Download More ebooks [PDF]. Format PDF ebook download PDF KINDLE.

Full download ebooks at ebookmass.com

Human Anatomy: Color Atlas and Textbook

6th Edition John A. Gosling

For dowload this book click BUTTON or LINK below

https://ebookmass.com/product/human-anatomy-color-
atlas-and-textbook-6th-edition-john-a-gosling/

OR CLICK BUTTON

DOWLOAD NOW

Download More ebooks from https://ebookmass.com

More products digital (pdf, epub, mobi) instant
download maybe you interests ...

Koneman’s Color Atlas and Textbook of Diagnostic

Microbiology (Color Atlas & Textbook of Diagnostic
Microbiology) 7th Edition, (Ebook PDF)

https://ebookmass.com/product/konemans-color-atlas-and-textbook-
of-diagnostic-microbiology-color-atlas-textbook-of-diagnostic-
microbiology-7th-edition-ebook-pdf/

Imaging Atlas of Human Anatomy 4th Edition

https://ebookmass.com/product/imaging-atlas-of-human-anatomy-4th-
edition/

McMinn’s Color Atlas of Lower Limb Anatomy 5th Edition

Bari M. Logan

https://ebookmass.com/product/mcminns-color-atlas-of-lower-limb-
anatomy-5th-edition-bari-m-logan/

Human Anatomy (6th Edition) Michael Mckinley

https://ebookmass.com/product/human-anatomy-6th-edition-michael-
mckinley/
Atlas of Human Anatomy (Netter Basic Science) 7th
Edition

https://ebookmass.com/product/atlas-of-human-anatomy-netter-
basic-science-7th-edition/

atlas of human anatomy 7th Edition Frank H Netter

https://ebookmass.com/product/atlas-of-human-anatomy-7th-edition-
frank-h-netter/

Atlas of Human Anatomy 7th Edition Frank H. Netter

https://ebookmass.com/product/atlas-of-human-anatomy-7th-edition-
frank-h-netter-2/

Netter Atlas of Human Anatomy Frank H. Netter

https://ebookmass.com/product/netter-atlas-of-human-anatomy-
frank-h-netter/

Clinical Atlas of Human Anatomy 8th Edition Peter H.

Abrahams

https://ebookmass.com/product/clinical-atlas-of-human-
anatomy-8th-edition-peter-h-abrahams/
HUMAN
ANATOMY
J.A. Gosling MD, MB ChB, FRCS, FAS Contributors to previous editions
Photography by:
Professor of Anatomy
Stanford University A.L. Bentley ABIPP, AIMBI, MBKS
USA
Formerly Medical Photographer
Faculty of Life Sciences
P.F. Harris MD, MB ChB, MSc, FAS
University of Manchester
Emeritus Professor of Anatomy UK
University of Manchester
UK J.L. Hargreaves BA(hons)
Formerly Medical Photographer
J.R. Humpherson MB ChB
Faculty of Life Sciences
Formerly Senior Lecturer in Anatomy University of Manchester
Faculty of Life Sciences UK
University of Manchester
UK Embalming and section cutting by:

I. Whitmore MD, MB BS, LRCP MRCS, FAS J.T. Davies LIAS

Professor of Anatomy Formerly Senior Anatomical Technician
Stanford University Faculty of Life Sciences
USA University of Manchester
UK
P.L.T. Willan MB ChB, FRCS
Formerly Professor of Anatomy
University of UAE
Al-Ain
United Arab Emirates

HUMAN
SIXTH
EDITION

ANATOMY
Color Atlas and Textbook
Edinburgh London New York Oxford Philadelphia St Louis Sydney Toronto 2017
First edition 1985
Second edition 1990
Third edition 1996
Fourth edition 2002
Fifth edition 2008
Sixth edition 2017

© 2017 Elsevier Ltd. All rights reserved.

The right of J.A. Gosling, P.F. Harris, J.R. Humpherson, I. Whitmore and P.L.T.
Willan to be identified as author/s of this work has been asserted by them in
accordance with the Copyright, Designs and Patents Act 1988.

No part of this publication may be reproduced or transmitted in any form or by

any means, electronic or mechanical, including photocopying, recording, or any
information storage and retrieval system, without permission in writing from
the publisher. Details on how to seek permission, further information about the
Publisher’s permissions policies and our arrangements with organizations such as
the Copyright Clearance Center and the Copyright Licensing Agency, can be found
at our website: www.elsevier.com/permissions.

This book and the individual contributions contained in it are protected under
copyright by the Publisher (other than as may be noted herein).

ISBN 978-0-7234-3827-4
eISBN 978-0-7234-3828-1

Notices
Knowledge and best practice in this field are constantly changing. As new research
and experience broaden our understanding, changes in research methods,
professional practices, or medical treatment may become necessary.
Practitioners and researchers must always rely on their own experience and
knowledge in evaluating and using any information, methods, compounds, or
experiments described herein. In using such information or methods they should be
mindful of their own safety and the safety of others, including parties for whom
they have a professional responsibility.
With respect to any drug or pharmaceutical products identified, readers are
advised to check the most current information provided (i) on procedures featured
or (ii) by the manufacturer of each product to be administered, to verify the
recommended dose or formula, the method and duration of administration, and
contraindications. It is the responsibility of practitioners, relying on their own
experience and knowledge of their patients, to make diagnoses, to determine
dosages and the best treatment for each individual patient, and to take all
appropriate safety precautions.
To the fullest extent of the law, neither the Publisher nor the authors,
contributors, or editors, assume any liability for any injury and/or damage to
persons or property as a matter of products liability, negligence or otherwise, or
from any use or operation of any methods, products, instructions, or ideas
contained in the material herein.

The
publisher’s
policy is to use
paper manufactured
from sustainable forests

Printed in China
For Elsevier:
Senior Content Strategist: Jeremy Bowes
Content Development Specialist: Nani Clansey
Project Manager: Andrew Riley
Designer/Design Direction: Miles Hitchen
Illustration Manager: Amy Faith Naylor
 Preface to the Sixth Edition

The prime purpose of the first edition of Human Anatomy was to In this edition we have continued to improve the text and the
present topographical anatomy as it is seen in the dissecting room. diagrams by remedying omissions and removing errors and
The unique combination of photographs with accompanying ambiguities. In addition, we have added new radiographs and
labelled diagrams and concise text is preserved in this edition. scans. The numerous examples of clinical and applied anatomy
However, the book has evolved to accommodate modern trends in each chapter are now clearly identified. After discussions
in the teaching of anatomy to emphasise clinical applications and with the publisher, we elected to indicate clinical comments by
problem solving. highlighting in blue and to employ enclosing arrows in some
electronic media.
Changes have included the addition of introductory sections for
each chapter to provide an overview of each region; the incorpora- Whilst the book was initially written for medical and dental stu-
tion of selected radiographs and CT scans and MR images; and dents, the content will now also be useful to candidates preparing
the use of cross sections of all regions of the body to provide a for higher qualifications in surgical specialties and radiology. It
basis for interpreting body scans. will also be relevant to students in other professions where
anatomy is a significant component of the course.
Self-assessment exercises have included clinical case histories and
multiple choice questions, as well as radiographs and scans, It is with sadness that we report the death of John Davies whose
together with anatomical sections. skills as an embalmer enabled the authors to prepare the many
dissections presented in this atlas.
In previous editions the terminology was updated to conform to
Terminologia Anatomica and a list of alternative terms is included. J.A.G., P.F.H., J.R.H., I.W., P.L.T.W.
On occasions fonts have changed to improve readability. 2016
Preface to the First Edition

Despite the many anatomical atlases and textbooks currently subsequent chapters describe anatomy primarily through dissec-
available, there appeared to be a need for a book which combined tion, a regional approach has been employed. Features of bones
the advantages of each of these forms of presentation. This book are described only when considering their related structures,
was conceived with the intention of filling that need. With a especially muscles and joints; osteology is not considered in its
unique combination of photographs of dissections, accompanying own right. The internal structure of the ear and eye are beyond
diagrams and concise text, this volume aims to provide the student the scope of this book since the study of these topics requires
with a better understanding of human anatomy. microscopy; the anatomy of the brain and spinal cord are also
excluded as they are usually taught in special courses.
The basis of this work is the cadaver as seen in the dissecting
room; therefore, reference to surface and radiological anatomy is The level of detail contained in this book is appropriate for current
minimal. Likewise, comments on the clinical and functional sig- courses in topographical anatomy for medical and dental under-
nificance of selected anatomical structures are brief. However, graduates. In addition, it will be of value to postgraduates and to
comparison is made where appropriate between the anatomy of students entering those professions allied to medicine in which
the living and that of the cadaver. anatomy is part of the curriculum.

Each dissection was specially prepared and photographed to The terminology employed is that which is most frequently
display only a few important features. However, since photo- used in clinical practice. Where appropriate, alternatives (such
graphs of dissections are inherently difficult to interpret, each is as those recommended in Nomina Anatomica) are appended in
accompanied by a guide in the form of a drawing. Each drawing brackets.
is coloured and labelled to highlight the salient features of the
dissection and is accompanied by axes to indicate the orientation Preparation of the dissections and the text has occupied the
of the specimen. Adjacent photographs often depict different authors for nearly five years. Our objective was to create a high
stages of the same dissection to help the student construct a three quality and visually attractive anatomical work and we hope that
dimensional image. the time and effort spent in its preparation is reflected in the fin-
ished product.
The first chapter introduces anatomical terminology, provides
general information about the basic tissues of the body, and J.A.G., P.F.H., J.R.H., I.W., P.L.T.W.
includes overall views of selected systems. Because the six Manchester, 1985
 Acknowledgements for All Editions

The authors are indebted to Drs Victoria Clague, Gulraiz Ahmad Our families deserve special mention, as without their untiring
and Peter Mullaney, Professors Waqar Bhatti, R.S. Harris and support and patience these editions would certainly not have
A.R. Moody, and to the Departments of Radiology at Kaiser come to publication.
Permanente, San Rafael CA and Manchester University for the We thank them all.
provision of radiographs, CT scans and MR images. J.A.G., P.F.H., J.R.H., I.W., P.L.T.W.
 MISSING

USE CHAPTER OUTLINES WITH DIRECT PAGE LINKS

 Human Anatomy User Guide

Organization In diagrams showing muscle attachments on bone, the areas are

shown using the muscle colour enclosed by different coloured
This book begins with a chapter on basic anatomical concepts.
lines. In other diagrams colour indicates the extent of a compart-
This is following seven chapters, each with its own introduction,
ment or space.
on the different regions of the body. Information is usually pre-
sented in dissection order, progressing from the surface to deeper
structures. The limbs are described from proximal to distal with
the joints considered last.

