it passes downwards posterior to the pyramid. It enters the
base of the pyramid and thus reaches the stapedius muscle.

The communicating twigs to the auricular branch of the

vagus arise a short distance above the stylo-mastoid foramen.

Chorda Tympani. The chorda tympani represents to a

large extent the sensory fibres set free from the trunk of
the facial nerve. It is the largest branch given off by the
facial during its passage through the canalis fadalis. It takes
origin a short distance above the stylo-mastoid foramen, and
arching upwards and forwards, in a narrow canal in the
petrous portion of the temporal bone (the canaliculus chordae
tympani), it appears in the tympanum by passing through
the tympanic aperture of the canaliculus chordae, below the
base of the pyramid, and close to the posterior margin of
membrana tympani. The bony tunnel which it occupies can
easily be opened up in a decalcified bone, but is somewhat
difficult to expose in the hard bone. After entering the
tympanum the chorda tympani runs forwards, upon the upper
part of the membrana tympani, under cover of the mucous
layer. It crosses the handle of the malleus on the medial
aspect near its root. Finally, reaching the anterior end of
the tympanic cavity it crosses the anterior process (O.T.
gracilis) of the malleus, passes above the tensor tympani, and
traverses the medial end of the petro-tympanic fissure, which
conducts it to the exterior of the skull. From its exit to
its junction with the lingual nerve the chorda tympani has
already been traced (p. 182).

Nervus Acusticus. In the internal acoustic meatus the

acoustic nerve lies at a lower level than the facial, and at the
bottom of the passage it splits into two parts, termed the
cochlear and vestibular divisions. The two divisions again sub-
divide and supply the different parts of the labyrinth of the
ear through the foramina of the lamina cribrosa (Fig. 209).

INTERNAL EAR 527

INTERNAL EAR.

Dissection. After the examination of the intrapetrous part

of the facial nerve and the acoustic nerve is completed the
dissector should display the labyrinth of the internal ear by
means of two saw cuts (i) an antero-posterior vertical cut,
carried from the upper surface of the bone downwards to the
floor of the tympanum, along the junction of its medial and
posterior boundaries ; (2) a horizontal cut. This cut should be
commenced at the apex of the petrous part of the temporal bone
and should be carried laterally till it joins the vertical cut,
posteriorly, and enters the tympanic cavity, anteriorly, at the
level of the mid-height of the promontory. When the upper
part of the petrous portion of the temporal bone, separated by
the two cuts, is removed, the vestibular and cochlear parts of
the labyrinth and portions of the semicircular canals will be
displayed. The dissector should demonstrate the positions and
curves of the semicircular canals and the canalis facialis by
passing bristles through them.

Auris Interna. The internal ear or labyrinth consists of an

intricate system of cavities in the petrous part of the temporal
bone, called the osseous labyrinth, and a series of hollow
membranous structures, connected with the filaments of the
acoustic nerve, which lie in the osseous labyrinth and constitute
the membranous labyrinth.

The osseous labyrinth is composed of a chamber termed

the vestibule, posterior to which are placed the three
semicircular canals, whilst anteriorly is the cochlea. All the
cavities communicate with one another. The corresponding
membranous parts do not completely occupy the osseous
chambers, and the intervening space is filled with a fluid
termed the perilymph. The membranous labyrinth also contains
a fluid which receives the name of endolymph.

Vestibulum. The vestibule is a small bony chamber of

ovoid form, which possesses an antero-posterior diameter of
about 4 mm. (one-sixth of an incJi). It is situated between the
medial wall of the tympanum and the bottom of the internal
acoustic meatus.

Into the posterior part of the vestibule the three semi-

circular canals open by five round apertures', whilst in its
lower and anterior part is the opening of the scala vestibuli
of the cochlea.

On the lateral wall is the fenestra vestibuli, which is closed,

in the recent state, by the delicate periosteal lining of the
chamber and by the base of the stapes. When those parts
are removed, the vestibule communicates directly with the

528

THE AUDITORY APPARATUS

tympanum. In the anterior part of the medial wall of the

vestibule there is a circular depression, termed the recessus
sphcericus \ it is bounded posteriorly by a vertical ridge,
called the crista vestibuli. In the bottom of the recessus
sphaericus are some minute holes through which pass
filaments from the acoustic nerve. In the roof of the
vestibule is another depression, named the recessus ellipticus.
It is placed posterior to the crista vestibuli.

A small aperture in the posterior part of the medial

wall also deserves mention. It is the mouth of the aquce-
ductus vestibuli a small canal which passes backwards to

Recessus ellipticus
Crista vestibuli
Recessus sphaericus

Lateral semi-
circular canal

Posterior semi-
circular canal
Scala tympani
Lamina spiralis ossea j
Scala vestibuli

Opening of

aquaeductus cochleae I j Opening of crus commune

Fenestra cochleae I
Recessus cochlearis P enin S of aquaeductus vestibuli

FIG. 223. Interior of the Left Bony Labyrinth viewed from

the lateral aspect. (Howden. )

the posterior surface of the petrous part of the temporal bone,

where it opens under the dura mater.

Canales Semicirculares Ossei. There are three bony semi-

circular canals or tubes placed posterior to the vestibule.
They are bent upon themselves, so that each forms consider-
ably more than half a circle, and they occupy planes at right
angles to each other like three faces of a cube. They are
termed superior, posterior, and lateral, and they open into
the posterior part of the vestibule by five round orifices, the
number of openings being reduced to five because the
adjoining extremities of the superior and posterior canals
are fused into a common canal called the crus commune,
which opens by a single orifice. One extremity of each
canal where it joins the vestibule becomes expanded into

LABYRINTH

529

what is termed its ampulla. There are, therefore, three

ampullated ends.

The superior semicircular canal forms the highest part of

the labyrinth. Its highest part lies beneath the eminentia
arcuata on the anterior surface of the petrous part of the
temporal bone. It is placed vertically, and is almost trans-
verse to the long axis of the petrous part of the temporal
bone. The posterior semicircular canal, which is the longest
of the three tubes, is also vertical, and lies in a plane parallel
to the posterior surface of the petrous part of the temporal
bone. The lateral semicircular canal is the shortest of the

Superior semicircular canal

with its ampulla

Canalis
facialis

Cochlea |

Fenestra cochleae

Fenestra vestibtil

Ampulla of posterior semicircular canal

Ampulla of lateral semicircular canal

Posterior semi-
circular canal
Crus commune

Lateral semicircular canal

FIG. 224. Left Bony Labyrinth viewed from lateral side. (Howden. )

tubes. It lies in a horizontal plane, in the angle between

the superior and posterior canals.

Cochlea. The cochlea is a tapering tube which is coiled

spirally, for two turns and a half, around a central pillar, termed
the modiolus. The appearance produced is somewhat similar
to that of a spiral shell. The cochlea lies anterior to the
vestibule ; its base is directed towards the bottom of the in-
ternal acoustic meatus ; its long axis runs antero - laterally
from the base, and its apex lies in close relation with the
canal for the tensor tympani muscle.

The cochlear tube rapidly diminishes in diameter as it

is traced towards the apex of the cochlea. Its closed ex-
tremity is termed the cupola. The first turn which the
cochlea takes around the modiolus produces the bulging on

VOL. in 34

530 THE AUDITORY APPARATUS

the medial wall of the tympanum which has been described

under the name of the promontory (Figs. 223, 209).

The modiolus is thick at the base, but rapidly tapers

towards the apex. Its base abuts against the bottom of the
internal acoustic meatus. It forms the inner wall of the
cochlear tube, and winding spirally round it, like the thread
of a screw, is a thiri lamina of bone, termed the lamina spiralis,
which partially subdivides the osseous tube into two passages.

Numerous minute canals traverse the modiolus, and one more con-
spicuous than the others, called the longitudinal canal of the modiolus,
extends along its centre. The spiral lamina also is tunnelled by small
canals in communication with those in the modiolus, whilst one, the
spiral canal of the modiolus, winds spirally around the central pillar in
the attached margin of the spiral lamina. All these channels convey
filaments from the cochlear division of the acoustic nerve to the membranous
cochlea, whilst the spiral canal lodges the ganglion spirale cochlece, which
is the peripheral ganglion of the cochlear part of the acoustic nerve.

The membranous cochlear tube or ductus cochlearis is placed

between the free margin of the spiral lamina and the
opposite side of the wall of the cochlear tube. It completes
the subdivision of the bony cochlea into two compartments,
which are termed the scala tympani and the scala vestibuli.
The scala tympani is the larger of the two. It begins at the
fenestra cochleae, where the secondary membrane of the
tympanum shuts it off from the tympanic cavity. At the
apex of the cochlea it communicates with the scala vestibuli
by means of an aperture termed the helicotrema. At the
base of the cochlea the scala vestibuli communicates with
the lower and anterior part of the vestibule. The perilymph
therefore, in the semicircular canals and vestibule, is
directly continuous with that in the scala vestibuli and
scala tympani.

It can now be understood how vibrations of the membrana tympani

are communicated to the perilymph within the osseous labyrinth. The
chain of auditory ossicles, through the base of the stapes, affects the
perilymph in the vestibule. The vibrations of the perilymph passing
along the scala vestibuli into the scala tympani affect in turn the secondary
membrane of the tympanum, which is stretched across the fenestra cochleae.
With every inward movement of the membrana tympani and of the base
of the stapes, there is an outward movement of the membrane of the
fenestra cochleae, and vice versa. The vibrations of the perilymph affect
the endolymph in the membranous labyrinth, and thus excite the termina-
tions of the acoustic nerve.

Membranous Labyrinth. In the vestibule there are two mem-

branous sacs, termed the utricle and the saccule. The utricle occupies
the recessus ellipticus on the upper wall of the vestibule, and lies above

LABYRINTH 531

and posterior to the saccule. Into it open the membranous semicircular

ducts which lie in the bony semicircular canals.

Each semicircular duct corresponds in general form with the semi-

circular canal *In which it lies, but it is of smaller diameter. Its convex
margin is attached to the adjacent part of the wall of the bony canal.
The saccule is smaller, and occupies the recessus sphaericus on the anterior
part of the medial wall of the vestibule. It communicates by means of a
short narrow tube, termed the canalis reuniens, with the ductus cochlearis
or membranous cochlear tube.

The saccule and the utricle are only indirectly brought into communica-
tion with one another ; a slender tube termed the ductus endolymphaticus

Ductus endolymphaticus

Dura mate
Vestibule

Osseous
cochlea

Stapes

Fenestra cochleae

Aquaeductus cochlea

FIG. 225. Diagram of the Osseous and Membranous Labyrinth.

(Modified from Testut.)

U. Utricle. .S". Saccule. D.C. Ductus cochlearis.

occupies the aquseductus vestibuli, and divides into two branches which
pass respectively into the saccule and the utricle (Fig. 225).

The ductus cochlearis, or scala media, lies between the two scake of the
bony cochlear tube. It ends blindly at each extremity, but close to its
basal end it is brought into communication with the saccule by the canalis
reuniens.

BULBUS OCULI.

THE bulbus oculi or eyeball is not perfectly spherical. In-

deed, it may be said to be composed of the segments of two
spheres. The anterior or corneal segment, which forms
only about one-sixth of the entire eyeball, possesses a
shorter radius than the posterior or scleral segment. The

532 BULBUS OCULI

anterior, clear corneal part of the eyeball appears, therefore,

as a convex window or prominence on the front of the
globe of the eye. The terms anterior pole and posterior fole
are respectively applied to the central points of the anterior
and posterior segments of the eyeball. The imaginary line
which joins the two poles receives the name of the sagittal
axiS) whilst another line drawn in a frontal direction around
the globe of the eye, midway between the two poles, so as
to divide the eyeball into two hemispheres, is termed the
equator. Imaginary meridional lines also are drawn between
the two poles so as to cut the equatorial line at right angles.

Dissection of the Eyeball. A satisfactory dissection of the

globe of the eye can be made only when the eyeball is fresh, or
after it has been hardened for several days in a 10% solution
of formol. In the dissecting-room it is often impossible to
obtain suitable specimens ; but it is always easy to procure
eyeballs of the pig, sheep, or ox, and those suit the purpose
admirably. It is advisable, however, that the dissector should
complete his study of the organ by the examination of a fresh
human eyeball obtained from the post-mortem room. In point
of size, and also in other particulars, the eyeball of the pig more
closely resembles the human eyeball than the eyeball of the
sheep or ox ; but it is perhaps better that the student should
begin with the eyeball of the ox, because the necessary dissection
can be more easily carried out in it than in smaller eyeballs.

When the dissector has provided himself with six eyeballs

obtained from oxen, he should remove from them the conjunc-
tiva, fascia bulbi, ocular muscles, and fat, which adhere to
them. Pinching up, with the forceps, the conjunctiva and the
fascia bulbi close to the corneal margin, he should snip through
those layers with the scissors and divide them round the whole
edge of the cornea. He can then easily strip all the soft parts
from the surface of the sclera, working steadily backwards
towards the entrance of the optic nerve. A little posterior to
the equator of the eyeball the vence vorticosce will be noticed
issuing from the sclera, at wide intervals from each other ; and
as the posterior aspect of the eyeball is approached the posterior
ciliary arteries and the ciliary nerves will be seen piercing the
sclera around the entrance of the optic nerve.

Before the student begins the actual dissection of the eyeball,

it is important that he should obtain a general conception of
the parts which compose it. That can be done by sections made
through three hardened specimens in three different planes.
One specimen should be divided, at the equator, into an anterior
and a posterior portion. Another should be divided, in an
antero-posterior direction, into a medial and a lateral half. A
third should be divided horizontally and a portion of the vitreous
body should be removed (Fig. 226). When the sections are
made, they should be placed under water in a cork-lined tray,
and preserved for reference as the study of the eyeball is pro-
ceeded with.