Text and Photographs

Where possible the text and photographs are arranged on
self-contained two-page spreads, so that the reader can locate
relevant illustrations without turning a page. Clinical content is
highlighted in blue in the print edition or indicated by enclosing
arrows in eBook versions ( ). Coracobrachialis

Brachialis
Accompanying Diagrams
Pectoralis major
Adjacent to each photograph is a line diagram in which colour is
Deltoid
used to focus attention on particular structures in the dissection.
The colours usually conform to the following code:

Artery Ligament/Tendon

Labels and Leader Lines

The structures of particular interest in each diagram are labelled.
Bone Mesentery/Peritoneum
A single structure is named in a label either with a single leader
line or by a leader line which branches to show different parts of
the same structure. However, if two or more structures are named,
Capsule/Fascia Muscle
the first has the main leader line terminating on it while the sub-
sequent structures are indicated by side branches given off at
progressively shorter distances from the label. A leader line
Duct Nerve
ending in an arrow indicates a space or cavity.

Fat Organ

Lumen of
vein
Fibrocartilage Space Vein,
artery
and nerve
Vein

Gland Vein

Hyaline cartilage Mucous membrane

xii Human Anatomy User Guide

Orientation Guides Terminology Self-assessment

Next to the diagrams are orientation guides The book conforms to Terminologia Ana- The photographs in the main body of each
in which the following abbreviations tomica, using the English terms. The list of chapter are unfettered by labels, leader
are used: alternative terms relates older non-official lines or other superimposed markings;
L left P posterior pr proximal terms to their modern equivalent. thus, readers can readily test their knowl-
R right A anterior d distal edge by either masking the whole of
S superior la lateral the accompanying diagram and studying
I inferior m medial the photograph alone, or covering only the
labels.
Orientation guides in oblique views Exams Skills, Clinical Case Skills &
employ large and small arrow heads and Observations Skills are provided after each
long and short arrow shafts. Here are four chapter to allow readers to further self-test.
examples: Answers to Exam Skills and Clinical Case
Skills are at the end of the book; those for
from in front; Observation Skills are at the bottom of the
same page as the picture.

R L

from behind;

m la

pr

from the left side and

slightly in front;

A P

from the left side, slightly

above and in front.

A P
I
 Chapter 1
BASIC ANATOMICAL CONCEPTS
Terms of Position and Movement 2 Bone 10
Basic Tissues and Structures 5 Skeleton 11
Skin 5 Joints 12
Subcutaneous tissue (superficial fascia) 5 Serous membranes and cavities 15
Deep fascia 5 Blood vessels 16
Muscle 7 Lymphatic vessels and nodes 19
Cartilage 9 Nervous tissue 20
2 CHAPTER • 1 •Basic Anatomical Concepts

To avoid ambiguity and confusion, anatomical terms of position

Terms of Position and Movement and movement are defined according to an internationally
accepted convention. This convention defines the anatomical
position as one in which the human body stands erect with the
feet together and the face, eyes and palms of the hands directed
forwards (Fig. 1.1).
Superior With the subject in the anatomical position, three sets of planes,
mutually at right angles, can be defined.
Lateral Vertical (or longitudinal) planes are termed either coronal or
Medial
sagittal. Coronal (or frontal) planes (Fig. 1.2) pass from one side
Medial
Lateral to the other, while sagittal planes (Fig. 1.3) pass from front to back.
Median
sagittal
S
plane
R L

I
Brain
Coronal
plane

Horizontal
plane

Proximal

Mandible Oral cavity

Fig. 1.2 Coronal section through the head.

Distal
S

A P

I
Heart Lung

Posterior
Right

Left
Anterior

Inferior

Fig. 1.2 Fig. 1.4

Fig. 1.3 Fig. 1.5

Diaphragm Stomach Liver
Fig. 1.1 Anatomical position and the terms used Fig. 1.3 Sagittal section through the trunk. This section lies to the left of the median sagittal plane.
in anatomical description.
 Terms of Position and Movement 3

One particular sagittal plane, the median sagittal (midsagittal) Superior and inferior are terms used to indicate the relative
plane, lies in the midline and divides the body into right and left head/foot positions of structures (Fig. 1.1). Those lying towards
halves (Fig. 1.4). the head (or cranial) end of the body are described as superior to
Horizontal (or transverse) planes (Fig. 1.5) transect the body others, which are inferior (or caudal). Thus the heart lies superior
from side to side and front to back. to the diaphragm; the diaphragm is inferior to the heart. In the
Sections cut at right angles to the long axis of an organ or parts limbs, the terms proximal and distal have comparable meanings.
of the body are also known as transverse. Similarly, longitudinal For example, the elbow joint is proximal to the wrist but distal to
sections are cut parallel to the long axis. the shoulder. These terms are also used to indicate the physiologi­
The terms medial and lateral are used to indicate the position cal direction of flow in tubes, such as the oesophagus is proximal
of structures relative to the median sagittal plane. For example, to the stomach.
the ring finger lies lateral to the little finger but medial to the The terms superficial and deep indicate the location of struc­
thumb. The front and back of the body are usually termed the tures in relation to the body surface. Thus the ribs lie superficial
anterior (or ventral) and posterior (or dorsal) surfaces, respec­ to the lungs but deep to the skin of the chest wall (Fig. 1.5).
tively (Fig. 1.1). Thus one structure is described as anterior to
another because it is placed farther forwards.

A P
Vertebrae of
I Trachea spinal column

Liver Sternum
Fig. 1.4 Median sagittal section through the trunk.

Skin Heart Left lung

A
Ribs
R L

Fig. 1.5 Transverse section through the thorax at the level of the intervertebral disc between the sixth and seventh thoracic vertebrae. Inferior aspect.
(Compare Fig. 2.71.)
4 CHAPTER • 1 •Basic Anatomical Concepts

Movements at joints are also described by specific terms. From

the anatomical position, forward movement of one part in relation S

to the rest of the body is called flexion. Extension carries the same la m

part posteriorly (Fig. 1.6). However, because in the fetus the devel­ I

oping upper and lower limbs rotate in different directions, the

movements of flexion and extension in all joints from the knee
downwards occur in opposite directions to the equivalent joints
in the upper limb. In abduction, the structure moves away from
the median sagittal plane in a lateral direction, whereas adduction
moves it towards the midline (Fig. 1.7). For the fingers and toes,
the terms abduction and adduction are used in reference to a
longitudinal plane passing along the middle finger or the second
toe, respectively. Movement around the longitudinal axis of part
of the body is called rotation. In medial (or internal) rotation, the
anterior surface of a limb rotates medially, while lateral (or exter­
nal) rotation turns the anterior surface laterally (Fig. 1.8). Move­
ments that combine flexion, extension, abduction, adduction and Adduction
medial and lateral rotation (for instance, the ‘windmilling’ action Abduction
seen at the shoulder joint) are known as circumduction.

P A Fig. 1.7 Movements of abduction and adduction. In adduction, flexion of the

I shoulder joint allows the limb to be carried anterior to the trunk.

la m

Flexion
Medial rotation

Lateral rotation
Extension

Fig. 1.6 Movements of flexion and extension of the shoulder joint. Fig. 1.8 Movement of the forearm indicates medial and lateral rotation at the
shoulder joint. The elbow is flexed.
 Basic Tissues and Structures 5

hair follicles are absent and the epidermis innervated by superficial (cutaneous)
Basic Tissues and Structures is relatively thick. The skin in these regions branches of spinal or cranial nerves. The
is also firmly anchored to the underlying area of skin supplied by each cranial or
Skin structures, reducing its mobility during spinal nerve is known as a dermatome
Skin (Fig. 1.9) is a protective covering for gripping and standing. Lines of tension (Figs 1.37 & 1.38).
the surface of the body and comprises a (Langer’s lines) occur within skin and are
superficial layer, called the epidermis, and of importance to surgeons. Scars following Subcutaneous tissue
a deeper layer, the dermis. The epidermis surgical incisions made along these lines (superficial fascia)
is an epithelium consisting of a surface tend to be narrower than those made across Immediately deep to the skin is a layer of
layer of dead cells, which are continually the lines of tension. loose connective tissue, the subcutaneous
shed and replaced by cells from its deeper Skin is usually well vascularized and tissue (Fig. 1.9), which contains networks
germinal layer. The dermis is a layer of receives blood from numerous subcutane­ of superficial veins and lymphatics and is
connective tissue containing blood vessels, ous vessels. Knowledge of this vascular traversed by cutaneous nerves and arter­
lymphatics and nerves. In most areas of the supply is important when operations that ies. It also contains fat, which varies con­
body, the skin is thin and mobile over the involve the use of skin flaps are under­ siderably in thickness from region to region
underlying structures. Specializations of taken. Skin has a rich nerve supply, and between individuals. For example,
the skin include fingernails and toenails, responding to touch, pressure, heat, cold, over the buttock the fat is particularly
hair follicles and sweat glands. On the vibration and pain. In certain areas, such thick, while on the back of the hand it is
palms of the hands and soles of the feet as the fingertips, the skin is especially relatively thin. Over the lower abdomen
(and corresponding surfaces of the digits), sensitive to touch and pressure. Skin is this tissue is subdivided into two layers, a
superficial fatty layer and a deeper mem­
branous layer.

Deep fascia
The deep fascia (Fig. 1.9) consists of a layer
of dense connective tissue immediately
beneath the subcutaneous tissue. Although
thin over the thorax and abdomen, it forms
a substantial layer in the limbs (e.g. fascia
lata; p. 260) and neck (e.g. investing fascia;
p. 324). Near the wrist and ankle joints, the
deep fascia is thickened to form retinacula,
which maintain the tendons in position as
they cross the joints. Deep fascia also pro­
vides attachment for muscles and gives
anchorage to intermuscular septa, which
separate the muscles into compartments.
Bleeding and swelling within muscle com­
partments due to crushing injuries or frac­
tures may raise the pressure so much that
it compresses blood vessels and reduces
blood flow. The resulting ischaemia may
be followed by scarring and deformity
Fibula Neurovascular with contracture of muscles.
bundle
Tibia
Intermuscular
septum
Periosteum

la m

Deep fascia I

Skin
Subcutaneous tissue
Fig. 1.9 Multilevel ‘step’ dissection through the right midcalf to show
layers of skin, fascia and intermuscular septa.
6 CHAPTER • 1 •Basic Anatomical Concepts

External
oblique
(cut)

Costal
cartilages

External
oblique

Apo-
neurosis

S S
R L R L
I I

Fig. 1.10 External oblique is a flat muscle with an extensive aponeurosis. Fig. 1.11 External oblique cut to show its thickness.
 Basic Tissues and Structures 7

ratory systems and in the walls of blood heart and can be modified by the auto­
Muscle vessels. Capable of slow, sustained con­ nomic nervous system.
Muscle is a tissue in which active contrac­ traction, smooth muscle is usually con­ Skeletal muscle (voluntary striated
tion shortens its component cells and/or trolled by the autonomic nervous system muscle) is the basic component of those
generates tension along their length. There (p. 22) and by endocrine secretions muscles that produce movements at joints.
are three basic types: smooth muscle, (hormones). These actions are controlled by the somatic
cardiac striated muscle, voluntary striated Cardiac striated muscle (myocardium) nervous system (p. 20) and may be volun­
muscle. Striated and smooth describe the is confined to the wall of the heart and is tary or reflex. Each muscle cell (fibre) has
microscopic appearance of the muscle. able to contract spontaneously and rhyth­ its own motor nerve ending, which initi­
Smooth muscle is present in the organs mically. Its cyclical activity is coordinated ates contraction of the fibre. Muscles may
of the alimentary, genitourinary and respi­ by the specialized conducting tissue of the be attached to the periosteum of bones
either directly or by fibrous connective
tissue in the form of deep fascia, intermus­
cular septa or tendons. Direct fleshy attach­
ment can be extensive but tendons are
usually attached to small areas of bone.
Muscles with similar actions tend to be
grouped together, and in limbs these
groups occur in compartments (e.g. exten­
sor compartment of the forearm).
Usually, each end of a muscle has an
attachment to bone. The attachment that
remains relatively fixed when the muscle
S
performs its prime action is known as the
la m
origin, whereas the insertion is the more
I
mobile attachment. However, in some
movements, the origin moves more than
the insertion; therefore, these terms are of
only limited significance.
The muscle fibres within voluntary
muscle are arranged in differing patterns,
which reflect the function of the muscle.
Sometimes they are found as thin flat
sheets (as in external oblique; Figs 1.10 &
1.11). Strap muscles (such as sartorius;
Fig. 1.12) have long fibres that reach
without interruption from one end of the
muscle to the other.

Sartorius

Fig. 1.12 Sartorius is a strap muscle.

8 CHAPTER • 1 •Basic Anatomical Concepts

Dorsal interossei

Flexor
pollicis
longus

la m

pr
pr
Fig. 1.14 Dorsal interossei are bipennate muscles.
m la

Fig. 1.13 Flexor pollicis longus is a unipennate muscle.

Pennate muscles are characterized

by fibres that run obliquely. Unipennate
muscles (e.g. flexor pollicis longus;
Fig. 1.13) have fibres running from their
origin to attach along only one side of the
tendon of insertion. In bipennate muscles
(such as dorsal interossei; Fig. 1.14) the
fibres are anchored to both sides of the
Subscap- tendon of insertion.
ularis
Multipennate muscles (e.g. subscapula­
ris; Fig. 1.15) have several tendons of origin
and insertion with muscle fibres passing
S
obliquely between them. Some muscles,
m la for instance digastric, have two fleshy
I parts (bellies) connected by an intermedi­
Fig. 1.15 Subscapularis is a multipennate muscle. ate tendon (p. 348).
 Basic Tissues and Structures 9

Most tendons are thick and round or which prevent ‘bowstringing’ when the actions tend to be supplied by nerve
flattened in cross-section, although some joints are moved. Examples include the fibres derived from the same spinal cord
form thin sheets called aponeuroses retinacula at the wrist and ankle joints, segments.
(Fig. 1.10). When tendons cross projections and tendon sheaths in the fingers and toes As very metabolically active tissue,
or traverse confined spaces, they are often (Figs 1.16 & 1.17). muscle has a rich arterial blood supply,
enveloped in a double layer of synovial The nerve supply to a skeletal muscle usually carried by several separate vessels.
membrane to minimize friction. Where contains both motor and sensory fibres, The contraction and relaxation of muscles
they cross joints, tendons are often held in which usually enter the fleshy part of the in the limbs compresses the veins in each
place by bands of thick fibrous tissue, muscle. Groups of muscles with similar compartment. As the veins contain unidi­
rectional valves, this muscle pump action
assists the return of venous blood from the
limbs to the trunk.

Cartilage
Cartilage is a variety of hard connective
d

la m
tissue, which gains its nutrition by diffu­
pr sion from blood vessels in the surrounding
tissues. It is classified by its histological
structure into hyaline cartilage, fibrocarti­
lage and elastic cartilage.
Hyaline cartilage occurs in costal carti­
lages (Fig. 1.11), the cartilages of the larynx
and trachea, and in developing bones. In
Tendons synovial joints (Fig. 1.23) it forms the
glassy, smooth articular surfaces, which
reduce friction during movement. Articu­
lar cartilage is partly nourished by diffu­
Fibrous sion from the synovial fluid in the joint
sheaths
cavity.
The inclusion of tough inelastic collagen
fibres in the matrix constitutes fibrocarti­
lage, which is stronger and more flexible
than the hyaline type. Fibrocartilage is
found in intervertebral discs (Fig. 1.22),
Fig. 1.16 Anterior view of the left hand, dissected to reveal its fibrous sheaths and tendons. the pubic symphysis, the manubriosternal
joint, and as articular discs in some synovial
d
joints (e.g. knee and temporomandibular).
m la Elastic cartilage, which occurs in the
pr external ear and epiglottis, is the most flex­
ible form of cartilage. It contains predomi­
nantly elastic fibres and has a yellowish
appearance.
Cartilage may become calcified in old
age, becoming harder and more rigid.
Tendons Brittle costal cartilages may be subject to
fracture during chest compressions of
cardiopulmonary resuscitation, particu­
larly in older people.

Extensor
retinaculum

Fig. 1.17 Posterior view of the left hand, dissected to show the extensor retinaculum at the wrist.
10 CHAPTER • 1 •Basic Anatomical Concepts

Bone
Bone forms the basis of the skeleton and is
characterized by a hard, calcified matrix,
which gives rigidity. In most bones two
zones are visible. Near the surface the
outer cortical layer of bone appears solid
and is called compact bone, whereas cen­
trally the bone is known as spongy (cancel­
lous) bone. Many bones contain a cavity
(medulla) occupied by the bone marrow,
a potential site of blood cell production
(Fig. 1.18).
The numerous bones comprising the
human skeleton vary considerably in shape
and size, and are classified into long bones
(e.g. femur); short bones (bones of the
carpus); flat bones (parietal bone of skull);
irregular bones (maxilla of skull); and
sesamoid bones (patella). Sesamoid bones
develop in tendons, generally where the
tendon passes over a joint or bony projec­
tion. Some bones are described as pneuma­
tized because of their air-filled cavities (for
instance, ethmoid).
Bone is enveloped by a thin layer of
fibrous tissue called periosteum (Fig. 1.9),
which provides anchorage for muscles,
tendons and ligaments. Periosteum is a
source of cells for bone growth and repair
and is richly innervated and exquisitely
sensitive to pain. The pain of fractures or
tumours in bone is often due to distur­
S
bance of the periosteum.
la m Bone has a profuse blood supply pro­
I vided partly via the periosteal vessels and
partly by nutrient arteries, which enter
Spongy
bone bones via nutrient foramina and also
supply the marrow. Fractured bones often
Medullary bleed profusely from damaged medullary
cavity
and periosteal vessels.
Several names are given to the different
Diaphysis
parts of a long bone in relation to its devel­
opment (Fig. 1.19). The shaft (or diaphysis)
Cortical
compact ossifies first and is separated by growth
Metaphysis
bone plates from the secondary centres of ossifi­
Site of cation (or epiphyses), which usually lie at
growth the extremities of the bone. The part of a
plate
S
diaphysis next to a growth plate is called a
A P Epiphysis
metaphysis and has a particularly rich
I blood supply. When increase in bone
Fig. 1.18 Longitudinal section of an adult tibia. Fig. 1.19 Anterior view of a child’s tibia. length ceases, the growth plates disappear
and the epiphyses fuse with the diaphysis.
Fractures involving epiphyses and meta­
physes often disrupt bone growth.
 Basic Tissues and Structures 11

Frontal Parietal
Temporal Maxilla

Zygomatic Occipital
Seventh cervical vertebra

Mandible
First thoracic vertebra
First rib
Clavicle
Pectoral
Manubrium girdle Scapula
Body of
sternum

Humerus

Twelfth rib

Lumbar
Radius
vertebra
Ulna

Ilium Phalanges Sacrum

Hip Femur Metacarpals
Ischium
bone Carpals Coccyx
Pubis

Patella

Tibia

Fibula

Tarsals
Metatarsals
S Phalanges S

R L L R

I I

Fig. 1.20 Anterior and posterior views of the skeleton.

Skeleton body. It has axial and appendicular com­ skeleton comprises the bones of the upper
The skeleton (Fig. 1.20) is composed of ponents. The axial component includes and lower limbs and their associated
bones and cartilages held together by the skull, vertebral column, ribs, costal girdles. In this book, individual bones are
joints, and gives rigidity and support to the cartilages and sternum. The appendicular described in the appropriate regions.
12 CHAPTER • 1 •Basic Anatomical Concepts

Joints between the ribs and sternum. In secondary cartilaginous joints

(Fig. 1.22), fibrocartilage unites the bone ends. These joints, which
Joints are classified according to their structure into fibrous, car­
generally allow more movement than those of the primary type,
tilaginous and synovial types. In fibrous joints (Fig. 1.21), which
all lie in the midline. Examples include the intervertebral discs,
are relatively immobile, the two bones are joined by fibrous tissue
the manubriosternal joint and the pubic symphysis.
(e.g. sutures seen between the bones of the skull).
Cartilage is interposed between bone ends in cartilaginous Synovial joints
joints. Primary cartilaginous joints contain hyaline cartilage, are The most common type of joint is the synovial joint, which is
usually capable of only limited movement, and are described complex and usually highly mobile. They are classified according

Fibula Tibia

Anterior
tibiofibular
ligament
Medial
malleolus

Lateral S
malleolus la m

Fig. 1.21 The inferior tibiofibular joint is an example of a fibrous joint.

P A

Lumbar vertebra

Spinal nerve
Intervertebral foramen

Intervertebral disc

Pedicle

Anterior longitudinal ligament

Fig. 1.22 Sagittal section to show an intervertebral disc,

a secondary cartilaginous joint.
 Basic Tissues and Structures 13

to the shape of the joint surfaces (such as plane, saddle, ball-and- The capsule is usually thickened to form strengthening bands
socket) or by the type of movement they permit (such as sliding, known as capsular ligaments (e.g. the pubofemoral ligament). In
pivot, hinge). In a typical synovial joint (Fig. 1.23) the articulating addition, fibrous bands, discrete from the capsule, may form
surfaces are coated with hyaline cartilage and the bones are joined extracapsular ligaments (such as the costoclavicular ligament). In
by a fibrous capsule, a tubular sleeve, which is attached around some joints, there are intracapsular ligaments (for instance, the
the periphery of the areas of articular cartilage. In every synovial ligament of the head of the femur), which are covered by synovial
joint, all of the interior (except for intra-articular cartilage) is lined membrane. Tendons sometimes fuse with the capsule (as in the
with synovial membrane. This thin vascular membrane secretes rotator cuff) or they may run within the joint, covered by synovial
synovial fluid into the joint space, providing nutrition for the membrane, before reaching their bony attachment (e.g. biceps
cartilage and lubrication for the joint. brachii at the shoulder joint; Fig. 1.24).

m la

pr

Articular cartilage

Synovial cavity

Collateral ligaments

Fig. 1.23 Coronal section through a metacarpophalangeal joint, a synovial joint. The collateral ligaments are thickenings of
the joint capsule.