EYEBALL
533

General Structure of the Eyeball. The eyeball consists

of three concentrically arranged coats enclosing a cavity in
wHich three refracting media are placed.

The coats or tunics are: (i) an external fibrous envelope

composed of a posterior, opaque part, called the sclera, and
an anterior, clear transparent portion, called the cornea ; (2)
a middle vascular envelope, known as the uveal tract, in
which three subdivisions are recognised, viz., a posterior part
called the chorioid, an anterior pcrtion termed the iris, which

. Pupil

Anterior chamber L ens

Iris ' ', .

Posterior chamber

Ciliary body
Corona ciliaris

Cornea

Zonula ciliaris
/ Venous sinus of sclera
Conjunctiva

Vitreous body

Sclers

Hyaloid canal

/ / I-/ ,- . .

I i <ff Central fovea

tmj Optic nerve

FIG. 226. Diagrammatic section of Eyeball.
lies posterior to the cornea, and an intervening ciliary body ;
(3) the nervous internal tunic or retina, in which the fibres
of the optic nerve are outspread.

The refracting media are: (i) the cornea; (2) posterior

to the cornea a watery fluid called the aqueous humour, con-
tained in a space partially subdivided by the iris into the
anterior and posterior chambers of the eye; (3) the crystalline
lens, behind the posterior chamber; and (4) the vitreous body,
which occupies the posterior part of the interior of the eyeball.

Dissection. The superficial surface of the sclera and of the

cornea should now be examined ; but to complete the study of

534 BULBUS OCULI

the external tunic a further dissection is required. Select an

eyeball for that purpose, and make an incision, with a sharp
knife, through the sclera at the equator. The incision must be
made carefully, and the moment that the subjacent black
chorioid coat appears the knife should be laid aside. The cut
edge of the sclera should now be seized with the forceps, and the
incision carried completely round the eyeball, with the scissors,
along the line of the equator. The outer fibrous tunic is thus
divided into an anterior and a posterior portion. Both parts
must now be raised from the subjacent structures. As the
anterior portion is turned forwards, some resistance will be met
with, close to the margin of the cornea ; it is due to the attach-
ment of the ciliary muscle to the deep surface of the sclera.
The attachment can easily be broken through with the blunt
point of the closed forceps ; as soon as that is done the aqueous
humour escapes. In the case of the posterior part of the sclera,
the complete separation of the sclera can be effected by dividing
the fibres of the optic nerve close to the point where they enter
the sclera from the inner side.

When the above dissection is successfully carried out, the

outer fibrous tunic is isolated in two portions, whilst a con-
tinuous view of the intermediate vascular coat is obtained.
The eyeball, denuded of its external tunic, should now be placed
in a shallow vessel filled with water.

Sclera. The sclera is what is commonly known as the

white of the eye. It is a dense, resistant tunic, opaque-
white in colour, which envelops the posterior five-sixths of
the globe of the eye. It is thickest posteriorly, and becomes
thinner as it is traced forwards. Near the cornea, however,
it again becomes thicker, owing to the accession of fibres
which it receives from the tendons of the ocular muscles.
Except at the entrance of the optic nerve and close to the
margin of the cornea, where it adheres to the surface of the
subjacent ciliary muscle, the deep surface of the sclera is very
loosely attached to the chorioid coat. Some pigmented floc-
culent connective tissue, called the lamina fusca, connects the
two coats and traverses what is, in reality, an extensive lymph
space, termed the perichorioidal space.

The point at which the optic nerve pierces the sclera

does not correspond with the posterior pole of the eyeball.
The optic entrance, as it is termed, is situated about 3 mm. to
the medial or nasal side of the posterior pole and i mm.
below it. There the outer fibrous sheath of the optic
nerve, which is derived from the dura mater, blends with
the sclera, and the bundles of nerve fibres pass through a
number of small apertures. The perforated portion of the
sclera through which the fibres of the optic nerve pass is
called the lamina cribrosa.

SCLERA

535

The sclera is pierced also by numerous blood-vessels and

nerves. The long and short posterior ciliary arteries, with
the ciliary nerves, perforate the sclera around the optic
entrance ; four or five venae vorticosse issue from the interior
of the eyeball by piercing the sclera a short distance posterior
to the equator, at wide intervals from each other ; whilst the
anterior ciliary arteries pierce it near the corneal margin.

Anteriorly, the sclera is not only contiguous to, but is

directly and structurally continuous with, the cornea. The
region of union is termed the corneo-scleral junction, and
the faint groove on the surface, which corresponds with it,
receives the name of the scleral sulcus. At the junction the

Vena vorticosa

Long posterior
ciliary arteries

ptic entrance
Short ciliary
arteries and
ciliary nerves

FIG. 227. Diagram of the posterior aspect of the Left Eyeball. The
excentric position of the optic entrance is somewhat exaggerated. (After
Testut, modified.)
scleral tissue slightly overlaps the corneal tissue ; therefore
the line of union, when seen in section, is oblique. Close to
the corneo-scleral junction, a minute canal in the substance
of the sclera, termed the sinus venosus sclerce (O.T. canal of
Schlemm), encircles the margin of the cornea.

Cornea. The cornea forms the anterior sixth of the outer

tunic of the eye. It is transparent and glass-like, and it
forms the window through which the rays of light gain
admittance into the eyeball. The curvature of the cornea is
more accentuated than that of the sclera, and thus it consti-
tutes the segment of a smaller sphere. When viewed from
the posterior aspect it appears circular, but when looked at
from the front it is seen to be slightly wider in the transverse

536 BULBUS OCULI

direction than in the vertical. That is due to the fact that

the sclera overlaps it to a greater extent above and below
than it does at the sides. The posterior, concave surface of
the cornea forms the anterior boundary of the anterior chamber
of the eyeball, and is separated by the aqueous humour from
the anterior surface of the iris.

The anterior convex surface of the cornea is clothed with

the conjunctiva, reduced to a transparent epithelial layer.
On its posterior aspect there is an elastic, glassy stratum,
termed the posterior elastic lamina. When the cornea is
relaxed that membrane becomes wrinkled, and it can be
torn away in shreds from the proper corneal tissue. ,

Ligamentum Pectinatum Iridis. At the margin of the

cornea the posterior elastic lamina is fibrillar, and some of
its fibres are continued into the iris, forming the ligamentum
pectinatum iridis, whilst others are prolonged backwards into
the chorioid and the sclera. The ligamentum pectinatum
iridis bridges across the angle between the cornea and the
iris, and the bundles of fibres into which the posterior elastic
lamina breaks up in that region constitute the boundaries of
an annular mesh-work or sponge-like series of minute spaces
termed the spatia anguli iridis (O.T. spaces of Fontana). The
spaces communicate with the anterior chamber of the eyeball,
and are filled with aqueous humour.

Tunica Vasculosa Oculi. The middle or vascular tunic,

frequently spoken of as the uveal tract, is exposed, in its
entire extent, in the eyeball from which the sclera and the
cornea have been removed. It is separable into three
parts (i) a posterior portion, the chorioidea; (2) a middle
part, the corpus ciliare ; and (3) an anterior segment, the
iris.

Chorioidea. The chorioid is the largest part of the vas-

cular tunic. It lines the posterior segment of the eyeball,
between the sclera externally and the retina internally. It
is thickest posteriorly, where it is pierced by the optic nerve,
and becomes thinner anteriorly, as it approaches its union
with the ciliary body. Its superficial surface is connected
with the deep surface of the sclera by some lax connective
tissue, called the lamina fusca, and also by blood-vessels and
nerves which pass from the one into the other. The deep
surface of the chorioid is moulded upon the retina and is
covered with a layer of deeply-pigmented cells which usually

CHORIOIDEA

537

adheres to the chorioid when that tunic is removed, although,

in reality, it is a portion of the retina.

In the eyes of many mammals, but not in man, the posterior part of the
chorioid, when viewed from the front, presents an extensive brightly-coloured
area, which exhibits a metallic lustre. The appearance is due to the
presence of an additional layer in the chorioid, termed the tapetum. In
the horse, elephant, and ox, the tapetum is composed of fibres (tapetum
fibrosum) ; in carnivora, it is formed of cells (tapetum cellulosum). In the
ox, it is a brilliant green colour with a golden lustre ; in the dog, it is white
with a bluish border ; in the horse, it is blue with a silvery lustre.

The chief bulk of the chorioid coat is composed of blood

vessels. They are arranged in two well-marked layers, viz.,

Sinus venosus sclerae

Anterior ciliary,
artery

Scler

Vena vorticosa

Long posterior
ciliary artery'

Anterior ciliary
artery
Ciliary muscle

_Long posterior
ciliary artery

Vena vorticosa

.Long posterior
ciliary artery

FIG. 228. Dissection of the Eyeball showing the Vascular Tunic and
the Arrangement of the Ciliary Nerves and Vessels.

a deep, closely-meshed capillary layer called the lamina chorio-

capillaris, and a more superficial venous layer composed of
the vasa vorticosa. The short posterior ciliary arteries pass
forwards between the two vascular layers.

The eyeball in which the outer surface of the chorioid is exposed should
be immersed in water and the pigment washed out of it by means of a
camel-hair brush. The vasa vorticosa will then appear as white curved
lines converging towards four or five points, from which the venae vorticosse
take origin (Fig. 228).

Corpus Ciliare. The ciliary body is separable into an

antero-external part, the orbiculus ciliaris, and a postero-
internal part, the corona ciliaris.

The orbiculus ciliaris consists of the ciliary muscle, the

BULBUS OCULI

ganglionated ciliary nerve plexus, and plexuses of arteries

and veins associated with the iris and ciliary body. It is
continuous with the iris internally, the sclera anteriorly, and
the corona ciliaris and the chorioid posteriorly.

Musculus Ciliaris. The ciliary muscle is composed of in-

voluntary muscular tissue. The arrangement of its fibres can
be seen only when thin sections of the eyeball are examined
under the microscope. It is then obvious that the fibres are
disposed in two groups, viz., a radiating and a circular.

The radiating fibres arise from the deep aspect of the

sclera close to the margin of the cornea. From their origin
they radiate backwards, in a meridional direction, and gain
Chorioid (cut
edge of)

Ciliary fol

Lens

Ciliary process

FIG. 229. Posterior view of Lens and Zonula Ciliaris.

(Professor Arthur Thomson. )

insertion into the chorioid coat in the region of the ciliary

processes. The circular fibres consist of two or three bundles
placed upon the deep aspect of the radiating portion of the
muscle. They form a muscular ring around the outer circum-
ference of the iris. The ciliary muscle is supplied by the
oculo-motor nerve. It draws the anterior part of the chorioid
forwards, and so relaxes the suspensory ligament of the lens,
which then becomes more convex on account of its own
elasticity.

Dissection. To obtain a view of the ciliary processes, a

frontal section should be made through an eyeball, a short
distance anterior to the equator. The portion of the vitreous
body which occupies the posterior segment of the eyeball should
be carefully removed. When that is done, the deep aspect of

CILIARY BODY 539

the corona ciliaris will be seen. It is covered with ciliary pro-

cesses which radiate backwards from the circumference of the
crystalline lens. Wash out the pigment from the anterior part
of the vascular tunic, in order to display the arrangement of the
processes more fully.

A second dissection may be made, in another eyeball, with

the object of exposing the ciliary processes from the front. In
that case remove the cornea by cutting round the corneo-scleral
junction with the scissors. The iris is then brought conspicu-
ously into view, and may, with advantage, be studied at this
stage. Several cuts in the meridional direction, and at equal
intervals from each other, should, in the next place, be made
Ligamentum pectinatum iriclis and spatia anguli iridis

Scleral spur I .. , . ....

Venous sinus of sclera ' Ra . dial mUSC r le . of ins

Sclera

Iris

Meridional fibres of ciliary muscle

Parts of ciliary processes

India! angle Circular fibres of ciliary muscle

FIG. 302. Section of Iridial Angle. (Prof. Arthur Thomson.)

through the anterior part of the sclera. The specimen should

then be placed in a cork-lined tray, filled with water, and the
strips of sclera should be separated from the ciliary muscle, bent
aside and pinned to the cork. The last step in the dissection
consists in the removal of the iris.

The corona ciliaris lies on the posterior aspect of the

orbiculus ciliaris and is continuous, anteriorly, with the iris,
and, posteriorly, with the chorioid. It consists of a number
of larger folds, called \\\e processus ciliares, 70 to 72 in number,
which are intermingled with a number of smaller folds, called
the plica ciliares. The ciliary processes extend from the
anterior margin of the chorioid to the anterior margin of the

540 BULBUS OCULI

corona ciliaris, where they end in bulbous extremities. The

bulbous ends occupy the space between the peripheral margin
of the iris and the margin of the anterior surface of the
crystalline lens, and they form the peripheral boundary of the
posterior chamber of the eyeball. The //foe ciliares are much
less prominent than the ciliary processes. Both the processes
and the folds are in relation, posteriorly, with the hyaloid
membrane, which separates them from the vitreous body,
and with the peripheral part of the zonula ciliaris (see p.
544) to which they are attached.

Iris. The iris lies anterior to the crystalline lens, and it

is separated from the cornea by the anterior chamber filled
with aqueous humour. By its circumference it is continuous
with the ciliary body, and it is connected, by the ligamentum
pectinatum iridis, with the margin of the cornea.
The iris is circular in form, it is coloured differently in
different subjects, and it has a central perforation termed the
pupil. Its anterior surface is faintly striated in a radial
direction. Its posterior surface is deeply pigmented. The
pupil presents a very nearly circular outline, 1 and during
life it constantly varies in its dimensions so as to control
the amount of light which is admitted into the interior
of the eyeball. The changes in the size of the pupil
are produced by the two groups of involuntary muscular
fibres which are present in the substance of the iris. One
group is composed of muscular fibres arranged circularly
around the pupil in the form of a sphincter; the second
group consists of fibres which have a radial direction, and
pass from the sphincter towards the circumference of the
iris, so as to constitute a dilatator muscle. By some
anatomists these radial fibres are considered to be elastic
and not muscular. The circular fibres, which act as a
sphincter, are supplied by the oculo-motor nerve. The
dilator fibres are supplied by sympathetic nerve fibres.

Ciliary Nerves. The ciliary nerves arise from the ciliary

ganglion and the naso-ciliary nerve. They pierce the sclera
around the optic entrance, and extend forwards, between
the sclera and the chorioid, in the perichorioidal lymph space.
They will be seen, in the specimen in which the sclera has

1 It may be as well to mention here that the pupil in the ox and the
sheep is greatly elongated in the transverse direction. In the pig, how-
ever, it is approximately circular.

CILIARY ARTERIES 541

been turned aside in separate flaps, in the form of delicate

white filaments (Fig. 228). In the posterior part of the
eyeball they occupy grooves on the deep surface of the sclera,
and can be separated from it only with difficulty. Reaching
the ciliary zone the ciliary nerves break into branches, which
join in a plexiform manner and send twigs to the ciliary
muscle, the iris, and the cornea. The long ciliary nerves are
sensory nerves. The short ciliary nerves contain motor
fibres derived from the motor- oculi, sensory fibres from
the naso-ciliary nerve, and sympathetic fibres which convey
motor impulses to the dilator muscle of the iris.

Ciliary Arteries. There are three groups of ciliary

arteries: (i) the short posterior ciliary arteries; (2) the long
posterior ciliary arteries ; and (3) the anterior ciliary arteries.

The short posterior ciliary arteries, branches of the

ophthalmic, pierce the sclera around the optic entrance,
and are distributed in the chorioid coat between the venae
vorticosae and the lamina chorio-capillaris.

The long posterior ciliary arteries, also branches of the

ophthalmic, are only two in number. They perforate the
sclera, one on the medial side of the optic nerve and the
other on its lateral side (Fig. 227), a short distance beyond
the short ciliary arteries, and then pass forwards between
the sclera and the chorioid. When they gain the ciliary
zone each artery divides into an ascending and a descending
branch, which anastomose with the anterior ciliary arteries at
the periphery of the iris, and form an arterial ring termed the
circulus iridis major. Branches are given off from the major
circle to the ciliary muscle, the ciliary processes, and the iris.

The circtilus iridis minor is the name applied to a second arterial ring
in the iris at the outer border of the sphincter pupillae.

The anterior ciliary arteries are very small twigs which

arise from the branches of supply to the recti muscles.
They pierce the sclera close to the margin of the cornea,
take part in the formation of the circulus iridis major, and
send twigs to the ciliary processes.

Venae Vorticosse. From each venous vortex in the

chorioid a large vein arises, which makes its exit from the
eyeball by piercing the sclera, obliquely, a short distance
posterior to the equator. They are four or five in number.

Dissection. The vitreous body and retina, in the posterior

part of the eyeball which was cut into two for the purpose of

542 BULBUS OCULI

exposing the ciliary processes from the posterior aspect, should

now be dislodged. By raising the chorioid coat from the deep
surface of the sclera, under a flow of water from the tap, the
dissector will bring into view the venae vorticosae as they enter
the deep surface of the sclera. When the venae vorticosae are
divided, and the separation of the two coats is carried backwards
towards the optic entrance, the short posterior ciliary arteries,
as they emerge from the sclera and enter the posterior part of
the chorioid, will be seen.

To expose the external surface of the retina take the eyeball

from which the sclera and cornea have been removed, and care-
fully strip off the iris, ciliary processes, and the chorioid, piece-
meal, under water.

Eetina. The retina is composed of two strata viz., a

thin pigmentary layer^ which adheres to the deep surface of
the chorioid coat, and has been removed with it, and a
delicate nervous layer^ which is moulded on the surface of
the vitreous body, but presents no attachment to it except at
the optic entrance. The retina extends forwards, beyond
the equator of the eyeball, and, a short distance from the
ciliary zone, it appears to end in a well-defined, wavy or
festooned border termed the ora serrata. This appearance,
however, is somewhat deceptive. The nerve elements, it
is true, come to an end along the ora serrata, but a lamina in
continuity with the retina is in reality prolonged forwards as
far as the margin of the pupil. The part in relation to the
ciliary processes is exceedingly thin, and cannot be detected
by the naked eye. It is termed the pars ciliaris retina. The
portion on the deep surface of the iris is called the stratum
pigmenti iridis.

During life the retina proper is transparent, but after death

it soon assumes a dull greyish tint and becomes opaque.
Posteriorly it is tied down at the optic entrance. When
viewed from the anterior aspect the optic entrance appears as
a conspicuous circular disc termed fae papilla nervi optici, upon
which is a depression, the excavatio papilla. From that spot
the optic nerve fibres radiate out so as to form the deep or
anterior layer of the retina. The optic disc, in correspond-
ence with the entrance of the optic nerve, lies to the medial
or nasal side of the antero -posterior axis of the eyeball.
Exactly in the centre of the human retina, and therefore in
the axis of the globe of the eye, there is a small yellowish
spot termed the macula lutea. 1 It is somewhat oval in

1 There is no macula lutea in the eyeball of the ox or sheep.

RETINAL ARTERIES AND VEINS 543

outline, and a depression in its centre is called the fovea

centralis.

Retinal Arteries and Veins. In a fresh eyeball the

arteria centralis retina will be seen entering the retina at
the optic disc. 1 It immediately divides into a superior and
an inferior division, and each of them breaks up into a large
lateral or temporal division, and a smaller medial or nasal
division. The various branches of the terminal divisions
ramify in the retina as far as the ora serrata ; but they do not
anastomose with each other, nor with any of the other arteries
in the eyeball.

' The retinal veins converge upon the optic disc, and
disappear into the substance of the optic nerve in the form
of two small trunks which soon unite.

The retinal vessels, the optic disc, and the macula can all be examined
in the living eye by means of the ophthalmoscope. The red reflex obtained
from the fundus of the eyeball, so examined, is produced by the blood
in the lamina chorio-capillaris.

Dissection. For the study of the vitreous body and the

crystalline lens, which together may be termed the " eye-kernel,"
it is better to take an eyeball which is not perfectly fresh
(Anderson Stuart). The eyeball selected for this purpose should
be allowed to stand untouched from one to three days, according
to the season. Divide the coats of the eye round the equator ;
gently separate the cut edges, and turn the coats forwards and
backwards, and the " eye-kernel " will slip out. It should be
allowed to drop into a vessel filled with clean water. The
examination of the parts forming the " eye-kernel " will be
greatly facilitated if it is placed en masse in strong picro-carmine
solution for a few minutes. When removed from the staining
fluid, it should be well washed in water. In this way the hyaloid
membrane enclosing the vitreous body, the capsule of the lens,
and the zonula ciliaris, are stained red, and their connections
become very apparent (Anderson Stuart).

Corpus Vitreum. The vitreous body is a soft, yielding,

transparent, jelly-like body, which occupies the posterior four-
fifths of the interior of the eyeball. The retina is spread
over its surface as far forwards as the ora serrata, but is in
no way attached to it, except at the optic disc. Anterior to
the ora serrata, the ciliary processes are applied to the
vitreous body and indent its surface. More anteriorly, the
vitreous body presents a deep concavity, called the fossa

1 When the living retina is examined with the aid of the ophthalmoscope
it is not the vessels which are seen but the blood circulating through them,
for the walls of the vessels are transparent.

544 BULBUS OCULI

hyaloidea, for the reception of the posterior, convex surface

of the crystalline lens.

The substance of the vitreous body is enclosed within a

delicate transparent membrane, which completely envelops
it, and receives the name of the hyaloid membrane. Extend-
ing forwards through the midst of the vitreous mass, from the
region of the optic disc to the crystalline lens, is a minute
canal, lined with a tube-like prolongation of the hyaloid
membrane, and containing a watery fluid. The canal is termed
the hyaloid canal ; it represents the path taken by a branch .of
the arteria centralis retinae, which, in the foetus, extends to and
supplies the capsule of the lens, but afterwards disappears.

The hyaloid canal, as a rule, cannot be seen in an ordinary dissection

of the eyeball ; but if the " eye-kernel " is shaken up in the picro-carmine
solution as recommended by Anderson Stuart, it may sometimes be rendered
evident through the staining fluid entering it. It is represented diagram -
matically in Fig. 226.

Zonula Ciliaris (O.T. Zonula of Zinn). Between the

corona ciliaris externally and the margin of the lens internally
lies a fibrous membrane called the zonula ciliaris. Its
peripheral margin is attached to the posterior surfaces of the
ciliary processes and the hyaloid membrane, and its central
margin is connected with the lens. As it approaches the
margin of the crystalline lens, it splits into two parts, viz., an
exceedingly delicate, deep lamina, which lines the fossa
hyaloidea, and a more superficial, stronger part, which becomes
attached to the capsule of the crystalline lens.

The zonula ciliaris lies subjacent to the ciliary processes,

and is radially wrinkled in correspondence with the depres-
sions between the processes. Thus, the elevations or wrinkles
of the zonula extend into the intervals between the ciliary
processes, whilst the ciliary processes in their turn lie in the
depressions between the wrinkles of the zonula. When the
eye is fresh, these opposing parts are closely adherent.
The zonula ciliaris is strengthened by radially directed
elastic fibres, and the anterior and stronger of the two layers
into which it divides is called the suspensory ligament of the
lens. It is attached, mainly, to the anterior surface of the
capsule of the lens a short distance beyond the margin of that
body, but this is not the only attachment of the suspensory
ligament. Some of its fibres are attached to the circum-
ference or equator of the lens (equatorial fibres), whilst others

ZONULA CILIARIS

545

are fixed to its posterior surface close to its margin (post-

equatorial fibres).

In that way the crystalline lens is firmly held in its place

in the fossa hyaloidea. Further, the degree of tension of its
suspensory ligament is influenced by the radiating fibres of
the ciliary muscle, which by their contraction pull upon the
ciliary processes, and produce relaxation of the zonula
ciliaris.

Spatia Zonularia (O.T. Canal of Petit). In reality the

spatia zonularia constitute a more or less continuous circular
lymph space, which surrounds the circumference of the lens.

Retina

,Sclera

-Perichorioidal space

Ciliary muscle (radiating fibres)

Ciliary muscle (circular fibres)

Sinus venosus sclerae

Spatia anguli iridis

Ciliary process
Spatia zonularia
""Suspensory ligament

[ris
Cornea
FIG, 231. Diagrammatic representation of the Ciliary Region,
as seen in vertical section.

It lies between the anterior and posterior layers of the

suspensory ligament and is filled with a watery fluid.

If the point of a fine blow-pipe is introduced into the spatia zonularis

through the suspensory ligament, the spatia can be partially, or, perhaps,
completely, inflated with air. Then the spatia present, collectively, the
appearance of a circular sacculatecl canal.

Dissection. Remove the crystalline lens by snipping through

the suspensory ligament with scissors.

Lens Crystallina. The crystalline lens is a biconvex,

solid, and transparent structure which lies between the iris
and the vitreous body, in the posterior wall of the posterior
and anterior chambers. It is enclosed within a glassy, elastic
capsule, to which the different parts of the zonula ciliaris

VOL. in 35

546 BULBUS OCULI

are firmly cemented, and it presents for study an anterior

surface, a posterior surface, and a circumference or equator.

The anterior surface is not so highly curved as the posterior

surface. Its central part, which corresponds with the pupillary
aperture of the iris, looks, through the pupil, into the anterior
chamber of the eye. Around that part the margin of the
pupillary orifice of the iris is in contact with the lens, whilst
nearer the equator the anterior surface of the lens is separated
from the iris by the fluid in the posterior chamber of the eyeball.
The posterior surface of the lens presents a higher degree of
curvature than the anterior surface, and is received into the
fossa hyaloidea of the vitreous body. The equator or circum-
ference is rounded. It forms one of the boundaries of the
spatia zonularia. The manner in which the zonula ciliaris is
attached to the capsule in this vicinity has been described
already.

Faint radiating lines may be seen on both surfaces of the

lens, and they give a clue to its structure. They indicate
the planes along which the extremities of the lens - fibres
come into apposition with each other.

The capsule of the lens is a resistant glassy membrane,

which is considerably thicker anteriorly than posteriorly.

Dissection. The anterior wall of the capsule may now be

divided with a sharp knife. A little pressure will cause the
body of the lens to escape through the opening. The stained
capsule can be very advantageously studied whilst floating in
water.

If the lens body is compressed between the finger and thumb,

it will be noted that the outer portion or cortical part is soft,
whilst the central part or nucleus is distinctly firmer. When
the lens is hardened in alcohol it can easily be proved that it is
composed of numerous concentrically arranged laminae.

Chambers of the Eyeball. The anterior chamber of the

eyeball is the space between the cornea, anteriorly, and the
iris and central part of the lens, posteriorly. At the irido-
corneal angle it is bounded by the ligamentum pectinatum
iridis, and there the aqueous humour which fills this chamber
finds access to the spatia anguli iridis.