Scapular
spine Coracoid Joint
(cut) process capsule
S

m la

Tendon of
long head
of biceps
brachii

Head of
humerus

Fig. 1.24 Removal of part of the shoulder joint capsule reveals the intracapsular but extrasynovial tendon of the long head of biceps brachii.
14 CHAPTER • 1 •Basic Anatomical Concepts

Fluid-containing sacs of synovial membrane called bursae surfaces, the strength of the capsule and associated ligaments,
(Fig. 1.25) separate some tendons and muscles from other struc­ the tone of the surrounding muscles and, where present, intra-
tures. Bursae, which lie close to joints, may communicate with the articular discs and ligaments. At the hip joint, the ligaments and
cavity of the joint through a small opening in the capsule (as does the shape of the bones provide the main stability, whereas the
the subscapularis bursa). tone of the surrounding muscles is more important in stabilizing
In some joints (e.g. knee) a disc of cartilage is interposed the shoulder joint. Lack of stability associated with muscle weak­
between the articular cartilage covering the bone ends (Fig. 1.26). ness or trauma may result in dislocation, so that the cartilage-
This provides a matched shape for each bone end, thus allowing covered surfaces may no longer make contact. Dislocation may
freer movement without compromising stability. In addition, dif­ damage adjacent blood vessels and nerves.
ferent types of movement are permitted in each half of the joint. Joints, particularly their capsules, receive a rich sensory inner­
Stability varies considerably from one synovial joint to another, vation derived from the nerves supplying the muscles that act on
as several factors limit excessive movement and contribute to the the joint. For instance, the axillary nerve supplies the shoulder
stability of the joint. These include the shape of the articulating joint and deltoid.

Synovial
Humerus cavity
S

A P

Olecranon
bursa

Joint
capsule

Ulna
Radius

Fig. 1.25 Sagittal section through the elbow joint. The olecranon bursa does not communicate with the joint cavity.

Medial meniscus

Articular
surface
of tibia

Lateral
meniscus

m la

Fig. 1.26 Disarticulated knee joint to show the menisci.

 Basic Tissues and Structures 15

Blood vessels around joints frequently

take part in rich anastomoses, which allow
alternative pathways for blood flow when
the joint has moved to a different position
and ensure an adequate supply to the
synovial membrane (such as in the knee
S joint; Fig. 1.27).
m la

I Serous membranes and cavities

Pericardium, pleura and peritoneum com­
prise the serous membranes lining the
Hamstring cavities that separate the heart, lungs and
muscles abdominal viscera, respectively, from their
(separated)
surrounding structures. Where the mem­
brane lines the outer wall of the cavity it is
called parietal and has somatic sensory
innervation, and where it covers the appro­
Popliteal
artery priate organ it is called visceral with no
somatic innervation. The spread of disease
Arterial to involve parietal membranes usually pro­
anasto-
motic vokes pain felt at a site which the patient
branches
can identify precisely. The parietal and vis­
ceral parts are in continuity around the
root of the viscus and are separated from
each other by a cavity, which normally
contains only a thin film of serous fluid.
Fig. 1.27 Branches of the popliteal artery anastomose around the knee joint.
The membranes are in close contact but are
lubricated by the intervening fluid, which
permits movement between the viscus and
its surroundings (Fig. 1.28).

A
L R
Visceral Pleural
P pleura cavity

Right lung Parietal

pleura

Fig. 1.28 Transverse section through the thorax at the level of T5 showing the right pleural cavity. Superior aspect.
16 CHAPTER • 1 •Basic Anatomical Concepts

located arteries, such as the abdominal aorta, may require firm

Blood vessels pressure.
Blood vessels convey blood around the body and are classified Capillaries link the smallest arteries (arterioles) and the small­
into three main types: arteries, capillaries and veins. est veins (venules) and convey blood at low pressure through the
Arteries are relatively thick-walled vessels, which convey tissues. Collectively, these thin-walled microscopic vessels have a
blood in a branching system of decreasing calibre away from very extensive surface area, facilitating gaseous and metabolic
the heart (Fig. 1.31). Some arteries are named after the region exchange between the blood and tissues.
through which they pass (such as the femoral artery), while Veins carry blood at low pressure from the capillary bed
others are named according to the structures they supply (for back to the heart (Fig. 1.32). They may be deep (accompanying
instance, the renal artery). The largest vessels, such as the arteries) or superficial (lying in the superficial fascia) (Fig. 1.29)
aorta, have elastic walls and therefore are called elastic arter­ and are usually linked by venous anastomoses. Veins accompany­
ies. They give rise to arteries whose walls are more muscular ing arteries are often arranged as several interconnecting vessels
(muscular arteries), such as the radial artery in the forearm. called venae comitantes. In the limbs, the deep veins can be com­
A particularly thick smooth muscle coat is also a feature of pressed by local muscular action, thus assisting venous return.
the walls of the microscopic arterioles. The tone of arteriolar Many veins (excluding the venae cavae, those draining viscera
smooth muscle is under the control of the autonomic nervous and those within the cranium) contain unidirectional valves,
system and hormones and is an important factor in the main­ which direct the flow of blood towards the heart (Fig. 1.30).
tenance of pressure in the arterial system. In general, there Damage to these valves can lead to dilated veins known as vari­
are few alternative pathways for arterial blood to reach its cose. The venous pattern is often variable, and numerous anasto­
destination. However, in some regions (e.g. joints and at the motic connections provide alternative pathways for venous
base of the brain), arterial supply is provided by more than return. In some regions, numerous intercommunicating veins
one vessel (Fig. 1.27). Such arteries may communicate directly form meshworks called plexuses (such as the pelvic venous
with each other at sites known as arterial anastomoses. plexus). In the cranial cavity, venous blood is carried in special
Arterial pulses may be felt easily in superficial arteries, such vessels formed by the dura mater lining the interior of the skull.
as the radial artery at the wrist. Identifying pulses in deeply These dural sinuses receive blood from the brain.

A
m la

P Tibia Artery Fibula

Superficial Deep Nerve Vena

veins vein comitans
Fig. 1.29 Multilevel ‘step’ dissection through the right leg
showing the blood vessels.

Valve cusps
Fig. 1.30 Portion of saphenous vein opened longitudinally and in
cross-section.
 Basic Tissues and Structures 17

Superficial temporal
S
Posterior auricular
Maxillary R L

Facial Occipital

Lingual External carotid

Superior thyroid
Internal carotid
Right common carotid
Left common carotid
Right vertebral
Left subclavian

Right subclavian Brachiocephalic

Axillary Right coronary

Profunda brachii Thoracic aorta

Brachial Coeliac

Radial Renal

Gonadal Superior mesenteric

Interosseous Abdominal aorta

Ulnar
Inferior mesenteric

Common iliac

Superficial
Internal iliac
palmar arch

External iliac
Femoral
Profunda femoris

Popliteal

Posterior tibial

Fibular

Anterior tibial

Medial plantar Lateral plantar

Plantar arch Dorsalis pedis

Fig. 1.31 Principal systemic arteries.

18 CHAPTER • 1 •Basic Anatomical Concepts

R L
Superficial temporal
I

Facial
Left external jugular
Right internal jugular
Left internal jugular
Right vertebral
Subclavian Left brachiocephalic
Axillary
Right brachiocephalic

Cephalic
Superior vena cava

Hepatic

Inferior vena cava Basilic

Renal
Gonadal
Venae comitantes
Common iliac

Internal iliac

External iliac
Dorsal arch

Femoral
Great saphenous

Popliteal

Small saphenous
Venae comitantes

Deep veins

Dorsal arch Superficial veins

Fig. 1.32 Principal systemic veins.

 Basic Tissues and Structures 19

Lymphatic vessels and nodes

Tissue fluid is collected by microscopic
open-ended channels called lymphatics.
From a particular region or organ, these
valved lymphatic vessels drain into aggre­
gations of lymphoid tissue (called lymph
nodes; Fig. 1.33), which filter lymph.
Groups of lymph nodes are often found
close to an organ (e.g. hilar nodes) or at
the root of a limb (e.g. axillary lymph
Lymph
nodes). Ultimately, lymph drains into
node the venous system in the root of the neck
Efferent through larger lymph channels called the
and
afferent
thoracic duct and the right lymphatic trunk
lymphatics (Fig. 1.34).
Because they filter the fluid passing
S
through them, lymph nodes may become
la m
involved in the spread of infection or
I
malignancy (e.g. cancer). Thus the surgeon
Fig. 1.33 Inguinal lymph node.
removing a cancerous organ may also
excise the lymph nodes draining that
organ.

S
Right lymphatic R L
trunk & tributaries I

Thoracic duct
& tributaries

Subclavian trunk
Cervical nodes

Jugular trunk
Axillary nodes

Right lymphatic trunk

Thoracic duct

Cisterna chyli

Aortic nodes

Iliac nodes

Inguinal
nodes

Fig. 1.34 The main lymphatic

nodes and vessels.
20 CHAPTER • 1 •Basic Anatomical Concepts

Nervous tissue S

Nervous tissue contains two types of cell: neurones and neuroglia. A P

The neurone is the functional unit responsible for the conduction I

of nerve impulses. It consists of a cell body and its associated

processes. One type of process, of which there is only one per First cervical
neurone, is the axon. This may be relatively short but sometimes
is very long, as in peripheral nerves, where axons comprise the
Cervical plexus
individual nerve fibres. The neuroglia undertake supporting roles (C2–C4)
and include Schwann cells, which provide the myelin sheaths Brachial plexus
around axons. These sheaths insulate the axons, increasing their (C5–Tl)
speeds of conduction.
The nervous system consists of central and peripheral parts. Median
The brain and spinal cord comprise the central nervous system. Ulnar
The peripheral nervous system consists of spinal, cranial and
Radial T2–Tl2
autonomic nerves, and their associated ganglia. Bundles of nerve
cell processes and their supporting Schwann cells form peripheral
Musculocutaneous
nerves. Several nerve processes, bound together by connective
tissue, form a nerve bundle; numerous bundles, surrounded by a
fibrous sheath (epineurium), constitute the complete peripheral
Lumbar plexus
nerve. Nerve cell bodies also form part of the peripheral nervous
(Ll–L4)
system and are usually grouped together into ganglia. The periph­
eral nervous system is divided into somatic and autonomic parts.
Sacral plexus
First lumbar
Somatic nerves (L4–S4)

In general, the somatic nerves innervate skeletal muscle and trans­

Fifth sacral
mit sensation from all parts of the body except the viscera. A total and first
of 12 pairs of cranial nerves are attached to the brain and are coccygeal
named: olfactory (I); optic (II); oculomotor (III); trochlear (IV);
trigeminal (V); abducens (VI); facial (VII); vestibulocochlear (VIII); Femoral

glossopharyngeal (IX); vagus (X); accessory (XI); hypoglossal Obturator

(XII). Most of these nerves supply structures in the head and neck,
but the vagus nerve also supplies thoracic and abdominal viscera.
Sciatic
Spinal nerves are also in pairs and each is attached to a specific
segment of the spinal cord by anterior and posterior roots. There
are eight cervical (C1–C8); 12 thoracic (T1–T12); five lumbar (L1–
L5); five sacral (S1–S5); and one or two coccygeal (Co) spinal Common fibular
nerves (Fig. 1.35).

Tibial

Saphenous

Superficial
Deep fibular
fibular

Medial plantar
Lateral
plantar

Fig. 1.35 Lateral view of the distribution of the anterior rami of the spinal
nerves.
 Basic Tissues and Structures 21

Thoracic spinal nerves illustrate the typical segmental pattern

of distribution to the body wall (Fig. 1.36). The area of skin sup­ S
R L
plied by one spinal (or cranial) nerve is called a dermatome I
(Figs 1.37 & 1.38). In the trunk the dermatome pattern involves
substantial overlap between adjacent areas. Similarly, all the
muscles supplied by a single spinal (or cranial) nerve comprise a
myotome.

C4

T2
A

R L T3
P
T4
T5
Cutaneous T6
branches T7
Muscle T8
branch
T9
T10
Anterior root
T11
Sympathetic T12
trunk Cervical
L1 Thoracic
Anterior ramus Lumbar
Posterior Spinal Posterior Rami
ramus cord root communicantes

Fig. 1.36 Course and distribution of a typical thoracic spinal nerve. Inferior aspect. Fig. 1.37 Dermatomes of the trunk.

S S
R L L R
I I

Cervical
Thoracic
Lumbar
Sacral

Fig. 1.38 Dermatomes of the limbs.

22 CHAPTER • 1 •Basic Anatomical Concepts

The regular pattern of innervation in the trunk is modified in

the limbs, each being supplied by several spinal nerves through
a complex network, a plexus (such as the brachial plexus of the
upper limb; Fig. 1.39). Plexus formation modifies the pattern of
myotomes so that spinal cord segments innervate muscles accord­
ing to their prime actions. For example, flexors of the elbow joint
are supplied by the spinal cord segments C5 and C6. Sensory cell
bodies are located in ganglia on peripheral nerves near the central
nervous system (for instance, trigeminal ganglion, posterior root
ganglia). However, the cell bodies of somatic motor nerves are
located in the central nervous system.
Autonomic nerves S
The autonomic nervous system innervates smooth and cardiac la m

muscle and glands. It is divided into two parts: sympathetic and I

parasympathetic, whose effects for the most part are antagonis­

tic (e.g. sympathetic stimulation increases while parasympathetic
stimulation reduces heart rate). In both sympathetic and para­ Brachial
sympathetic components, preganglionic myelinated axons leave plexus
the central nervous system and synapse on neurones in periph­
eral ganglia distributed throughout the body. The postgangli­
onic axons that pass to the effector organs are nonmyelinated.
Autonomic sensory fibres accompany autonomic efferent fibres Fig. 1.39 The axilla has been dissected to show the brachial plexus.
in peripheral nerves, but their cell bodies are located in the pos­
terior root ganglia in company with somatic sensory neurones.
Pain from diseased organs, called visceral pain, which is usually
poorly localized, is transmitted by autonomic sensory nerves.
The parts of the central nervous system from which the auto­
nomic nerves emerge differ for the sympathetic and parasympa­ Parasympathetic nerves In the parasympathetic system, myeli­
thetic components (Fig. 1.40). nated preganglionic fibres leave the central nervous system as
part of cranial nerves III, VII, IX and X and as part of sacral spinal
Sympathetic nerves Preganglionic sympathetic fibres leave the nerves S2, S3 and S4, to form the craniosacral autonomic outflow.
central nervous system in the spinal nerves of all the thoracic and These preganglionic fibres synapse in ganglia lying close to or in
the upper two lumbar segments (thoracolumbar outflow) and the wall of the target organ. Relatively short nonmyelinated post­
enter the ganglionated sympathetic trunks via white rami com­ ganglionic axons emerge from these ganglia to innervate the
municantes. The two sympathetic trunks lie on either side of the appropriate tissue. In the head there are four paired ganglia
vertebral column and extend throughout most of its length. Each (ciliary, pterygopalatine, submandibular and otic) that receive
trunk consists of sympathetic ganglia and interconnecting nerve preganglionic parasympathetic fibres from cranial nerves III, VII
trunks. and IX. The postganglionic fibres from these ganglia supply the
Unmyelinated postganglionic axons destined for the blood eye, and lacrimal, nasal and salivary glands. Preganglionic fibres
vessels and sweat glands of the body wall, including the limbs, from the vagus (X) nerve synapse with postganglionic neurones
leave the ganglia by grey rami communicantes and are distributed that innervate cervical, thoracic and abdominal viscera. Pregan­
by the spinal nerves. Special visceral branches pass directly from glionic fibres from the sacral nerves (pelvic splanchnic nerves or
the trunks to reach the appropriate organ. nervi erigentes) supply the pelvic organs. The parasympathetic
Postganglionic sympathetic nerve fibres are often conveyed to ganglia associated with the vagus and sacral nerves usually com­
their destinations as plexuses intimately related to the walls of prise small clusters of cells in the walls of the innervated organs
arteries. (Fig. 1.40).
 Basic Tissues and Structures 23

Outflow Intermediate
Target
from ganglion
sites
CNS or plexus

Ciliary Sphincter pupillae and

III
ganglion ciliary muscle of eye
Pterygopalatine Lacrimal and
ganglion nasal glands
VII
Submandibular Submandibular and
ganglion sublingual glands
IX Otic ganglion Parotid gland
Pulmonary
Lungs
plexus
Cardiac
X Heart
plexus
Plexus in gut
Gut as far as
wall as far as
splenic flexure
splenic flexure

Arteries Head and neck

Cardiac and
T1 pulmonary Heart and lungs
branches

Sympathetic Body wall

Spinal nerves
trunk and limbs

Thoracic Coeliac and Gut wall as

splanchnic mesenteric far as splenic
nerves plexuses flexure

Hypogastric Gut wall beyond splenic

L2
nerves flexure and pelvic viscera

S2 Plexus in
gut wall Gut wall beyond
beyond splenic flexure
S3 splenic
flexure Pelvic and
and pelvic perineal viscera
S4 viscera
Parasympathetic nerves (craniosacral outflow)
Sympathetic nerves (thoracolumbar outflow)

Fig. 1.40 Pattern of innervation in the parasympathetic and sympathetic

autonomic nervous systems.
 Chapter 2
THORAX
Introduction 26 Heart 45
Skeleton of the Thorax 28 External features 45
Ribs 28 Chambers and valves 47
Sternum 29 Blood vessels 53
Thoracic Wall 30 Conducting system 56
Skin 30 Mediastinal Structures 58
Breast 30 Brachiocephalic veins 58
Muscles 31 Superior vena cava 58
Intercostal spaces 32 Arch of aorta and branches 58
Intercostal muscles 33 Phrenic nerves 60
Intercostal vessels and nerves 34 Trachea 60
Pleura 36 Oesophagus 62
Parietal pleura 36 Vagus (X) nerves 62
Visceral pleura 37 Descending thoracic aorta and branches 62
Thoracic duct 63
Lungs 38 Azygos venous system 63
Fissures 39 Thoracic sympathetic trunk 64
Surfaces, borders and relations 39
Exam Skills 65
Bronchi 42
Pulmonary vessels 42 Clinical Case Skills 66
Autonomic nerves 42 Observation Skills 67
Mediastinum 43
Pericardium 44
Fibrous pericardium 44
Serous pericardium 44
26 CHAPTER • 2 •Thorax

tumours in this location may compress adjacent structures, leading

Introduction to the clinical condition called, confusingly, thoracic outlet syn-
drome. Inferiorly, the cavity of the thorax is separated from the
The thorax is the region of the trunk that includes the sternum, abdominal contents by a fibromuscular sheet called the dia-
costal cartilages, ribs and thoracic vertebrae, together with the phragm. The oesophagus and other intrathoracic structures pass
structures they enclose. Superiorly, the thorax is limited by through the diaphragm to gain or leave the abdomen. Since the
the upper surfaces of the first ribs and their costal cartilages, the diaphragm is convex superiorly, some of the organs within the
manubrium of the sternum and the first thoracic vertebra. The abdomen are covered by the lower ribs and costal cartilages.
space bounded by these structures is the superior thoracic aper- The ribs, costal cartilages and sternum form a semi-rigid frame-
ture (thoracic inlet) (Fig. 2.1), which allows structures to pass work that provides attachment for several muscles; some connect
between the root of the neck and the thorax. Space-occupying adjacent ribs and costal cartilages, others attach to the pectoral

Superior
First and second First thoracic thoracic Manubriosternal
First rib costal cartilages vertebra aperture Manubrium joint

R L

A Fig. 2.1 The boundaries of the superior thoracic aperture

(pink line).

Trachea

Right main Left main

bronchus bronchus

Lobes of
Lobes of left lung
right lung
Xiphoid
process

Costal
margin

R L

I
Fig. 2.2 The trachea, bronchi and lungs.
 Introduction 27

girdle or humerus or descend from the second costal cartilages meet the sternum sternum, the xiphoid process, can usually
thorax to contribute to the musculature of at this level. It is normal practice to count be identified in the midline between the
the abdominal wall. The medial ends of the ribs starting at the second costal cartilages, costal margins (subcostal angle). The space
clavicles articulate with the upper border as the first ribs are obscured by the clavi- between adjacent ribs and costal cartilages
of the manubrium and flank the jugular cles. Inferiorly, the thoracic wall is limited is occupied by intercostal muscles, which
(suprasternal) notch. The manubrium by the costal margin, which is formed by are active during respiratory movements
articulates with the body of the sternum at the costal cartilages of the lower ribs. The of the thoracic wall. Intercostal vessels and
the manubriosternal joint (sternal angle, costal margin extends upwards and medi- nerves run between these muscles in each
angle of Louis), which usually forms a ally as far as the lower end of the sternum space and give branches to adjacent tissues
horizontal ridge. This is a useful landmark and forms the upper boundary of the and the overlying skin. In both sexes, the
during clinical examination because the abdominal wall. The inferior portion of the nipples are surface features, the anatomical
locations of which vary depending upon
the build of the individual. The glandular
components of the breast lie deep to the
Right common Left common nipple, embedded in the fat of the subcu-
carotid carotid taneous tissues that cover the muscles of
Right subclavian Left subclavian the chest wall. Posteriorly, the upper ribs
Arch of aorta are covered by the scapulae and their
Brachiocephalic muscles.
trunk Left pulmonary
The space contained within the thoracic
Right Descending
wall is occupied by several important
pulmonary thoracic aorta
organs. Some of these are confined to the
Ascending aorta Pulmonary thorax (e.g. heart), while others traverse
trunk
the region, passing from the neck into the
Diaphragm abdomen (e.g. oesophagus). On each side,
Heart the lung occupies a large proportion of the
thoracic cavity (Fig. 2.2) and is surrounded
by a serous sac called the pleura. The
pleura encloses a cavity (pleural cavity),
which usually contains a thin film of serous
S
fluid enabling the lungs and thoracic wall
R L

I
to move freely over one another. Each
pleural cavity is separated from its neigh-
Fig. 2.3 The heart and great arteries. bour by a midline partition called the
mediastinum. The mediastinum is the term
used to describe all the structures that
occupy this central portion, including the
Right internal Left internal heart and its great vessels (Figs 2.3 & 2.4)
jugular jugular and the intrathoracic parts of the trachea
Left subclavian and oesophagus.
Right
subclavian
Left
brachiocephalic
Right
brachiocephalic
Left pulmonary
Superior
vena cava
Right
pulmonary Inferior vena
cava

R L

Fig. 2.4 The heart and great veins.