The posterior chamber is a circular space or interval which

is bounded, anteriorly, by the posterior surface of the iris, and,
posteriorly, by the circumferential part of the anterior face of
the lens. Peripherally, the posterior chamber is closed by
the thick anterior projecting ends of the ciliary processes.
It also is filled with aqueous humour.

INDEX.

Aditus laryngis, 291, 322, 323

closure of, 345

tympanic, 510, 511, 516

Agger nasi, 310
Ala of cerebellum, 485, 486

cinerea, 492
Alveus, 436, 442

Ampulla of semicircular canal, 529

Anastomosis of anterior jugular

veins, 122, 123

Angle, irido-corneal, 546
Ansa hypoglossi, 134

subclavia, 140, 151, 161, 227

Antihelix, 44
Antitragus, 44
Antrum, tympanic, 516
Apertura tympanica canaliculi

chordae, 512, 526

Aperture of larynx, superior, 291,

3 2 2, 323

closure of, 345

Apertures in roof of fourth ventricle,
493
Aponeurosis, epicranial. * See

Galea

palatal, 296

pharyngeal, 210, 287, 295, 296

Apparatus, auditory, 505

lacrimal, 27

' Appendix ventriculi, 327

Aquceductus cerebri, 108, 355, 357,

450, 451, 455, 491

vestibuli, 528, 531
Arachnoid of brain, 353, 370

granulations, 100, 103, 104, 374

spinal, 82

Arbor vitae cerebelli, 488

Arch of cricoid, 343

glosso- palatine, 281, 290, 293,

347

Arch (contd.)

lumbo-costal, lateral, 62

pharyngo-palatine, 281, 290

superciliary, 2

tarsal, of eyelids, 26, 253

visceral, second, 347

zygomatic, 2
Arcus parieto-occipitalis, 404, 410,

411
Area acustica of fourth ventricle, 492

acoustic, of cortex, 412

motor, 361, 403, 406

paradentate, 367, 414

piriform, 367, 414, 418, 469

postrema, 492

sensory, 361, 410

for sight, 414, 415, 420

for smell, 414

for speech, 406

striata, 414, 415, 420

Areolar tissue of scalp, 5 1
Arteries

alveolar, inferior, 173, 181

in mandible, 182
superior, posterior, 174

angular, 15, 16, 18

auditory, internal, 1 12, 384

auricular, anterior, 208

deep, 173
posterior, in neck, 164, 207,

215
in scalp, 47, 48, 56

axillary, sheath of, 37

of back of neck, 65, 68, 71

of back of trunk, 71

basal, of brain, 381

of anterior cerebral, 387

of middle cerebral, 388
of posterior cerebral, 384

basilar, 108, 372, 379, 383

547

548 .

INDEX

Arteries (contd. )

of brain in pia, 375, 382

buccinator, 17, 170,. 174

bulbar, 382, 383

calcarine, 385

carotid, common, 131, 134, 147.

203, 227
carotid, external, 200

in carotid triangle, 130, 131,

134, 200, 213

above triangle, 165, 166, 167,

200, 213, 298

carotid, internal, 211, 239, 299

in neck, 130, 131, 134, 211,

298

in carotid canal, 299

in cranial cavity, 106, 117, 239,

374, 379
branches, 385
central, of brain, 381

of anterior cerebral, 387

antero-lateral, 388

antero-medial, 387

of middle cerebral, 388

of posterior cerebral, 384

postero-lateral, 385

postero-median, 384
centralis retinae, 253, 543
cerebellar, inferior, anterior, 384
posterior, 374, 382

superior, 108, 384

cerebral, anterior, 373, 386

middle, 373, 417, 387

posterior, 108, 374, 384

cervical, ascending, 141, 151, 216

deep, 68, 78, 156, 268

cervical, transverse, 36, 156

on scalenus anterior, 141, 144,

156, 216

in posterior triangle, 34, 36,

37, 38, 41

ascending branch, 58
descending branch, 233

unusual origin, 154

chorioid, of internal carotid, 386

posterior, 385
ciliary, 254, 532
anterior, 535
posterior, 532, 535

short, 532, 537

within eyeball, 541
communicating, anterior, 374, 387

posterior, 374, 385

cortical, of anterior cerebral, 387
of middle cerebral, 388
of posterior cerebral, 385

Arteries (contd.}

costo-cervical, 156, 1 60
crico-thyreoid, 127, 134, 203
dorsales linguae, 198
dorsalis nasi, 18, 255
deep cervical, 68, 78, 156, 268

of tongue, 198, 353

ethmoidal, 255, 317
of eyelids, 26

facial, transverse, 14, 17, 208

frontal, 6, 47, 48, 255
frontal, of brain, 387, 388
hyoid, of superior thyreoid, 202
of hypophysis, 241
incisor, 183

infra-orbital, 15, 17, 303

intercostal, of aorta, posterior

rami, 71
superior, 157

posterior rami, 71
labial, inferior, 15, 18, 206

superior, 15, 18
lacrimal, 245, 253
laryngeal, inferior, 155, 285, 330
in larynx, 337, 338
superior, 132, 203, 285, 329

in larynx, 337, 338

lingual, 131, 197, 203
lumbar, dorsal rami, 71
mammary, internal, 156
masseteric, 168, 170, 173
maxillary, external, 16, 204
in neck, 123, 131, 188, 189,

204, 298

in face, 7, 13, 16, 21

maxillary, internal, 172, 208, 320

third part, 320

of medulla oblongata, 382, 383

meningeal, accessory, 119, 178,

238, 242
of ascending pharyngeal, 119,

210

of ethmoidal, 118, 255

of lacrimal, 1 18
middle, 118, 178

below skull, 173, 177, 178,

199
within skull, 100, 108, 109,

118, 242

surface marking, 503

of occipital, 66, 119, 207
of vertebral, 119, 268
mental, 18, 206
mylo-hyoid, 129, 173, 189
nasal, dorsal, 18, 255
lateral, 15, 18

INDEX

549

Arteries (contd.}

nasal, lateral, of sphenopalatine,

321

of nasal septum, 308

of nasal cavity, side wall, 317
occipital, 56, 65, 206

in side of neck, 131, 165, 206

in back of neck, 34, 36, 39,

63, 65, 268

in scalp, 48, 56
descending branch, 66, 78
meningeal branches, 66, 119,

207

sterno-mastoid branches, 124,

130, 133, 207, 211, 213,

215

of oesophagus, 155
ophthalmic, 106/118, 250, 252
orbital, of brain, 387, 388
of palate, 297

palatine, ascending, 205, 210,

296, 297

descending, 297, 317, 321

great, 321

small, 321
of ascending pharyngeal, 210,

297

palpebral, 26, 253

parietal, of brain, 388
parieto-occipital, 385
parieto-temporal, 388
petrosal, of meningeal, 207

superficial, 242
pharyngeal, ascending, 131, 149,

210, 213

of pharyngeal canal, 321

of pharynx, 155, 210
to pons, 384

profunda cervicis, 68, 78,- 156,

268

linguae, 198, 353

pterygoid, 173
of pterygoid canal, 320, 321
retina? centralis, 253, 543
sacral, lateral, 74
of scalp, 47, 56
scapular, transverse, 38, 59, 156

on scalenus anterior, 123, 141,

144, 156, 216

behind clavicle, 34, 37, 38, 39

at scapula, 59

unusual origin, 154

septal, nasal, 18, 307, 308, 321
spheno-palatine, 317, 321
spinal, 79, 90

of ascending cervical, 155

Arteries (contd.}

spinal, of vertebral, 268, 382

sterno-mastoid, of occipital, 124,
130, 133, 207, 211, 213, 215
of superior thyreoid, 124, 133,

148, 203, 216

of transverse scapular, 125
stylo-mastoid, 178, 207
subclavian, 41, 151, 153

branches, 153
first part, 140, 144, 147, 151,

226, 227

second part, 151, 153, 231, 232

third part, 31, 37, 41, 52, 151,

233

sublingual, 198, 205

submental, 188, 205
supra-orbital, 6, 47, 48, 255
temporal, deep, 170, 174

middle, 168, 170, 208

superficial, 14, 47, 48, 56, 208

temporal, of brain, 385, 388
thyreo-cervical, 154, 217
thyreoid, inferior, 147, 154, 226,
229

superior, 131, 149, 202, 229

thyreoidea ima, 127, 229
of tongue, 131, 197, 203

deep, 353
of tonsil, 298

tonsillar, of external maxillary,

205

of ascending palatine, 210

of descending palatine, 297

of small palatine, 321

of ascending pharyngeal, 210

of trachea, 155
transverse cervical, 36, 156

on scalenus anterior, 141, 144,

156, 216

in posterior triangle, 34, 36,

37, 3.8, 41

ascending branch, 58
descending branch, 233

unusual origin, 154

transverse scapular, 38, 59, 156
on scalenus anterior, 123, 141,

144, 156, 216

behind clavicle, 34, 37, 38,

39

at scapula, 59

unusual origin, 154

of tuba auditiva, 210
tympanic, 173, 178
vertebral, 78, 154, 266, 382

first part, 148, 154, 227, 267

55

INDEX

Arteries, vertebral (contd. )

second part, 69, 267, 268
third part, 76, 78, 267, 268, 273
fourth part, no, 117, 268, 372,

379, 382
brandies, 382
zygomatico-orbital, 208
Articulation. See Joint
Atrium meatus medii, 310
Attic, 367
Auricle, 44, 505
Axis of eyeball, 532

Band, furrowed, 488

Base of brain, 389

Basis pedunculi, 108, 446, 454, 456,

464, 465, 471

Body. See also Corpus

ciliary, 536, 537, 540
geniculate, lateral, 448, 455

medial, 452, 496

hypothalamic, 466
pineal, 355, 445, 448, 452
restiform, 382, 479, 481, 489, 490,

49 2 > 493

vitreous, 540, 543

Brachia conjunctiva, 457, 483, 484,

489, 490, 492, 494, 496, 502

of corpora quadrigemina, 452,

453, 496
Brachium pontis, 482, 485, 488,

490, 502

Brain, 353. See also Hemisphere

base, 389

removal, 98, 105

alternative method, 115

surface marking, 503

Buccse. See Cheeks
Bulb of internal jugular vein, 213,
221, 51-1

olfactory, 105, 316, 365, 417

of posterior cornu, 435

Bulbus oculi, 531
Bulla ethmoidalis, 312
Bundle. See also Fasciculus
ciliary, 8
Bursa, hyoid, 127, 329

pharyngeal, 290

of tensor palati, 296

Buttresses of central sulcus, 403,
406

Calamus scriptorius, 491

Calcar avis, 43 5 ~
Canaliculus chordae tympani, 526
aperture, 512, 526

Canals-
central, of medulla oblongata, 475

of spinal medulla, 85
cervico-axillary, 52
facial, 512, 513, 517, 523
hyaloid, 544
mandibular, 182
of modiolus, 530
reuniens, 531
semicircular, 527, 528

lateral, 516
spiral, 530
Capsule, external, 460, 464, 468,

469, 474
internal, 446, 460, 464, 465. 467,

468, 470, 471

of lens, 544, 546
of thyreoid gland, 227
of tonsil, 297
Cartilage, arytenoid, 291, 292, 324,

343

auricular, 46
corniculate. 324, 343
cricoid, 291, 342
cuneiform, 323, 324, 345
of epiglottis, 338
of larynx, 338
of nose, alar, 30
lateral, 30, 306
lesser, 31
septal, 306

sesamoid, of vocal ligament, 336

of thyreo-hyoid ligament, 329
thyreoid, 339
superior horn, 121
triticea, 329
Caruncula lacrimalis, 5
Catheter, Eustachian, 289
Cauda equina, 80, 82, 87

fasciae dentatae, 440

Cavity, epidural, 80
of mouth, 278
of nose, 282, 293, 304, 308
of septum pellucidum, 440, 441
subarachnoid, of brain, 370

spinal, 82
subdural, cranial, 103

spinal, 82
tympanic, 299, 506, 510

mucous membrane, 517

Cavum Meckelii, 237
Cells, ethmoidal, 310
anterior, 312
middle, 313
posterior, 312
nerves of, 251, 381

INDEX

Cells (contd.)

mastoid, 516, 517

nerves of, 220

Centrum ovale, 423

semi-ovale, 418
Cerebellum, 108, 357, 369, 483

lobes, 485

Cerebrum, 396. See also Hemisphere

Chambers of eyeball, 536, 540, 545,

546

Cheek bone, 2
Cheeks, 279
Chiasma, optic, 362, 368, 376, 380,

390, 449

Choanre, 289, 308

Chorda tympani. See under Nerve
Chordae Willisii, 103
Chorioidea of eyeball, 536, 538, 539
Cilia, 3