28 CHAPTER • 2 •Thorax

the tubercle and lies in front of the transverse process. The tuber-
Skeleton of the Thorax cle of the rib faces posteriorly and the medial part of its surface
forms a synovial joint with the articular facet on the transverse
The skeleton of the thorax consists of 12 thoracic vertebrae, the 12 process of the corresponding vertebra. The shaft forms the remain-
pairs of ribs and their costal cartilages, and the sternum (Fig. 2.5). der of the rib and ends anteriorly at a shallow depression, which
Structures in continuity between the root of the neck and the receives the costal cartilage. Passing laterally from the tubercle,
upper part of the thoracic cavity pass through the superior tho- the shaft slopes downwards and backwards before turning for-
racic aperture (thoracic inlet), which is bounded by the first tho- wards and outwards to form the angle. Lateral to the angle,
racic vertebral body, the first pair of ribs and costal cartilages and the shaft possesses a sharp lower border, which bounds the
the upper border of the sternum. The inferior thoracic aperture costal groove.
(thoracic outlet), through which structures pass between the tho- The first rib is atypical. Its head possesses an articular facet
racic and abdominal cavities, is formed by the twelfth thoracic solely for its own vertebral body. The shaft is short and broad
vertebral body, the twelfth and eleventh ribs and the costal and has superior and inferior surfaces. In addition, its superior
margin (the fused costal cartilages of the seventh to the tenth ribs surface carries a ridge that forms a projection on the inner border
inclusive). of the rib, the scalene tubercle, to which is attached the scalenus
Ribs anterior. Two grooves lie across the shaft, one in front of the
ridge (for the subclavian vein) and the other behind (for the sub-
Although the ribs differ in size and shape, most (2–9 inclusive) clavian artery and lowest trunk of the brachial plexus). The tenth,
have features in common and are described as typical ribs eleventh and twelfth ribs are also atypical, in that each head pos-
(Fig. 2.6). Each typical rib consists of a head, neck, tubercle, shaft, sesses a single facet and the rib is usually devoid of a tubercle or
upper and lower borders and inner and outer surfaces. The heads an angle.
of the ribs are those parts that articulate with the thoracic vertebral
bodies. The lower part of the head forms a synovial joint with its Costal cartilages
own vertebral body, while the upper part articulates with the All ribs possess costal cartilages, and those of the upper seven
vertebra above. The intermediate part of the head lies against pairs (true ribs) articulate with the sides of the sternum. Pairs 8–12
the intervertebral disc. The neck of the rib connects the head and (false ribs) fall short of the sternum. These articulate with the

First
Body of thoracic
sternum vertebra Manubrium

First rib

Second
rib

Costal
cartilage

Xiphoid
process
Intervertebral
disc

Costal
margin
Twelfth rib

R L

Fig. 2.5 Articulated bones of the thorax showing the relationships between the vertebral column, ribs, costal cartilages and sternum.
 Skeleton of the Thorax 29

cartilage immediately above, while 11 and articulates with the medial end of each guide to the second costal cartilage, which
12 (floating ribs) are pointed and end freely clavicle at the sternoclavicular joint and abuts the sternum at the lateral margin of
in the muscle of the abdominal wall. with the first costal cartilage. Its upper the joint. The lateral margins of the body
margin includes the jugular notch, which of the sternum are indented by the medial
Sternum forms part of the superior thoracic aper- ends of the second to the seventh costal car-
The sternum is a flat bone and consists ture. A palpable secondary cartilaginous tilages. The xiphoid process lies in the sub-
of the manubrium, the body (Fig. 2.7) joint (the manubriosternal joint) unites the costal angle and projects downwards and
and the xiphoid process. The manubrium manubrium and body and forms a useful backwards from the body of the sternum.

Scalene
Neck Head Tubercle tubercle

Angle Shaft Shaft

Fig. 2.6 Superior view of the right first, seventh and twelfth ribs
showing their surface features and relative sizes.

Manubrium Suprasternal notch

R L

Articular surface for

sternoclavicular joint

Manubriosternal
joint

Body of sternum

Indentations for
costal cartilages

Fig. 2.7 The manubrium and the body of the sternum.

The xiphoid process is absent.
30 CHAPTER • 2 •Thorax

This is the axillary tail (process) and is the only part of the breast
Thoracic Wall to penetrate beneath the deep fascia. During clinical palpation of
the breast it is essential that the axillary tail is included as part
Skin of the physical examination.
The skin covering the thorax receives its nerve supply from lower The glandular elements consist of 15–20 lobes arranged radi-
cervical and upper thoracic spinal nerves. Above the level of the ally, each draining into a lactiferous duct. These ducts open inde-
manubriosternal joint, C4 gives cutaneous innervation, while tho- pendently onto the surface of the nipple. The nipple is surrounded
racic nerves T2–T11 provide the dermatomes for the remainder of by an area of pink skin, the areola, which may develop brown
the thoracic wall. The first thoracic nerve does not contribute to pigmentation during pregnancy.
the cutaneous nerve supply of the thorax but innervates some The gland is traversed by fibrous septa (ligaments of Astley
of the skin of the upper limb (Figs 1.35 & 3.6). Cooper) (Fig. 2.8), which subdivide the lobes and loosely attach
the skin of the breast to the deep fascia covering the chest wall.
Breast In certain types of breast carcinoma, these fibrous septa may
The breast (Fig. 2.8) consists of glandular tissue and a quantity of produce characteristic dimpling of the skin over the lesion. Nor-
fat embedded in the subcutaneous tissue of the anterior chest mally, the breast is freely mobile over the underlying muscles.
wall. In the male and immature female, the gland is rudimentary. However, lack of mobility when pectoralis major is contracted
Although the size and shape of the breast in the adult female vary, indicates that breast pathology has fixed the gland to the underly-
the base (the part lying on the deep fascia covering pectoralis ing chest wall muscles.
major, serratus anterior and rectus abdominis) is constant in posi- Blood supply
tion. In the adult female, the base is roughly circular and extends The fat and glandular elements of the breast receive blood from
between the second and sixth ribs. Medially, the gland overlies arteries that also supply the deeper structures of the chest wall.
the lateral border of the sternum. Part of the breast extends These vessels include perforating branches from the internal tho-
upwards and laterally and reaches the anterior fold of the axilla. racic artery (internal mammary artery) and the second, third and
fourth intercostal arteries. The lateral thoracic and thoracoacro-
mial arteries arising from the axillary artery also supply the breast.
The gland is drained by veins that accompany the arteries.
Lymph drainage
Within the substance of the breast, the lymphatic vessels form a
system of interconnecting channels that collect lymph from all
parts of the organ. The superior and lateral aspects of the breast
usually drain into central and apical axillary nodes via infracla-
vicular and pectoral nodes. It is therefore important to palpate
axillary lymph nodes in suspected cases of malignant breast
disease. The medial and inferior parts of the breast drain deeply
into glands along the internal thoracic vessels and thence via the
bronchomediastinal lymph trunk into the confluence of lymphatic