Cingulum, 419
Circulus arteriosus, 373, 380

iridis major et minor, 541

tonsillaris, 219
Cisterns, subarachnoid, 371

cerebello-medullaris, 371, 374,

493

chiasmatis, 373, 380

fossae lateralis, 373

interpeduncularis, 108, 380

pontis, 372

venae magnae cerebri, 373

Claustrum, 461, 468
Clava, 480
Clavicle, 31

Cochlea of ear, 299, 529

Colliculi of mid-brain, 356, 446, 451

inferior, 356, 446, 451, 483, 484,

496

superior, 356, 446, 451

Colliculus facialis, 492
Colon, 62
Columns of fornix, 442, 449, 464

of spinal medulla, 94
Commissure of brain, anterior, 354,

362, 448, 449, 468, 471

Gudden's, 453
habenular, 447, 448
hippocampal, 442
posterior, 448

of eyelids, 3

of spinal medulla, 92, 93, 94

Concha of ear, 44, 506
Conchce of nose, 310, 311

inferior, 312, 317

middle, 311, 312, 316, 317

superior, 311
Confluens sinuwrn, 109, 113
Conjunctiva, 4, 259, 536

fornix, 5, 26, 27

Conus elasticus, 127, 328, 330, 333,

334

medullaris, 84, 85
Convolution. See Gyrus
Cord, spinal. See Medulla Spinalis
Cords of brachial plexus, 52
Cornea, 3, 532, 535, 540
Corona ciliaris, 538, 539

radiata, 464, 465, 471

Corpus. See also Body

adiposum buccae, 15, 21

callosum, 105, 354, 362, 424, 432

splenium, 444, 451

mamillare, 355, 368, 390, 442,

448, 469

quadrigeminum inferius, 356, 446,

451, 483, 484, 496

superius, 356, 446, 451

striatum, 391, 463, 467

trapezoideum, 496, 502

Crista vestibuli, 528
Crura of fornix, 442
Crus commune, 528
Crypts of tonsil, 297
Culmen cerebelli, 486
Cuneus, 365, 422
Cupola cochleae, 529
Cushion, levator, 298

Declive cerebelli, 484, 486

Decussation, interolivary, 496, 498

of lemnisci, 496, 498

of pyramids, 475, 477

sensory, 496, 498

Deglutition. See Swallowing
Diaphragm a oris, 190

sellae, 107
Diencephalon, 395, 396, 449
Disc, articular, of mandibular joint,
176

optic, 542, 543

Dissections of Back, 55, 58, 59,

63, 64

arachnoidea spinalis, 83

dura mater spinalis, 80, 82

to expose kidney, 62

quadratus lumborum, 62

interspinales, 72

intertransversales, 72

lumbo-dorsal fascia, 61, 62

multifidus, 72

semispinalis capitis, 66
dorsi, 71

552

INDEX

Dissections of Back (contd. )

spinal medulla, 90
spinal nerve roots, 88
vertebral canal, 78
Dissections of Brain
basal ganglia, 458
brachia conjunctiva, 496
cerebellum, 488
cisterns, 373
corpus callosum, 418
dentate nucleus, 493
to divide brain, 398
to expose fornix, 440

mid-brain, 451

tela chorioidea, 443

lemniscus, 494, 496
lentiform nucleus, 470
olfactory stride, 418
pyramid, 482
to remove arachnoid and pia
mater, 389

brain, 105

alternative method, 115

hind-brain, no

opercula, 435

tela chorioidea, 445

temporal and occipital lobes,

439

septum pellucidum, 431

ventricle, fourth, 491

lateral, 426

Dissections of Ear and Eye-

auricle, 45

internal ear, 527

middle ear, 506, 509, 521

ciliary processes, 538

eyeball, 532, 533, 538, 541, 543,

545, 546

fascia bulbi, 248, 260

to inflate eyeball, 248

lens, 545, 546

retina, 541

vitreous body, 543

Dissections of Head and Face-
carotid canal, 299

to divide head and neck, 262

to disarticulate mandible, 177

eyelids, 23

to expose falx cerebri, 104

face, 14
deep, 20
face and scalp, 5

facial nerve in temporal bone, 523

fascia bulbi, 248, 260

to inflate eyeball, 248

infra-temporal region, 169, 177

Dissections of Head and Face

(contd. )

levator veli palatini, 295

lips, 22

mastoid air cells, 521

maxillary nerve, 300
middle cranial fossa, 234
nasal nerves, 316

septum, 307, 308

nose, external, 29
occipital artery, 65
to open cavernous sinus, 109

dura mater, 102

mandibular canal, 182

maxillary sinus, 313

nose, 304

orbit, 242
to open sphenoidal sinus, 120

sigmoid sinus, 113

superior sagittal sinus, 103

opening of naso-lacrimal duct, 314
orbit, 243, 250
orbital muscles, 256
palatine nerves, 319
pharyngeal canal, 320
pterygoid canal, 320
to remove falx cerebri, 109

parotid gland, 164

skull cap, 98

tentorium, no
scalp, 43, 47, 51
scalp and face, 5
soft palate, 294
spheno-palatine ganglion, 317
temporal fascia, 98

muscle, 168

region, 47
tongue, 350
trigeminal nerve, 238
zygomatic nerve, 261
Dissections of Neck-
anterior triangle, 121, 129
ascending pharyngeal artery, 210
atlanto-occipital ligaments, 274,

275, 276

cervical plexus, 140

deep fascia, 122
to divide head and neck, 262
to expose arteries of sterno-
mastoid, 124

brachial plexus, 51

vertebral artery, second part,

266

internal carotid artery and cere-

bral nerves, 211
joints of neck, 269

INDEX

553

Dissections of Neck (contd. )

ligamentum nuchos, 67
middle line of neck, 126
muscular triangle, 134
nerves in back of neck, 67
to open internal jugular vein, 217
posterior triangle, 32, 34, 36
rectus lateralis, 233
to remove head and neck from

trunk, 233
root of neck, 147
sterno-clavicular joint, 51
structures under sterno-mastoid,

138
stylo-pharyngeus, 208
submaxillary region, 183, 187,

190, 197

suboccipital triangle, 74, 75

suprasternal space, 122
sympathetic trunk, 224
Dissections of Pharynx and

Larynx
to remove pharynx from vertebral

column, 262
walls of pharynx, 283
constrictor superior, 285
stylo-pharyngeus, 208
to open pharynx, 287
soft palate, 294
levator veli palatini, 295
palatine nerves, 319
pharyngeal and pterygoid canals,

3 no

larynx, exterior, 328

back, 330

interior, 333, 334, 336

vessels and nerves, 336
cartilages, 338

Divisions of brachial plexus, 52

Ducts; Ductus
cochlea?, 530, 531
endolymphaticus, 531
lacrimal, 4, 27, 29
of lacrimal gland, 247
lymphatic, right, 144, 159
naso-lacrimal, 29

opening in nose, 314

parotid, 14, 164, 279
semicircular, 531
sublingual, 195

opening in mouth, 280

sub-maxillary, 194

opening in mouth, 280

thoracic, 144, 147, 149, 157,

2l6, 221

thyreo-glossal, 129

Dura mater of skull, 99, 273

on base of skull, 114
spinal, 80, 84

Ear, external, 44, 505, 506

internal, 506, 527

middle, 506, 510

Emboli, 385
Eminence, collateral, 439

frontal, 2

Eminentia medialis, 491

Emissaria. See Veins, emissary
Encephalon. See Brain
Endolymph, 506, 527
Enlargements of spinal medulla, 85
Ependyma, 429
Epicranius, 43
Epiglottis, 291, 323, 324

cartilage, 338

ligaments, 339

nerves, 337, 353

during swallowing, 345

tubercle, 324
Epithalamus, 355
Equator of eyeball, 53 2
Excavatio papillae opticae, 542
Eyeball, 531
Eyebrows, 3
Eye " kernel," 543
Eyelashes, 3
Eyelids, 3, 23

vessels and nerves, 26

Face, 2

Falx cerebelli, 112, 113

cerebri, 104, 424

Fascia, bucco-pharyngeal, 20, 279,

283

bulbi, 259
dentata hippocampi, 414, 426,

437, 4*0

luir. bo-dorsal, 59, 60, 63, 71

of neck, deep, 34, 122, 135
pretracheal, 126, 135, 137, 227
prevertebral, 37, 39, 136, 137,

227

superficial, 32, 121

palpebral, 24
parotid, 13, 136
perinephric, 62
pharyngo-basilar, 286
of scalp, superficial, 43
Sibson's, 153, 160
temporal, 14, 167
Fasciculus. See also Bundle
bulbo-spinal, 500

554

INDEX

Fasciculus (contd.}

cerebro-spinal, anterior, 97, 477

lateral, 97, 477, 499

circum -olivary, 482
cune'atus, 97, 480
fronto-pontine, 456, 472
gracilis, 97, 480
longitudinal, medial, 457, 500,

502

superior, 471

mamillo-thalamic, 442, 464, 469

occipito-frontal, 467
olivo-cerebellar, 482
rubro-spinal, 500
solitarius, 501
spino-cerebellar, dorsal, 97, 479,

482, 500
ventral, 500

spino-thalamic, 495, 498, 500

tecto-spinal, 500
temporo-pontine, 456
thalamo-olivary, 500
uncinatus, 470
Fasciola cinerea, 426, 440
Fauces, isthmus of, 278, 281,
290
Fenestra cochleae, 513, 514

vestibuli, 513, 527

Fibres, arcuate, external, 482,

497

fronto-pontine, 456, 472

olivo-cerebellar, 482
temporo-pontine, 456
Fibro-cartilage, intervertebral, 270,

271
Fila radicularia of spinal nerves,

86, 93, 96

Filum terminate, 81, 84, 85

Fimbria, 436, 442
Fissure. See also Sulcus

calcarine, 363, 364, 367, 384, 413,

415, 420, 435

chorioidal, 367, 413, 437, 445

collateral, 367, 413, 416, 439
interlobar, 400
lateral, 400

stem, 365, 397, 400

anterior rami, 401, 406
posterior ramus, 360, 401, 407,

411

longitudinal, 368, 396, 398

of medulla oblongata, 475
of medulla spinalis, 92
oral, 277

orbital, superior, 256

palpebral, 3

Fissure ^

parieto-occipital, 363, 419

lateral, 359, 403

prima, 407

rhinal, 367, 413

transverse, great, 438, 444

Flocculus, 487, 490
Folds. See also Plicae

ary-epiglottic, 291, 292, 323, 324,

339.

glosso-epiglottic, 324, 339, 347

malleolar, 509, 515
pharyngo-epiglottic, 324, 339
salpingo-pharyngeal, 289
ventricular, 322. 325
vocal, 322, 325

movements, 345
Folium vermis, 484, 486, 487
Foramen caecum of medulla, 475

of tongue, 347, 348

infra-orbital, 3
interventricular, 355, 429, 444,

447 , 45

mental, 3
Forceps major, 426, 435

minor, 426, 460

Formatio reticularis of medulla,

497 , 5o

of mid-brain, 457
Fornix of brain, 362, 441
body, 431, 433, 441
columns, 442, 449, 464
crura, 442

of conjunctiva, 5, 26, 27
Fossae

canine, 21

cranial, middle, 234

hyaloid, 543

interpeduncular, 356, 368, 390

lateralis, 417, 461

rhomboid, 491

scaphoid, of auricle, 44

supra-clavicular, 31

supra-tonsillar, 291

temporal, 2
triangularis, of auricle, 44
Fovea centralis, 543

inferior, 492

superior, 492
Frenulum labii, 22, 278

linguae, 194, 280

veli, 452
Funiculus. See also Fasciculus

of Rolando, 481

separans, 492

of spinal medulla, 95

INDEX

555

Galea aponeurotica, 6, 8, 43, 45, 50

Ganglia-
basal, in horizontal section, 460

in vertical section, 462

cervical, inferior, 54, 225, 227
middle, 54, 226
superior, 142, 222, 224, 225
ciliary, 250, 252

roots, 241, 251, 252, 258

geniculate, 226, 242, 524
jugular, 221
nodosum, 221

otic, 179, 181, 182, 199, 220

petrosum, 220
semilunar, 109, 234, 237, 241,

2 99
spheno- palatine, 317, 318

roots, 302, 320

spinal, 86, 88
spiral, 530
submaxillary, 195
superius of glosso-pharyngeal, 220
thoracic, first, 227
Genu of corpus callosum, 362, 425
of internal capsule, 468, 471
Gingivse. See Gums
Glabella, 2
Glands-
apical, of tongue, 351
buccal, 279

carotid. See Glomus caroticum

labial, 22, 278
lacrimal, 27, 245, 247
lymph. See Lymph glands
molar, 20, 21, 279
nasal, 305, 315
of Niihn, 351
palatine, 294, 320
parotid, 13, 20, 35, 40, 130, 161

accessory, 14, 164

duct, 14, 164, 279
pterygoid lobe, 1 66
pharyngeal, 287
sublingual, 194
ducts, 195

opening in mouth, 290

submaxillary, 123, 129, 188, 205
deep part, 194, 195
duct, 194

opening in mouth, 280

tarsal, 3, 24
thyreoid, 134, 149, 227
isthmus, 126, 229
middle lobe, 129, 322
Globus pallidus, 460, 468
Glornus caroticum, 149, 226

Granulations, arachnoid, 100, 103,

104, 374

Gullet. See CEsophagus '

Gums, 279
Gyri

surface marking, 503

angular, 411
annectant, 403, 410
central, anterior, 359, 361, 405

posterior, 359, 361, 410

cinguli, 363, 418
cuneus, 365, 422
cunei, 420
cuneo-lingual, 420
fornicatus, 414
frontal, 361
inferior, 406
middle, 406
superior, 406, 422
fusiformis, 367, 414, 416
of Heschl, 412
hippocampi, 367, 384, 389, 414,

453, 454
of insula, 417

lingual, 365, 367, 414, 416, 422

occipital, 415

occipito-temporal. See G. fusi-

formis

orbital, 365, 408

post-parietal, 411
praecuneus, 364, 422
rectus, 363, 365, 407
rostral, 422
subcallosus, 418, 426
supracallosus, 425, 426
supramarginal, 411
temporal, inferior, 362, 368, 412,
414

middle, 362, 412

superior, 362, 412

transverse, 412

Habenula, 355, 447

Hamulus, pterygoid, felt in mouth,

281

Helicotrema, 530
Helix, 44

Hemisphere of cerebellum, 483

cerebral, 354, 396

borders, 360, 362, 397

lobes, 404
structure, 399
surface, inferior, 365, 397
medial, 362, 396, 419
orbital, 365, 397, 407
supero-lateral, 361, 396, 399

556
INDEX

Hemisphere (contd.}

cerebral, surface, tentorial, 365,

397

Hiatus semilunaris, 312

Hind-brain, 355, 357, 474
Hippocampus, 426, 436
Humor, aqueous, 536, 546
Hyoid bone, 121

Hypophysis cerebri, 106, 120, 355,

368

nerve to, 241

Hypothalamus, 355, 449, 469

Incisura. See also Notch

intertragica, 45

tentorii, 357

thyreoidea, 339

tympanica, 514
Incus, 516, 517
Indusium griseum, 425, 426
Infundibulum of brain, 106. 120,
355> 368, 390, 450

of nose, 312
Inion, 359
Insula, 362, 373, 417, 461, 468

opercula, 401

Intumescenti?e of spinal medulla, 85

Iris, 536, 538, 539, 540
Isthmus, of fauces, 278, 281, 290

of gyrus fornicatus, 367, 414

naso-pharyngeal, 290, 291

rhombencephali, 490

of thyreoid gland, 126, 229

of tuba auditiva, 299

Joints
arytenoid, 344
ary-corniculate, 343
atlanto-epistropheal, 272

movements, 277
atlanto-occipital, 272, 274

movements, 277
crico-thyreoid, 338, 341
of larynx, 338, 341, 344
mandibular, 174

nerves, 180, 181

occipito-atloid, 272, 274
vertebral synchondroses, 269

" Kernel" of eye, 543

Kidney, 62

Labia oris, 278

Labyrinth of ear, 506

membranous, 530

osseous, 527

Lacunae laterales, 103, 104

Lacus lacrimalis, 3

Lambda, 98

Lamina chorio-capillaris, 537, 541,

543

cribrosa of eyeball, 534

of cricoid, 342
elastic, posterior, 536
fusca, 534, 536
medullary, of lentiform nucleus,

460, 468
of thalamus, 469
quadrigemina, 108, 356, 451, 460
spiralis, 530
terminalis, 355, 362, 368, 386,

391, 449

of thyreoid cartilage, 339

Laryngotomy, 328
Larynx, 322

aperture, superior, 291, 322, 323

cartilages, 338
closure, 345

conus elasticus, 127, 328, 330,

333, 334

mucous membrane, 328

muscles, 229-334
actions, 345

position and relations, 322

Lemniscus lateralis, 458, 496, 502

medialis, 458, 494, 498, 500, 502

Lens crystallina, 544, 545
Levator cushion, 298
Ligaments

alaria, 277

annular, of stapes, 519

apicis dentis, 276

atlanto - epistropheal, accessory,

275

atlanto-occipital. See Membrane

of atlas, oblique, 78
of auditory ossicles, 518
of auricle, 46
of cervical vertebrae, 270
check, of eyeball, 260
crico-thyreoid, 127, 330, 343
crico-tracheal, 343
cruciatum, 275
denticulatum, 83, 86, no
of epiglottis, 339
flava, 271

flava, first cervical, 273

hyo-epiglottic, 339
hyo - thyreoid. See L. thyreo-

hyoid

ilio-lumbar, 62
of incus, 519

INDEX

557
Ligaments (conld. )
interspinous, 272
intertransverse, 272
longitudinal, anterior, 270

at atlas, 273
posterior, 82, 270
of malleus, 518

nuchse, 57, 59, 63, 67, 135, 272

oblique, of atlas, 78
occipito - atlantal, posterior, 74,

76, 78

of ossicles of ear, 5 18
palpebral, lateral, 6, 25
medial, 6, 24, 25, 29
pectinatum iridis, 536, 540, 546
spheno - mandibular, 171, 173?

175, 176, 181, 182

of stapes, 519

sterno-clavicular, posterior, 146

stylo-hyoid, 193, 198, 202, 285
stylo-mandibular, 137, 176, 188
supraspinous, 272
suspensory, of eyeball, 260

of lens, 538, 544

temporo-mandibular, 175
thyreo-epiglottic, 323, 336, 339
thyreo-hyoid, lateral, 329

median, 127, 324, 328

transverse, of scapula, superior, 59
ventricular, 325, 336
of vertebrae of neck, 270
vocal, 330, 334, 335
Limen insulae, 417
Line, middle, of neck, 127
nuchal, superior, 31
temporal, 2

Linea splencfens, 83, 86

Lines, meridional, of eye, 532
Lingua. See Tongue
Lingula of cerebellum, 486, 492
Lips, 278

Lobes of cerebellum 485

central, 484, 485, 486
culminis, 486
declivis, 486
noduli, 487
pyramidis, 488
semilunaris superior, 487
tuberis, 488
uvulce, 488
of cerebrum

frontal, 361, 405

inferior surface, 407
medial surface, 408
supero-lateral surface, 405
occipital, 361, 415

Lobes of cerebrum (contd.}

occipital, inferior surface, 416

medial surface, 422
supero-lateral surface, 415
parietal, 361, 408, 422
temporal, 360, 362, 411
inferior surface, 412
lateral surface, 411
upper surface, 412
olfactory, 417

pterygoid, of parotid gland, 166

of thyreoid gland, 228

middle, 229, 322

Lobules of cerebellum
bi ventral, 487, 488
crescentic, 486
gracilis, 488
quadrate, 487
semilunar, 486, 487, 488
of cerebrum

paracentral, 363, 422

parietal, 361, 364, 410, 411
of ear, 44

Locus cceruleus, 492, 502

Lymph follicles of pharynx, 287
Lymph Glands-
auricular, anterior, 50, 163

posterior, 45, 50
axillary, 37
buccal, 22
cervical, deep, inferior, 37

superior, 133
rnastoid, 45, 50
occipital, 50
parotid, 50, 153
submaxillary, 123, 129
submental, 128
supraclavicular, 31
Lymph vessels of scalp, 50
Lyra, 443

Macula lutea, 542

Malleus, 517

handle, 509, 515

lateral process, 509

Mandible, 2, 31
Margin, infraorbital, 2

supraorbital, 2
Massa intermedia 448, 449
Mastoid temporal, 31
Maxilla, 2
Meatus, acoustic, external, 46, 506,

507
internal, 529

naso-pharyngeal, 314

of nose, 312

558

INDEX

Meatus (contd.)

of nose, communis, 314

inferior, 313
middle, 312
superior, 312

Medulla oblongata, 357, 369, 474

structure, 497
surfaces, 476
spinalis, 84

distinction between front and

back, 92
matter, grey, 93

white, 95
membranes, 80
preservation, 92
segments, 87
structure, 92
Membranes
atlanto-occipital, anterior, 273
posterior, 74, 76, 78, 268,

273
of brain, 99, 273, 353, 370,

375

chorio-capillaris. See Lamina

costo-coracoid, 34
flaccida, 509, 515
hyaloid, 540, 544
hyo-thyreoid. See M. thyreo-

hyoid

of medulla spinalis, 80
nictitans, 5

occipito-atloid. See M. atlanto-

occipital
tectoria, 275

thyreo-hyoid, 285, 292, 328

tympanic, 506, 509, 514, 526

secondary, 514
Meninges of brain, 99, 273, 353,

370, 375

of spinal medulla, 80
Meridians of eyeball, 532
Mesencephalon. See Mid-brain
Mid-brain, 108, in, 355, 356, 376,
384, 389, 451, 464, 465, 483
Modiolus, 529, 530,
Monticulus of cerebellum, 484
Mouth, 277
floor, 279
roof, 280

vestibule, 5, 20, 277

Muscles

antitragicus, 46
ary-epiglotticus, 324, 333, 334
arytsenoideus obliquus, 332

transversus, 324, 333

ary-vocalis, 335

Muscles (contd.}

of auricle, extrinsic, 45

auricularis anterior, 14, 45,

50

posterior, 45
superior, 14, 45, 50
intrinsic, 46
of the back, 56

actions, 65, 77
biventer cervicis, 67
buccinator, 15, 16, 20, 21
caninus, 16, 20
of cheek, 10

chondro-glossus, 351, 352

ciliaris, 534, 538
ciliary bundle of orbicularis oculi,

constrictors of pharynx, 284

inferior, 132, 285, 330
middle, 187, 197, 205, 209,

223, 285
superior, 21, 195, 205, 210,

219, 286, 296, 297

corrugator supercilii, 8
crico-arytenoideus lateralis, 330,

333, 335
posterior, 331

crico-thyreoideus, 127, 329, 334

depressor septi nasi, 6, 9
diaphragma oris, 190
digastricus, 185

nerve supply, 187

tendon, 130
anterior belly, 123, 126, 127,

130, 185

posterior belly, 65, 123, 130,

131, 162, 165, 166, 185,

215
dilatator pupilke, 540

tubse, 299
epicranius, 8

frontal belly, 6, 8

occipital belly, 47
frontalis, 6, 8
genio-glossus, 191, 192, 194, 196,

197, 198, 351, 352

genio-hyoideus, 191, 193
glosso-palatinus, 281, 294, 297,

35i, 352

glutoeus maximus, 73
helicis major and minor, 46
hyo-glossus, 130, 131, 133, 187,
188, 191, 192, 194, 195,
196, 198, 219, 351, 352
ilio-costalis, 64, 70, 73

cervicis, dorsi, lumborum, 64

INDEX

559

Muscles (contd.}
incisivi, 22
infrahyoid, 144
interaccessorii, 73
interspinales, 72
intertransversarii, 69, 71, 73

of neck, 265, 266

lacrimal part of orbicularis oculi,

8, 25, 29
of larynx, 329-334

actions, 345
latissimus dorsi, 56, 61
levator glandulae thyreoidea?, 126,

129, 229
palpebrae superioris, 24, 245,

247

insertion, 25
scapulae, 37, 39, 58, 63, 233

nerves, 36, 58
veli palatini, 210, 213, 286,

296, 297, 298

nerve, 297

levatores costarum. 73
longissimus, 64, 70, 73
capitis, 65
cervicis, 64
dorsi, 64, 70
longitudinalis of tongue, inferior,

198, 352
superior, 351
longus capitis', 148, 155, 213, 216,

225, 265
rerve, 142
colli, 148, 154, 225, 226, 231,

263

nerve, 54, 142

masseter, 20, 161, 162, 164, 166,

168, 180
mentalis, 22
of mouth, 10
mylo-hyoideus, 188, 190, 194,

205
multifidus, 72, 73, 74

nerves, 70
nasalis, 7, 9

obliquiis abdominis internus, 62

auriculae, 47
capitis inferior, 76
superior, 66, 76
oculi (both), origin, 256
insertion, 257
limitation of action, 261
relation to fascia, 260
inferior, 258, 259
superior, 244, 249, 251, 253
trochlea, 244, 249

Muscles (contd.}
occipitalis, 47
occipito-frontalis, 8
omo-hyoideus, 144

anterior belly, 129, 131, 133,

145, 148, 202, 203, 228

posterior belly, 34, 35, 36, 40,

58, 144

tendon, 216, 231

orbicularis oculi, 6, 7
ciliary bundle, 8
pars lacrimalis, 8, 25, 29
oris, 6, 7, 10
palato-glossus. See M. glosso-

palatinus
palato-pharyngeus. See M.

pharyngo-palatinus
pharyngo - palatinus, 209, 282,

291, 294
nerve, 297
platysma, 6, 7, 12, 15, 16, 32,

I2i, 127, 148, 151, 163

insertion, 12
procerus, 6, 9

pterygoideus externus, 170, 171,

172, 175, 178, 180, 181,
182
internus, 161, 166, 172, 182,

1 88, 189, 205, 286

quadratus labii inferioris, 7, 12,

18

labii superioris, 7, 10, 16, 17

angular head, 6, 10, 16, 18
infra-orbital head, 7, 10, 20
zygomatic head, 7, 10
lumborum, 62
rectus capitis anterior, 216, 265

nerve, 142
lateralis, 216, 233

nerve, 142
posterior major, 76

minor, 76

oculi (all), origin, 256

insertion, 257
limitation of action, 261
relation to fascia, 260
inferior, 258, 259
lateralis, 247, 258, 259
structures between heads,

256

medialis, 251, 258

superior, 249
rhomboidei, 68, 70
risorius, 7, 12, 16, 163
rotatores, 72
sacro-spinalis, 63, 70, 71
5 6

INDEX

Muscles (contJ.)

sacro-spinalis, actions and nerves,

65, 70, 77

salpingo-pharyngeus, 295
scalenus anterior, 37, 52, 144,
148, 151, 153, 154, I55>
: 5 6 J 59> 1 60, 216, 226,
231
medius, 36, 37, 39, 52, 54,

142, 160, 231, 232

posterior, 39, 233
actions, 233
nerves, 54, 142, 233
semi-spinalis, 66
actions, 77
nerves, 70

capitis, 39, 66, 70, 74, 76

cervicis, 72
dorsi, 72

serratus anterior, 39
posterior inferior, 59

nerves, 61
superior, 59, 68

nerves, 62
sphincter pupillse, 540

vestibuli laryngis, 346

spinalis, 65

cervicis, 65
splenius, 63, 70, 74
capitis, 39, 63, 65
cervicis, 63
stapedius, 512, 519
sterno-hyoideus, 128, 133, 134,

146, 148, 151, 216, 228

sterno-mastoideus, 31, 37, 63, 65,
124, 134, 138, 148, 151,
161, 163, 165, 228, 231
sterno-thyreoideus, 128, 133, 134,

145, 146, 148, 151, 155,

202, 228
stylo-glossus, 191, 193, 195, 205,

351 .