Clavicle

Subclavian
artery
and vein
Pectoralis minor
Pectoralis major
Skin

Second
rib
Fat

Lung

Diaphragm Nipple

Liver
S
Fibrous
septa
P A

Fig. 2.8 Sagittal section through the right breast and underlying chest wall. In this dissection,
the glandular structure of the breast cannot be distinguished.
Another random document with
no related content on Scribd:
demands everybody’s attention, and bores the greater part of his
audience; the former enables everybody to speak, and thus
produces the agreeable feeling of self-satisfaction in having
personally contributed to the enjoyment of the hour.
With desperate heroism, he endeavoured to break the spell which
tied the tongues of his companions. He told one of his best stories,
the point of which had never failed to set the table in a roar of
laughter. Lugubrious grimaces were the only response. He tried
another anecdote, with the same result. He descended to the lowest
depths of convivial intercourse; he propounded a conundrum, and
the eldest of the girls immediately answered it with the addition of the
galling commentary: ‘I knew that long ago.’ In his present condition
of absolute helplessness, he wished to goodness the child would
remember another conundrum, and give it for his benefit, if not for
that of the company. Probably, she would have done so, had not the
mother’s eye been upon her, suggesting the austere maxim,
‘Children should be seen, not heard.’
The Major took another tack. He put questions to his host about the
moors, about the horses, about the hounds, and about the cause of
Tally-ho’s illness—any one of which topics would at another time
have started the Squire into a gallop of chat. He would have
compared the seasons as affecting the moors for twenty years past;
he would have detailed the pedigree and merits of every horse in his
stables; he would have repeated endless anecdotes about the
hounds; and as to the illness of Tally-ho, he would have gone into
the most minute particulars as to its cause, his treatment, and the
probable result.
But on this day all was in vain. The Major’s suggestive queries were
responded to by: ‘Don’t know,’ ‘Much the same as usual,’ ‘Hope for
the best,’ and, ‘I daresay the brute will come round.’
When they rose from the table, the Major thanked heaven that this
trial was over. The Squire, with a curious mingling of awkwardness
and suppressed ill-temper, utterly opposed to his habitually jovial
manner, advanced to his unhappy guest: ‘I want to see you in the
library in about half an hour,’ he said, and walked out of the room.
‘That’s a comfort,’ thought the Major. ‘I shall have a man with some
common-sense to hear me.’
Meanwhile, he would have liked to speak a few words of consolation
to Maynard; but that gentleman met his advances with somewhat
repellent politeness.
‘If you want to speak to me about the trouble you have made
between Miss Carroll and me, you will have ample opportunity to do
so when we meet in the library,’ he said, and strolled out to the lawn
to seek the soothing influence of a cigar.
Then the Major wished to discharge the duty he had so rashly
undertaken, which was to bring the morbidly suspicious John Elliott
to reason. He was only now realising the difficulty of the task; and he
presently had a decisive indication that it was likely to be one he
could not accomplish. He had barely uttered half-a-dozen words of
his well-intentioned admonition which was to precede his explanation
of ‘the incident,’ when John Elliott peevishly interrupted him: ‘I have
promised not to discuss this subject until we are in the library.’
So, he was to meet the three of them. So much the better; they were
men, and they would give him a patient hearing. Still, he would have
liked a little private talk with John Elliott before the meeting in the
library, which was assuming the character of a sort of court-martial.
There were things to say to him which could only be uttered when
they were conversing confidentially. For instance, he could not say to
him before others: ‘You have been accusing Mrs John of behaviour
unbecoming your wife; you have magnified the circumstance of her
allowing young Maynard to kiss her under the mistletoe last
Christmas, until you have come to believe that every time she says a
friendly word to him or smiles on him, she is false to you. You have
even gone so far as to think of employing a private detective to
watch them. Now, my dear friend, do get all that confounded
nonsense out of your head. Remember that she has known Maynard
from his boyhood; and although she is not old enough to be his
mother, she still looks on him as a boy, and he regards her as an
elder sister. She is naturally frank, and naturally treats him with more
frankness than she does other men. You know that she long ago set
her heart upon making a match between him and Nellie Carroll, both
being suitable in every respect; and she has succeeded. What do
you think will happen if your absurd fancies get wind? Why, there will
be a general rupture—a split in the camp which may separate the
young folk, and, possibly, you and Mrs John, who has been and is
devoted to you.’
There, that would have brought him to reason, if he had a scrap of
sense left. But it could not be spoken in the presence of others. Very
likely, suspicious John would ask him how he came to know all this,
and the question would be troublesome—a thousand times more
troublesome since all the letters had got into the wrong hands. The
one for John Elliott had reached Mrs Joseph, instead of the simple
intimation of the date of the Major’s arrival; that for Nellie had been
delivered to Mrs John, and Mrs John’s to Nellie. It was awkward.
‘As to the question,’ the Major reflected: ‘I got the information from
Matt Willis, the brother of Mrs John; and he made me promise not to
mix him up in the affair. He got the information from John Elliott
himself, who complained to his brother-in-law about the way his wife
was carrying on with Maynard. Matt had an unconquerable antipathy
to family squabbles, and would not interfere; but thinking that
something should be done to shut John up before serious harm
came of his insane suspicions, he asked me, as the friend of the
family, to put things right. Like a fool, I consented; and the blame of
all the trouble falls on me! Am I to blame?—Stop a minute. By Jove!
—it is John Elliott who is the author of the whole mischief, and I’ll tell
him so.’
Greatly consoled by the discovery that he was not the original culprit
in causing what promised to be a serious breach in the relationships
of valued friends, the Major was prepared to face the court-martial
before which he was presently to stand. Ay, and he would have no
nonsense about the affair. He would tell Squire Joseph bluntly that
Mrs Joseph had taken possession of a letter which did not belong to
her. He would tell Maynard to go and speak to Nellie, and assure
her, as he had done, that she had misinterpreted the letter she had
received, even if it had been intended for her; and he would tell John
Elliott that he must either speak to him in private, or take the
consequence of his speaking in the presence of the Squire and
Stanley Maynard.
 AN OLD TULIP GARDEN.
A quiet, sunny nook in the hollow it is, this square old garden, with
its gravelled walks and high stone walls; a sheltered retreat left
peaceful here, under the overhanging woods, when the stream of the
world’s traffic turned off into another channel. The gray stone house,
separated from the garden by a thick privet hedge and moss-grown
court, is the last dwelling at this end of the quiet market-town, and,
with its slate roof and substantial double story, is of a class greatly
superior to its neighbours, whose warm red tiles are just visible over
the walls. It stands where the old road to Edinburgh dipped to cross
a little stream, and, in the bygone driving days, the stagecoach, after
rattling out of the town and down the steep road there, between the
white, tile-roofed houses, when it crossed the bridge opposite the
door, began to ascend through deep, embowering woods. But a
more direct highway to the Scottish metropolis was opened many a
year ago: just beyond the bridge, a wall was built across the road;
and the gray house with its garden was left secluded in the sunny
hollow. The rapid crescendo of the coach-guard’s horn no longer
wakens the echoes of the place, and the striking of the clock every
hour in the town steeple is the only sound that reaches the spot from
the outside world.
The hot sun beats on the garden here all day, from the hour in the
morning when it gets above the grand old beeches of the wood, till it
sets, away beyond the steeple of the town. But in the hottest hours it
is always refreshing to look, over the weather-stained tiles of the
long low toolhouse, at the mossy green of the hill that rises there,
cool and shaded, under the trees. Now and then a bull, of the herd
that feeds in the glades of the wood, comes down that shaded bank,
whisking his tawny sides with an angry tail to keep off the pestering
flies, and his deep bellow reverberates in the hollow. In the early
morning, too, before the dewy freshness has left the air, the sweet
mellow pipe of the mavis and the fuller notes of the blackbird float
across from these green depths, and ever and again throughout the
day the clear whistle of some chaffinch comes from behind the
leaves.
Standing here, among the deep box edgings and gravel paths, it is
not difficult to recall the place’s glory of twenty years ago—the glory
upon which these ancient plum-trees, blossoming yet against the
sunny walls, looked down. To the eye of Thought, time and space
obstruct no clouds, and in the atmosphere of Memory, the gardens of
the Past bloom for us always. Years and years agone! It is the day of
the fashion for Dutch bulbs, when fabulous prices were paid for an
unusually ‘fancy’ bulb, and in this garden some of the finest of them
are grown. The tulips are in flower, and the long narrow beds which,
with scant space between, fill the entire middle of the garden, are
ablaze with the glory of their bloom. Queenly flowers they are, and
tall, each one with a gentle pedigree—for nothing common or
unknown has entrance here—and crimson, white, and yellow, the
velvet petals of some almost black, striped with rare and exquisite
markings, they raise to the sun their large chaste chalices. The
perfection of shape is there, as they rise from the midst of their
green, lance-like leaves; no amorous breeze ever invades the spot
to dishevel their array or filch their treasures; and the precious
golden dust lies in the deep heart of each, untouched as yet save by
the sunshine and the bee. When the noonday heat becomes too
strong, awnings will be spread above the beds; for with the fierce
glare, the petals would open out and the pollen fall before the
delicate task of crossing had been done.
But see! Through the gate in the privet hedge there enters as fair a
sight. Ladies in creamy flowered muslins and soft Indian silks,
shading their eyes from the sun with tiny parasols, pink and white
and green—grand dames of the county, and grander from a
distance; gentlemen in blue swallow-tailed coats and white
pantaloons—gallants escorting their ladies, and connoisseurs to
examine the flowers—all, conducted by the owner, book in hand,
advance into the garden and move along the beds. For that owner,
an old man with white hair, clear gray eyes, and the memory of their
youthful red remaining in his cheeks, this is the gala time of the year.
Next month, the beds of ranunculus will bloom, and pinks and
carnations will follow; but the tulips are his most famous flowers,
and, for the few days while they are in perfection, he leads about,
with his old-world courtesy, replying to a question here, giving a
name or a pedigree there, a constant succession of visitors. These
are his hours of triumph. For eleven months he has gone about his
beloved pursuit, mixing loams and leaf-moulds and earths, sorting,
drying, and planting the bulbs, and tending their growth with his own
hand—for to whose, else, could he trust the work?—and now his toil
has blossomed, and its worth is acknowledged. Plants envied by
peers, plants not to be bought, are there, and he looks into the heart
of each tenderly, for he knows it a child of his own.
Presently he leads his visitors back into the house, across the mossy
stones of the court, where, under glass frames, thousands of
auricula have just passed their bloom, and up the outside stair to the
sunny door in the house-side. He leads them into the shady dining-
room, with its furniture of dark old bees-waxed mahogany, where
there is a slight refreshment of wine and cake, rare old Madeira, and
cake, rich with eggs and Indian spice, made by his daughter’s own
hand. Jars and glasses are filled with sweet-smelling flowers, and
the breath of the new-blown summer comes in through the open
doors.
The warm sunlight through the brown linen blind finds its way across
the room, and falls with subdued radiance on the middle picture of
the opposite wall. The dark eyes, bright cheeks, and cherry mouth
were those of the old man’s wife—the wife of his youth. She died
while the smile was yet on her lip and the tear of sympathy in her
eye; for she was the friend of all, and remains yet a tender memory
among the neighbouring poor. The old man is never seen to look
upon that picture; but on Sundays for hours he sits in reverie by his
open Bible here in the room alone. In a velvet case in the corner
press there, lies a silver medal. It was pinned to his breast by the
Third George on a great day at Windsor long ago. For the old man
peacefully ending his years here among the flowers, in his youth
served the king, and fought, as a naval officer, through the French
and Spanish wars. As he goes quietly about, alone, among his
garden beds, perchance he hears again sometimes the hoarse word
of command, the quick tread of the men, and the deep roar of the
heavy guns, as his ship goes into action. The smoke of these battles
rolled leeward long ago, and their glory and their wounds are alike
forgotten. In that press, too, lies the wonderful ebony flute, with its
marvellous confusion of silver keys, upon which he used to take
pleasure in recalling the stirring airs of the fleet. It has played its last
tune; the keys are untouched now, and it is laid past, warped by age,
to be fingered by its old master no more.
But his guests rise to leave, and, receiving with antique grace their
courtly acknowledgments, he attends the ladies across the stone-
paved hall to their carriages.
Many years ago! The old man since then has himself been carried
across that hall to his long home, and no more do grand dames visit
the high-walled garden. But the trees whisper yet above it; the
warmth of summer beats on the gravelled walks; and the flowers,
lovely as of old in their immortal youth, still open their stainless
petals to the sun.
 ABOUT COBRAS.
BY AN OFFICER.
While at home on furlough from India a short time ago, I was much
amused at finding a very general impression among my friends that
to come across a cobra is an every-day kind of occurrence in India.
How erroneous this idea is may be gathered from the fact that not
many days ago a brother-officer told me that although he had been
about ten years in India, he had never yet seen a cobra in a wild
state. His is, it is true, probably an exceptional case; but still it shows
that an Englishman may pass a considerable time in India without
coming across one of these venomous reptiles. Cobras, however,
are met with quite often enough, and sometimes in very curious and
uncomfortable places. For instance, a young lady who had just
returned from a ball in a small station in Southern India, noticed, as
she was on the point of getting into bed, that the pillow looked
disarranged; and on taking it up to smooth it out, she discovered a
cobra coiled up underneath it. She called out for assistance; and her
father coming to the rescue, speedily despatched the obnoxious
intruder with a stick. I happened to mention this circumstance to an
officer one day, and he informed me that the very same thing had
happened to himself soon after his first arrival in the country, and
that, in consequence, he never got into bed until he had examined
the pillows.
In the year 1873, while quartered at Bellary, on going into the
drawing-room of the bungalow, which at that time I shared with a
friend, I discovered a cobra curled up on the sofa cushion. I
hastened out of the room to fetch a stick; but in doing so, I must, I
suppose, have made some noise, as on returning the snake had
disappeared. A few evenings later, however, just as my ‘chum’ was
leaving the house to go out to dinner, he called out to me that there
was a snake crawling up the steps of the veranda in front of the
drawing-room. I ran out with a stick, and succeeded in killing the
unwelcome visitor. It turned out to be a fairly large cobra, and was in
all probability the one which I had seen a few days previously on the
sofa. It is, however, in the bathrooms of an Indian bungalow that
cobras, when met with within doors, are most frequently
encountered, as they come there in pursuit of the frogs which delight
to take up their quarters there; for froggy is an article of diet to which
the cobra is very partial. An officer of the Madras cavalry, since
deceased, told me that when quartered at Arcot, he one day
observed in his bathroom, emerging from the waste-water pipe, the
head of a cobra, which was holding in his mouth a frog. The pipe
was too narrow to admit of the snake’s withdrawing his head unless
he released his victim; this, however, from unwillingness to forego
his meal, he would not do, and in consequence, paid the penalty for
his gluttony with his life.
One day, my wife’s ayah came running into our bedroom saying
there was a large snake in the bathroom. Arming myself as usual
with a stick, I went into the bathroom just in time to see the snake
disappear into the waste-water pipe, which ran under another small
room to the back of the house, where the water found its outlet. The
servants stationed themselves at the outlet, while I endeavoured to
drive the reptile out from the rear, first with my stick, and afterwards
by pouring the contents of a kettle of boiling water down the pipe.
Both attempts to dislodge the intruder from his position proving
ineffectual, I commenced a vigorous assault on him by thrusting a
bamboo about five feet long down the pipe, and this time success
rewarded my efforts, and the snake, driven from his refuge, was
killed by the servants outside. This cobra measured about five feet
six inches in length, and was the largest that I have ever seen killed.
I may here mention that the ordinary ideas about the size attained by
this species of snake are greatly exaggerated. Some years ago, a
surgeon-major serving in the Madras presidency, with whom I was
acquainted, took a great interest in this matter, and offered a
considerable reward to any one who would bring him a cobra six feet
in length; but, if my memory serves me right, the reward was never
gained, although a very large number of cobras were produced for
his inspection.
Once I witnessed a wonderful escape from the almost invariably fatal
effects of a cobra bite. I was marching with some native troops in the
cold weather, and halted for the night at a place called Maikur,
where, instead of having our tents pitched, my wife and I preferred
occupying a small bungalow belonging to the department of Public
Works, which was situated opposite the encamping-ground. Sitting
outside the bungalow after dinner, I had occasion to call my head-
servant to give him some orders for the next morning. As he ran up, I
saw him kick something off his left foot, and at the same time he
called out: ‘Sāmp, sahib, sāmp!’ (‘A snake, sir, a snake.’) There was
a bright wood-fire burning close by, and I saw by its light the snake
with its hood up. It was immediately killed by some of the camp-
followers, and was brought to me, and proved to be a small cobra.
On examining my servant’s foot, I found one tiny puncture on the
ankle, on which was a single drop of blood. The man was at once
taken to the hospital tent, and attended to by the hospital assistant in
medical charge of the troops, who applied ammonia and did all that
was in his power. I was very anxious about the man; but he awoke
me at the hour for marching next morning as if nothing had
happened, and for some time apparently experienced no
inconvenience. Some weeks later, however, after we had reached
our destination, his left leg swelled very much, and he suffered great
pain for a considerable time; but he eventually recovered. The snake
was seen by eight or ten persons besides myself, and was beyond
doubt a cobra; and the only possible explanation of the man’s
escape seems to be that the reptile must have bitten something else
very shortly before, and so to a great extent exhausted the deadly
poison in its fangs.
One of our children had a narrow escape, though of a different kind,
when quite a baby. My wife picked him up one day from the floor,
where he was lying enjoying himself in baby fashion. She had hardly
done so, when a cobra fell from the roof on the very spot on which
the little one had been disporting himself the moment before.
On one occasion, a curious native superstition with regard to the
subject of these notes came to my notice. A cobra which had been
killed in the hut of one of the men was brought up to be shown to
me, when a havildar (native sergeant) called my attention to the fact
that the end of his tail was blunt, saying in Hindustani: ‘Look, sahib;
this is a downright villain; he has bitten some man, and so lost the tip
of his tail.’ On my making further inquiries, I was confidently assured
that whenever a cobra bites a man, the tip of his tail invariably
becomes blunted!
 MITIS METAL.
The introduction of wrought-iron castings by the ‘Mitis process,’ to
which attention has lately been directed, forms a new and an
important departure in the employment of this class of iron. Up to the
present time, wrought-iron has been worked into the requisite forms
by means of hammering; whilst a system of stamping in moulds was
deemed a considerable advance in economical working. It is now,
however, proposed to treat wrought-iron in the same manner as
cast-iron—namely, by melting and pouring it into moulds made in
sand, and corresponding in shape with the object desired. By such a
process a considerable saving in the cost of production is obtained.
Annealing is found to be unnecessary.
The difficulty which has hitherto barred the adoption of this method
has been the high temperature to which it has been necessary to
heat the iron before it became sufficiently fluid to flow into the
moulds. Wrought-iron fuses at about four thousand degrees
Fahrenheit, but a considerably higher temperature had to be
obtained before the metal passed out of the viscid state; and on
reaching this increased heat, it was found to absorb gases which
caused cavities and flaws in the castings, rendering them worthless,
and what are technically known in the foundry as ‘wasters.’ To
obviate this difficulty, Peter Ostberg, a Swedish engineer, has taken
advantage of the fact that the melting-point in alloys is considerably
below that of their components; and by combining with the iron a
small percentage of aluminium, he has succeeded in lowering the
temperature of fusion of the mixture to such an extent that excellent
castings can be obtained, the temperature reached not being high
enough to cause the absorption of gases. The castings are clean
and sharp in form, and remarkably strong and fine in texture, being
in some cases, it is said, half as tough again as the metal from which
they were made. The great reduction in price cannot fail to procure
for the new process an opening commensurate with its intrinsic
merits.
In the United States and Sweden, Mitis Metal has already
established itself as an article of commerce at once reliable and
economical; and there can be little doubt that the engineers of this
country will avail themselves of this new form of iron, placed at their
disposal by an invention which promises to rival in importance any
introduced into this branch of industry for many years past.
 MISSION TO DEEP-SEA FISHERMEN.
In the year 1844, the Thames Church Mission was instituted. A few
years ago, an accidental development of the organisation led to the
establishment of a missionary enterprise among the fishermen
engaged in the North Sea. But the possibilities of the new field of
labour soon justified the formation of a separate body to cope with
them; and on the 30th of November 1884, the Mission to Deep-sea
Fishermen was started. Its primary object is to give religious
teaching to the twelve thousand men and lads who labour on the
twelve fishing-fleets cruising in the North Sea. It has six smacks in its
service, a seventh being, at the time of writing, on the stocks. These
smacks supplement their philanthropic labours by fishing with the
fleets with which they sail. Each vessel carries a missionary skipper,
who, as often as the weather will permit, gathers together in his
spacious hold a congregation of fellow-fishermen for worship. The
earnestness of a devout mariner has often been noted; and from a
short cruise the writer recently took on one of the Mission vessels,
he can testify not only to the exceptional enthusiasm and fervour
which characterised the services held on board, but also to the
sound moral tone which, as a result of such services, prevails
generally in the fleets—a condition of things in happy contrast to the
riots and crimes which were rife there in former years.
But not only are the Mission vessels centres of religious instruction;
each carries a quantity of healthy literature, which, circulating
through the fleets, beguiles many a fisherman’s leisure hour of its
tedium. Then, too, medicine-chests and surgical appliances are
always kept on board; and with these at hand, the skipper and mate,
qualified by their certificates from the St John’s Ambulance
Association and the National Health Society, treat the sick and
injured fishermen of the fleet, who would otherwise suffer until
reaching land the pangs of untreated disorders and undressed
wounds. Besides this, each missionary skipper labours to
promulgate temperance principles among the fleets both by personal
example and gentle persuasion. Another feature of the Mission’s
work is the collecting and forwarding of knitted cuffs and comforters
—made by friends on shore—to the North Sea fishermen, as
preventives against the terrible ‘sea-blisters’ which oil-skins produce
on unprotected wrists and necks. Lastly, we should mention that the
fishermen of the fleets are encouraged to come frequently aboard
the Mission vessels to join in social gossip over a mug of cocoa.
Thus each of these vessels exists in the various capacities of
church, library, temperance hall, dispensary, and social lounge. The
methods by which the Mission has fought the ‘coper’ or ‘floating
grog-shop’ are tolerably well known, and so need not be dwelt upon
here.
Glancing at statistics, we note that, during last year, there were 1856
visits paid to vessels; 10,375 attendants at the seven hundred
services held; 515 temperance pledges were taken; 74,127 tracts
and 45,258 magazines distributed; 2725 cases medically and
surgically treated; 6665 comforters, 16,210 pairs of cuffs, and 668
helmets, given away; and 626 copies of the Scriptures sold. Thus the
Mission shows a most healthy growth. It has recently been
established in new offices at 181 Queen Victoria Street, London,
E.C.; and a new phase of its enterprise is the circulation of a
twopenny monthly journal entitled Toilers of the Deep, being a
‘record of Mission-work among them.’ The magazine is an excellent
one, and we commend it to all who feel an interest in the twelve
thousand men and boys ‘who toil through furious blast and sleety
storm—who hazard their lives, and fall victims, hundreds of them, to
the pitiless waves, that markets at home may be well supplied.’
 LOST AT SEA.