stylo-hyoideus, 123, 130, 131,

162, 165, 166, 187, 202, 215

stylo-pharyngeus, 202, 205, 209,

210, 211, 215, 219, 286,

2 95
subclavius, 52

nerve, 36, 37, 54, 144

temporalis, 168, 169, 170, 180, 181
tensor tympani, 220, 509, 512,

519, 526, 529

veli palatini, 178, 199, 200,

286, 295, 296, 298, 299

nerve, 297
tendon, 319

Muscles (contd.)

thyreo-arytaenoideus, 334
thyreo-epiglotticus, 333, 334
thyreo-hyoideus, 133, 134, 145,

146, 202
of tongue, 350
tragicus, 46
transversus abdominis, 62

auriculae, 46

linguae, 352
trapezius, 38, 56, 70

nerves, 36, 58
triangularis, 7, 12, 18, 20
of tympanum, 519
uvulae, 295, 296

nerve, 297

verticalis linguae, 352

vocalis, 330, 334, 344
zygomaticus, 11, 1 6, 20
Nares. See Nostril
Nasal bone, 2
Nasion, 359
Naso-pharynx, 288
Nerves

abducent, 239, 257, 258, 395

at brain, 369, 395

piercing dura, no, 112, 113

in sinus, 239, 241, 300

in fissure, 257

in orbit, 258
accessory, 41, 58, 217, 218, 223,

297, 394, 476

at brain, 369, 394, 476
palatal muscles supplied, 294,

295, 296, 297

in skull, in, 217
below skull, 133, 135, 165,

213, 217, 218, 221, 223,

225
in posterior triangle, 35, 36,

41, 58
acoustic, 394, 526

at brain, 369, 394, 492

within skull, 110, 112
in meatus, 526

alveolar, inferior, 178, 181, 182

superior, anterior, 303

middle, 302, 303

posterior, 302
. hvi

ansa hypoglossi, 134

subclavia, 140, 227

auricular, great, 13, 35, 40, 48

posterior, 47, 48, 221
of vagus, 220, 221, 526
INDEX

Nerves (contd.}

auriculo-temporal, 14, 47, 175,

177, 178, 181, 199

axillary, 53

buccal, of facial, 14, 15, 20, 164

buccinator, 15, 20, 22, 170, 180
cardiac, of sympathetic, inferior,

227

middle, 226
superior, 222, 225, 226
of vagus, 223

carotico-tympanic, 220, 300

carotid, external, 225, 226

internal, 225, 226, 300

cerebral, attachment to brain, 391

sheaths, 114
cervical, rami, anterior, 140, 266,

268

posterior, 56, 69, 76, 266

first, roots, 89, in, 393, 476
trunk, 86, 88, 268, 273
anterior ramus, 265, 266, 268
posterior ramus, 67, 69, 74,

75, 77, 266, 268

second, roots, 89
trunk, 86, 88
anterior ramus, 265, 266
posterior ramus, 69, 266
cervical, of facial, 14, 15, 20,

122, 163

chorda tympani, 178, 182, 199,

510, 520, 526

ciliary, 250, 540

long, 250, 251, 532, 535

short, 250, 252, 532, 535

coccygeal, posterior ramus, 74
communicans cervicalis. See N.

descendens
ctitaneous, of arm, medial, 54

of back of neck, 56, 69

of back of trunk, 70

of cervical plexus, 32-41

of forearm, medial, 54

of head, 47

of suboccipital, 78
cutaneus colli, 15, 20, 32, 35, 122
deep temporal, 180
descendens cervicalis, 131, 141

hypoglossi, 131, 21 1, 224

dorsalis scapulre, 36, 54 2 33
ethmoidal, anterior, 251, 317

posterior, 251
of eyelids, 26
facial, 18, 164, 395, 524

at brain, 369, 395, 524

within skull, no, 112
VOL. Ill 36

Nerves, facial (contd.}

in temporal bone, 221, 523,

524

in parotid, 164, 165, 207

communications, 19, 20, 181,

219, 221
temporal branches, 14, 15, 19,

26, 47

zygomatic branches, 14, 15, 19,

27, 164

buccal branches, 14, 15, 20, 164

mandibular branch, 14, 15, 20,

164
cervical branch, 14, 15, 20,

122, 163
frontal, 239, 244, 245, 257
glosso-pharyngeal, 217, 218, 219,

352
at brain, 369, 393, 476, 493,

500, 501

in skull, no, 113, 217

below skull, 202, 208, 213, 217,

218, 219, 221, 225

in submaxillary region, 192,

219, 35 2
hypoglossal, 196, 224, 392

at brain, 369, 382, 392, 478,

499

in skull, ill, 224

below skull, 142, 213, 217,

224, 225
in carotid triangle, 130, 131,

213, 218, 224

in submaxillary region, 130,

189, 196

to hypophysis, 241
incisor, 183

infra-orbital, 15, 20, 27, 302

infra-trochlear, 27, 251
intercostal, 73

lacrimal, 24, 26, 27, 239, 245, 257

laryngeal, external, 132, 134,

202, 222

inferior, 223, 285, 330, 337

internal, 132, 202, 222, 285,

329, 337

branches to tongue, 353

superior, 132, 222, 226
laryngo-pharyngeal, 225, 226
to levator scapuloe, 36, 58
lingual, in infra-temporal region,

181, 182
in submaxillary region, 191,
194, 195

lingual, of vagus, 224

to longus capitis, 142

562

INDEX

Nerves (contd.}

to longus colli, 54, 142

lumbar, posterior rami, 70
mandibular, 109, 178, 199

of facial, 14, 15, 20, 164

masseteric, 168, 170, 180
maxillary, 109, 238, 301
median, 52, 53
meningeal, of hypoglossal, 224

of mandibular. See N. spinosus

of maxillary, 238

of ophthalmic, 239

of vagus, 221
mental, 15, 20, 183
musculo-cutaneous, 52
mylo-hyoid, 129, 189
nasal, external, 30, 252

internal, 252

medial, 308

of palatine, 316, 320

of N. of pterygoid canal, 307,

316

of spheno-palatine ganglion,

307, 316, 318

of nasal septum, 307
naso-ciliary, 239, 251, 257, 300
naso-palatine, 307, 318, 320
of nose, side wall, 316
occipital, greater, 48, 55, 56, 69,
70
lesser, 35, 41, 48

third, 48, 55, 70

to occipitalis, 45

oculo-motor, 108, 239, 245, 257,

258, 390, 455

at brain, 368, 374, 384, 390,

.395,455

piercing dura, 106, 108

in sinus, 109, 234, 239, 241,

3o

in fissure, 257
in orbit, 245, 258
olfactory, 106, 305, 307, 316, 395,

417

to omo-hyoid, posterior belly, 36

ophthalmic, 109, 234, 238, 239,

241, 300
optic, 106, 250, 252, 395, 396,

534, 536

orbital, of spheno-palatine gan-

glion, 320

palatine, anterior, 319

great. See N. pal. ant.
middle, 297, 319
posterior, 297, 319
of palate, 297

Nerves (contd. }

palpebral, of lacrimal, 27
petrosal, deep, great, 241, 300

superficial, external, 226, 242,

526

greater, no, 234, 241, 299

lesser, 199, 220, 234, 241,

526

pharyngeal, of glossopharyngeal,
219
of spheno-palatine ganglion, 319

of sympathetic, 226

of vagus, 202, 222, 297

phrenic, 141, 142, 154, 156, 216
of pterygoid canal, 241, 320
to pterygoideus externus, 180

internus, 179, 199

radial, 53

rami communicantes, 225

to rectus capitis anterior, 142

lateralis, 142
recurrent, 147, 222, 337
right, 1 60

of mandibular. See N. spinosus

sacral, posterior rami, 73
to scalenus anterior, 54

medius, 54, 142

posterior, 54
of scalp, 47

to semilunar ganglion, 241, 300

spheno-palatine, 302, 318
spinal, 86

roots, 8 1, 86

trunk, 86, 88

exit from vertebral canal, 88

meningeal ramus, 88

posterior rami, 69

sheaths, 81, 82, 83

spinosus, 178, 179
to stapedius, 526
to stylo-pharyngeus, 219
to subclavius, 36, 37, 54, 144
suboccipital, roots, 89, in, 393,
476

trunk, 86, 88, 268, 273

anterior ramus, 265, 266, 268

posterior ramus, 67, 69, 74, 75,

77, 266, 268

subscapular, 54
supra-clavicular, 32, 33, 34, 38
supra-orbital, 6, 9, 24, 27, 47,

245

supra-scapular, 36, 54, 59

supra-trochlear, 6, 24, 27, 47,

244, 245
sympathetic trunk, 54, 147, 225

INDEX

563

Nerves (contd. )

temporal, of facial, 14, 15, 19,

26, 47
deep, 170, 180

of temporal region, superficial, 47

terminales, 391

thoracic, anterior rami, 73

posterior rami, 70
thoracic, anterior, 54

!ong, 36, 37, 233

thoraco-dorsal, 54
to thyreo-hyoideus, 131, 224
to thyreoid gland, 226
of tongue, 352

to tonsil, of glossopharyngeal, 219

to trapezius, 36, 58
trigeminal, no, 112, 236, 368,

395, 483
nuclei, 455, 501
motor root, 112, 238, 368, 395
sensory root, 109, 112, 236,

368, 395

tractus spinalis, 481, 501

trochlear, 112, 239, 455, 489
at brain, 368, 384, 395, 455,

485, 489
piercing dura, 108, 112, 239
in sinus, 109, 234, 239, 241,

300

in fissure, 244, 257

in orbit, 247

trunk, sympathetic, 54> 147 5 225

tympanic, 220
ulnar, 53
vagus, 217, 218, 220, 369, 393,

500
at brain, 369, 382, 394, 476,

499. 500, 501

within skull, in, 217, 220

below skull, 213, 218, 220,- 225
in carotid triangle, 213, 218, 220
in root of neck, 140, 147, 154,

218, 221
zygomatic, of facial, 14, 15, 19,

27, 164

zygomatic, of maxillary, 261, 302

zygomatico-facial, 14, 19, 262
zygomatico-temporal, 14, 19, 47,

262

Nose, cavity, 282, 293, 304, 308

cartilages, 30, 306
external, 2
floor, 309

olfactory region, 315

respiratory region, 315
roof, 308

Nose (contd.}

septum, 304, 306

vestibule, 304, 310

Nostrils, 308, 310
Notch, of cerebellum, 369, 483

intertragic, 45

pre-occipital, 360

supra-orbital, 3
of tentorium, 357

thyreoid, 339

tympanic, 514
Notochord, 276
Nucleus ambiguus, 499, 500

amygdaloid, 435, 469

arcuate, 500

caudate, 467
body, 431, 433
head, 432, 462, 463
tail, 435, 461, 469

of corpus mamillare, 442

cuneatus, 481, 495, 497, 501

dentatus, 489, 493

emboliformis, 494

fastigii, 494

globosus, 494

of glossopharyngeal and vagus,

499, 5 I

gracilis, 481, 495, 497, 501

hypoglossal, 499
lateralis, 499, 500
of lens, 546
lentiform, 462, 463, 465, 467,

469, 470
oculomotor, 455
olivary, 500

accessory, 500

superior, 502
pontis, 502
red or ruber, 458, 465
roof, 494
of thalamus, 469
of tractus spinalis, 500, 501
trigeminal, 455
trochlear, 455
vagus, 499, 501
vestibular, 5 QI

Obex, 492, 493. 497

Oesophagus, 231, 285
attachment to larynx, 330, 343
Olive, 369, 479, 500

accessory, 500

superior, 502
Opercula insulse, 401
Ophthalmoscope, 543
Ora serrata, 542

564

INDEX

Orbiculus ciliaris, 537, 539

Organ, vomero-nasal, 305
Ossicles, auditory, 517
Osteum pharyngeum of auditory
tube, 289, 296

Pad, suctorial, 15, 21

Palate, hard, 280

soft, 280, 287, 293

Palpebne, 23

nerves and vessels, 26

Papilla, incisive, 280
lacrimalis, 4
lingual, 348
conicse, 349
filiformes, 350
foliatse, 348
fungiformes, 349
vallatae, 348
nervi optici, 542
Pars basilaris, 406
ciliaris retinae, 542
lacrimalis of orbicularis oculi, 8,

25, 29

orbitalis, 407
triangularis, 407
Peduncle of cerebellum, inferior,

481, 489
middle, 482, 489
superior, 484, 489
of cerebrum, 108, in, 356, 376,
384, 389, 454, 464, 465, 483
of thalamus, 469
anterior, 472
temporal, 470
Pericranium, 98
Perilymph, 506, 527
Pes hippocampi, 436
Petiolus, 339
Pharynx, 282
interior, 287
nasal part, 288
oral part, 290
laryngeal part, 291
Pia mater of brain, 353, 375

arteries, 375, 382

spinal, 83

Pleura, cervical, 159, 217, 232, 233

Plexuses of Nerves

brachial, 31, 36, 37, 42, 52

relations, 54
roots, 52, 231, 232
buccal, 1 80
cardiac, 226, 227. (See imder

N. vagus also]
carotid, external, 202, 226

Plexuses of Nerves (contd. )

carotid, internal, 236, 238, 239,

241, 300

cavernous, 300

cervical, 41, 141

posterior, 76

ciliary, 538

infra-orbital, 15, 20, 27

pharyngeal, 222, 223, 283

tympanic, 300

vertebral, 227, 268

Plexuses of Veins

basilar, 80, 114, 379

chorioid, of lateral ventricle, 431,

433, 434, 438, 444

of inferior horn, 386
of fourth ventricle, 493 -
of third ventricle, 444
nasal, 315

pharyngeal, 117, 217, 235, 283,

284, 379

pterygoid, 16, 117, 118, 174, 235,

255, 284, 303

suboccipital, 50, 117, 269

vertebral, 268, 269

of vertebrae, internal, 79, 80

posterior, 74
Plicae. See also Folds

ciliares, 539

fimbriata, 348

lacrimalis, 29

semilunaris of eye, 5

sublingualis, 194, 279

triangularis of tonsil, 291

Pole of brain, frontal, 359, 396
occipital, 359, 396, 415
temporal, 360, 397

of eyeball, 532
Pons, 357, 368, 482

structure, 501
Portio major, 236

minor, 238
Prsecuneus, 364, 422
Process, auditory, 46

ciliary, 539, 543, 544, 546

cochleariformis, 512

frontal, of maxilla, 2

helicis caudatus, 46

lenticularis, 518

of malleus, 509, 517

muscular, of arytenoid, 344

vocal, 344
Prominence, laryngeal, 340
Promontory of ear, 5!3 53
Pulley of superior oblique, 244, 249
Pulvinar, 448, 470

INDEX

565

Puncta lacrimalia, 4, 29
Pupil, 540

Putamen, 460, 468, 469

Pyramid of cerebellum, 487, 488

of ear, 511

of medulla, 369, 476

Radiation, acoustic, 470, 471, 474,

496

of corpus callosum, 426

optic, 470, 471, 474

Kami communicantes, 54

of ganglion cervicale inferius, 227

medium, 226
superius, 225
Rami ad pontem, 384
Ramus of mandible, 2
Raphe of mylo-hyoids, 126, 190

of palate, 280.. 293

palpebral, lateral, 6, 25

of pharynx, 285

pterygo-mandibular, 21, 286

Recessus ellipticus, 528

epitympanicus, 367, 510, 513,

5H, 5 1 ?

infundibuli, 450

opticus, 450

pharyngeus, 289
pinealis, 450

piriformis, 291, 292, 337

sphaericus, 528

spheno-ethmoidalis, 314

sup--a- pinealis, 451

supra-tonsillaris. See Fossa

of ventricle, fourth, 490, 491, 493

third, 450

Reflex, red, of eye, 543

Region, subthalamic, 446, 465
Retina, 536, 542, 543
Rhombencephalon, 355, 357
Rima glottidis, 326, 336

closure and opening, 345

palpebrarum, 3

vestibuli, 325

Rostrum of corpus callosum, 362,

426

Sac, conjunctival, 29

lacrimal, 4, 24, 25, 29

Saccule of ear, 531
Scala, media. See Duct, cochlear

tympani, 530

vestibuli, 527, 530

Scalp, 42, 47, 48, 51
Sclera, 5, 531, 532, 534, 536, 538,
541

Segment, neural, 87
Septum of medulla spinalis, 83, 92
of nose, 304, 306
pellucidum, 362, 431, 432, 440
subarachnoid, 83
of tongue, 350, 353
Sheath of axillary artery, 37
carotid, 135, 136, 138
of cerebral nerves, 114
of optic nerve, 250, 259
of orbital muscles, 260
of parotid gland, 136
of spinal nerves, 81, 82, 83
of subclavian vein, 157
of submaxillary gland, 136
of thyreoid gland, 227
Sinuses, Air

ethmoidal, 310, 312, 313

nerves, 251, 318

frontal, 312, 313
maxillary, 302, 303, 310, 312, 313

nerves, 303
sphenoidal, 314

nerves, 251, 319

Sinuses, Blood, 114
basilar. See Plexus
cavernous, 108, 109, 235, 255,

302, 378

inter-cavernous, 107, 235

occipital, 80, 113, 378
petrosal, inferior, 109, 113, 114,

217, 235, 378, 379

superior, 109, 114, 235, 378
sagittal, inferior, 105, 108, 109,

378
superior, 99, 101, 103, 105, 109,

378, 360, 365

sigmoid, 113, 521
spheno-parietal, 106, 109, 235
straight, 105, 108, 109, 378, 398
transverse, 103, 109, 113, 213,

360, 378

venosus scleroe, 535

j Sinus of Morgagni, 286, 297
Space, epidural, 80

perichorioidal, 534, 540

subarachnoid, of brain, 370

spinal, 82
subdural, of skull, 103

spinal, 82
suboccipital, 74
supra-sternal, 122
Spatia anguli iridis, 536, 546

zonularia, 545, 546

Speculum, aural, 515
Sphincter. See Muscles
566

INDEX

Spina helicis, 46

Splenium of corpus callosum, 362,

425, 427, 444, 451

formation, 427
Stalks of thalamus, 469
Stapes, 513, 518, 527
Stratum pigment! iridis, 542

zonale of thalamus, 447, 469

Stria Gennari, 420

longitudinalis, 425, 426

medullaris of thalamus, 447

of fourth ventricle, 492

olfactory, 417, 418
Prussak's, 515

terminalis, 431, 433, 435, 462

Substantia ferruginea, 492, 502
gelatinosa in medulla oblongata,

481

in medulla spinalis, 94
nigra, 108, 455

perforata anterior, 365, 376, 384,

390, 407, 434, 463, 468, 469,

471

posterior, 368, 390, 449

Suctorial pad, 15, 21
Sulci. See also Fissures
of cerebellum ) horizontal, 485

valleculse, 484
of cerebrum , 399

surface marking, 503

callosal, 363, 420
central (Rolandi), 359, 363, 402
cinguli, 363, 420
corporis callosi, 363, 420
diagonal, 407
fimbrio-dentate, 440
frontal, inferior, 405

middle, 407

paramedial, 406, 407

superior, 405
fronto-marginal, 407
1 1 -shaped, 407
hypothalamic, 355, 450
insuke centralis, 417

circularis, 362, 401, 417

intraparietalis proprius, 361,

410

lunatus, 361, 415

occipital, lateral, 362, 415

paramedial, 362, 415

transverse, 410, 415

olfactory, .365, 407
orbital, 365, 407
parietal, superior, 411
par-occipital, 410, 411, 415
post-central, 361, 409

Sulci of cerebrum (conf<t.}-~

precentral, 361, 405
for superior sagittal sinus, 396
sub-parietal, 363, 421
temporal, 362
inferior, 367, 414
middle, 411, 412
superior, 411
of medulla oblongata
limitans, 492
postero-intermediate, 480
postero-lateral, 393
post-olivary, 393
of medulla spinalis, 92
oculo-motor, of mid-brain, 455
olfactory, of nose, 311
scleroe, 535
terminalis, 347, 348
tympanicus, 509, 514
Swallowing, closure of larynx, 346
Synchondroses of cervical vertebrae,
269

Trenia thalami, 447

of fourth ventricle, 491

Tapetum of corpus callosum, 426,

435

of eyeball, 537
Tarsi of eyelids, 23, 24
Tears, 27, 28
Tectum of mid-brain, 108. See also

Lamina quadrigemina
Teeth, 279

Tegmen tympani, 367, 510, 516

Tegmentum of mid-brain, 108, 449,

454, 456, 465, 469

Tela chorioidea of fourth ventricle,

492

of third ventricle, 431, 442, 443

Telencephalon, 355
Temporal bone, 2
Tentorium cerebelli, 104, 106, 108,

357
Thalamus, 355, 431, 433> ***> 449>

465

structure, 469
Tongue, 286, 346

mucous membrane, 346

muscles, 350
nerves, 352
papilla:, 348
septum, 350, 353
Tonsil of cerebellum, 487
palatine, 205, 282, 297, 319
pharyngeal, 290

INDEX

567

Torus tubarius, 289, 299

Trachea, 230

Tracts. See also Fasciculus

olfactory, 365, 418

optic, 368, 389, 453

spinal, of trigeminal, 481, 501

uveal, 533, 536

Tragus, 45
Triangle, anterior, boundaries,

120

subdivisions, 125

carotid, boundaries, 125, 130

contents, 130

digastric, 125, 129

muscular, 125, 133

posterior, 32, 37

submental, 126, 127

suboccipital, 74
Trigone, collateral, 435, 439

habenular, 355, 447, 469

hypoglossi, 492

olfactory, 418
Trochlea of orbit, 244, 249
Trunks of brachial plexus, 52

of corpus callosum, 362

costo-cervical, 156, 160

lymphatic, broncho-mediastinal,

159

jugular, 159
subclavian, 159.
sympathetic, 54, 147, 225
thyreo-cervical, 154, 217
Tube, auditory, 199. 200, 282, 287,

298, 512, 519, 520

cartilaginous, 295, 296, 298
isthmus, 299
nerves, 220, 318
opening in pharynx, 289, 296
opening in tympanum, 512, 520
osseous, 298, 512, 519, 520
Tuber cinereum, 355, 368, 390, 448,

45, 453
vermis, 488
Tubercle, amygdaloid, 435, 462

corniculate, 292

cuneiform, 292

Darwin's, 45

of epiglottis, 324

of thalamus, anterior, 447

of thyreoid cartilage, 340, 341

Tuberculum acusticum, 492

cinereum, 481, 497

impar, 347

Tuberosity, frontal, 2
Tunica vasculosa oculi, 536
Tympanum. See Cavity

Umbo, 509, 515

Uncus, 367, 391, 414, 437
Utricle of ear, 530
Uvula of cerebellum, .488
of palate, 280, 293

Vallecula cerebelli, 369, 484

of tongue, 324
Vallum, 349
Valves of external jugular vein, 37,

40

of internal jugular vein, 217

of right lymphatic duct, 159
of thoracic duct, 159
Vasa vorticosa, 537
Veins-
alveolar, inferior, 182
anastomotic, 378
angular, 7, 16, 26, 48, 117, 255
auditory, 1 12

auricular, posterior, 32, 40, 50

basal, 108, 376, 378, 379
of brain, 103, 376, 444
cephalic, 63
of cerebellum, 378
cerebral, 103, 376
anterior, 376, 378
great, 108, 373, 376, 378, 444
inferior, 235, 377
internal, 444
middle, deep, 376

superficial, 235, 377

superior, 377
cervical, deep, 66, 69, 154, 156

transverse, 34, 40, 123

of chorioid plexus, 444
comitans hypoglossi, 130, 191,

196, 198

condyloid, posterior, 117

deep cervical, 66, 69, 154, 156
facial, 1 6, 174
of tongue, 348
emissary ', 116

of cavernous sinus, 117, 235

mastoid, 66, 113, 117
from nose, 103, 116
parietal, 56, 117
post-condyloid, 117
of pterygoid plexus, 174
facial^ anterior^ 16, 206

in face, 7, 13, 16, 20, 48, 174

in neck, 50, 123, 130, 206
common, 50, 130, 131, 201,

206, 211
deep, 16, 174

568

INDEX

Veins, facial (contd. )

posterior, 14, 40, 48, 50, 130,

164, 20 1

frontal, 16, 26, 48

of hemispheres, cerebral, 376
infra- orbital, 303
innominate, 144

left, 140
intercostal, 71, 74, 79
intervertebral, 80
jugular, anterior, 123
anastomosis, 122, 123
in superficial fascia, 122, 123
under sterno-mastoid, 34, 40,

123, 144, 148, 151, 216

jugular, external, 40

on sterno-mastoid, 32, 34,

35, 40
in posterior triangle, 34, 37,

40, 123, 157

valves, 37, 40
external, posterior, 40
internal, 213

bulb, 213, 221, 511 .

below skull, 114, 213, 379
in carotid triangle, 131, 134,

213

in root of neck, 31, 144, 213

valve, 217
labial, 16
lingual, 130, 131, 191, 198, 201,

211

deep, 348
lumbar, 71, 74, 79
masseteric, 16

maxillary, internal, 174, 175

meningeal, 116, 119

middle, 100, 118

of mid-brain, 378
nasal, external, 16
occipital, 50, 66, 217
ophthalmic, 117, 235, 250, 255
inferior, 174, 255
superior, 255
palpebral, 16, 26
parotid, 16
pharyngeal, 284
of pons, 379
profunda cervicis, 66, 69, 154,

156

faciei, 16, 174

linguse, 348
Veins (contd. )
of retina, 543
of scalp, 48

scapular, transverse, 34, 40, 123

of spinal medulla, 91
striate, 376

subclavian, 39, 153, 157, 160, 231

supra-orbital, 16, 48
temporal, middle, 48, 1 68

superficial. 48
terminalis, 433, 445
thyreoid, inferior, 155, 230
middle, 148, 230
superior, 131, 148, 203, 230
of tongue, 130, 131, 191, 198,

201, 211
deep, 348
transverse cervical, 34, 40, 123

scapular, 34, 40, 123

vertebral, 66, 74, So, 151, 154,

1 60, 269

anterior, 154, 156

vorticosse, 532, 535, 537, 541
Velum, medullary, anterior, 395,

452, 484, 489, 492

posterior, 487, 489
palatinum. See Palate, soft
Ventricle of brain, fourth, 357, 490
apertures, 493
roof, 484

lateral, 355, 426, 429

central part, 432
anterior horn, 432, 462
inferior horn, 373, 435, 462,

466, 467, 468

posterior horn, 434
third, 355, 448
Ventricle of larynx, 327
Vermis of cerebellum, 483 '
inferior, 370
superior, 369
Vestibule of ear, 527, 529
of larynx, 323
of mouth, 5, 20, 277
of nose, 304, 310
Vibrissae, 304, 310
Vomero-nasal organ, 305
Windpipe. See Trachea

Zonula ciliaris, 540, 541, 544

Zygomatic bone, 2

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