Good-night, beloved; the light is slowly dying

From wood and field; and far away the sea
Moans deep within its bosom. Is it sighing
For those whose rest can never broken be;
For those who found their way to God; yet never
Beneath green sod may rest, the sea holds them for ever?

Yes, deep and still your grave; the ocean keeping

Whate’er it gains for ever in its hold.
I know that in its depths you now are sleeping,
Quiet and dreamless as in churchyard mould;
But I have no still mound, as others, only
The memory of times past, ’mid days that now are lonely.

Buried deep with you in the sea for ever

Is all the brightness earth had once for me.
The spring returns; flowers bloom again; but never
I feel the joy in bird, and flower, and tree;
I see, but feel not as in days of yore,
Those days that can come back to me, ah, nevermore!

But yet I know that I am not forsaken.

‘Lead Thou me on,’ I now can calmly say.
None know the bitterness of sorrow taken
From out my heart; when I that prayer could pray,
In His own time God took you in His keeping,
All earthly sorrows past; where there is no more weeping.

Florence Peacock.
Printed and Published by W. & R. Chambers, 47 Paternoster Row,
London, and 339 High Street, Edinburgh.

All Rights Reserved.

*** END OF THE PROJECT GUTENBERG EBOOK CHAMBERS'S
JOURNAL OF POPULAR LITERATURE, SCIENCE, AND ART,
FIFTH SERIES, NO. 137, VOL. III, AUGUST 14, 1886 ***

Updated editions will replace the previous one—the old editions

will be renamed.

Creating the works from print editions not protected by U.S.

copyright law means that no one owns a United States copyright
in these works, so the Foundation (and you!) can copy and
distribute it in the United States without permission and without
paying copyright royalties. Special rules, set forth in the General
Terms of Use part of this license, apply to copying and
distributing Project Gutenberg™ electronic works to protect the
PROJECT GUTENBERG™ concept and trademark. Project
Gutenberg is a registered trademark, and may not be used if
you charge for an eBook, except by following the terms of the
trademark license, including paying royalties for use of the
Project Gutenberg trademark. If you do not charge anything for
copies of this eBook, complying with the trademark license is
very easy. You may use this eBook for nearly any purpose such
as creation of derivative works, reports, performances and
research. Project Gutenberg eBooks may be modified and
printed and given away—you may do practically ANYTHING in
the United States with eBooks not protected by U.S. copyright
law. Redistribution is subject to the trademark license, especially
commercial redistribution.

START: FULL LICENSE

THE FULL PROJECT GUTENBERG LICENSE