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FOURTH EDITION
3
© 2023, Elsevier Limited. All rights reserved.
The right of Michael S. Delbridge and Wissam Al-Jundi to be identified as authors of this work has been asserted by them in accordance with the
Copyright, Designs and Patents Act 1988.
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Notices
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods,
compounds or experiments described herein. Because of rapid advances in the medical sciences, in particular, independent verification of
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CONTENTS
Preface vi
Acknowledgements vii
I ANATOMY
1 The Thorax 2
2 The Abdomen, Pelvis and Perineum 20
3 The Upper Limb and Breast 62
4 The Lower Limb 80
5 The Head, Neck and Spine 106
6 The Nervous System 145
II PHYSIOLOGY
7 General Physiology 171
8 Respiratory System 186
9 Cardiovascular System 204
10 Gastrointestinal System 214
11 Urinary System 232
12 Endocrine System 240
13 Nervous and Locomotor Systems 259
III PATHOLOGY
14 Cellular Injury 279
15 Disorders of Growth, Morphogenesis and Differentiation 297
16 Inflammation 305
17 Thrombosis, Embolism and Infarction 311
18 Neoplasia 317
19 Immunology 330
20 Haemopoietic and Lymphoreticular System 342
21 Basic Microbiology 360
22 System-Specific Pathology 386
IV APPENDIX
OSCE Scenario Answers 431
Index 490
v
AR
P C EKFA
N OCW
E LEDGE
The authors are grateful to the publishers, Elsevier, for the sample answers provided in an appendix at the back of
invitation to produce a fourth edition of Basic Science for the book. More than 20 new OSCE scenarios have been
the MRCS. added to this edition. In addition, to accompany this edi-
The book is a concise revision guide to the core basic tion there is an online question bank within the Student
sciences which comprise the essential knowledge for those Consult eBook comprising over 200 Single Best Answer
entering surgical training. It is a basic requirement that questions (SBAs) based on each chapter in the book. The
every surgical trainee has a thorough understanding of the reader can access the section from the Table of Contents
basic principles of anatomy, physiology and pathology irre- in the eBook.
spective of which speciality within surgery they intend to No book of this length could hope to be comprehensive
pursue as a career. It is equally important that they under- and we have therefore concentrated on the topics that tend
stand the clinical application of the basic sciences. This to be recurring examination themes. As with previous edi-
revision guide has been written with this in mind, using a tions, this book has been written primarily as a means of
bullet-point style which we hope will make it easier for the rapid revision for the surgical trainee. However, it should
reader to revise the essential facts. also prove useful for those in higher surgical training, as
Much has changed both in the undergraduate curricu- well as for the surgically inclined, well-motivated medi-
lum and in the post-graduate examination system since cal student. We hope that this fourth edition will provide
the first edition was published 16 years ago. In this fourth a simple and straightforward approach to the basic science
edition, the chapters have been updated where appropri- that underpins surgical training.
ate and sections expanded to cover topics which are par-
ticularly relevant to examinations. As most examinations
are Objective Structured Clinical Examinations (OSCEs), Michael S. Delbridge
each chapter has OSCE scenario questions at the end with Wissam Al-Jundi
vi
ACKNOWLED GEMENTS
ACKNOWLED GE
We are extremely grateful to the publishers, Elsevier, and in particular to Alexandra Mortimer, Content
Strategist, for her support and help with this project. We are also grateful to the following colleagues
at the Sheffield Teaching Hospitals NHS Foundation Trust who provided help, advice and criticism:
Dr Paul Zadik, Consultant Microbiologist; Dr TC Darton, NIHR Academic Clinical Research Fellow,
Infectious Diseases and Medical Microbiology; Mr BM Shrestha, Consultant General and Transplant
Surgeon. We would also like to thank our consultant radiologist colleagues, who provided images: Dr
Matthew Bull, Dr Peter Brown, Dr James Hampton, Dr Robert Cooper and Dr Rebecca Denoronha.
Mr Raftery would like to thank his secretary, Mrs Denise Smith, for the long hours and hard work she
has put in typing and re-typing the manuscript, and Anne Raftery for collating and organizing the
whole manuscript into its final format. The task could not have been completed without them.
The figures in this book come from a variety of sources, and many are reproduced from other pub-
lications, with permission, as follows:
Fig. 3.9 from the University of Michigan Medical School, with kind permission of Thomas R. Gest,
PhD
Figs 13.10A, 13.10B and 13.11 from Crossman & Neary (2000) Neuroanatomy: An Illustrated Colour
Text, 2nd edn. Churchill Livingstone, Edinburgh
Figs 3.11 and 4.14, and Tables 6.1 and 6.3 from Easterbrook (1999) Basic Medical Sciences for MRCP
Part 1, 2nd edn. Churchill Livingstone, Edinburgh
Fig. 9.1 from Hoffman & Cranefield (1960) Electrophysiology of the Heart. McGraw-Hill, New York
(now public domain)
Figs 4.20, 4.24, 5.25, 6.5 and 6.6 from Jacob (2002) Atlas of Human Anatomy. Churchill Livingstone,
Edinburgh
Figs 8.1, 8.12B, 8.12C, 10.3, 10.4, 10.5, 10.6, 10.7, 11.1, 11.3, 13.1, 13.5 and 13.6 from McGeown (2002)
Physiology, 2nd edn. Churchill Livingstone, Edinburgh
Figs 8.3 and 8.4 from Pocock & Richards (2004) Human Physiology: The Basis of Medicine, 2nd edn.
Oxford University Press, Oxford
Figs 1.1, 1.2, 1.3, 1.4, 1.5, 1.6, 1.7, 1.8, 1.9, 1.11, 1.13, 1.14, 2.1, 2.2, 2.3, 2.4, 2.7, 2.8, 2.9, 2.10, 2.12, 2.13,
2.14, 2.17, 2.18, 2.19, 2.20, 2.21, 2.22, 2.23, 2.24, 2.25, 2.27, 2.28, 2.29, 2.30, 2.31, 2.32, 5.1, 5.2, 5.7,
5.8, 5.16, 5.17, 6.1, 6.2, 6.3, 6.4, 6.7, 6.8, 6.9, 6.10, 6.11, 6.12, 6.13, 6.15, 8.2, 8.6, 8.10, 8.12A, 9.2, 9.4,
9.6, 11.4, 12.1, 12.4, 13.8, 19.2, 20.1, 20.2, 20.3, 21.1, 22.1, 22.2 and 22.3 from Raftery (ed) (2000)
Applied Basic Science for Basic Surgical Training. Churchill Livingstone, Edinburgh
Fig. 17.2 and A.3 (Q&A) from Pretorius & Solomon (2011) Radiology Secrets Plus, 3rd edn. Elsevier,
Philadelphia
Figs 5.35, 6.14, 22.2 & A.5 (Q&A), 22.3 & A.6 (Q&A) and 22.5 & A.7 (Q&A) from Raftery, Delbridge
& Wagstaff (2011) Pocketbook of Surgery, 4th edn. Churchill Livingstone, Edinburgh
Figs 1.10, 3.1, 3.2, 3.3, 3.4, 3.8, 3.12, 4.1, 4.2, 4.3, 4.4, 4.6, 4.7, 4.8, 4.9, 4.11, 4.12, 4.13, 4.15, 4.16, 5.3, 5.4,
5.5, 5.9, 5.10, 5.11, 5.13, 5.14, 5.21, 5.22, 5.24, 5.26, 5.27, 5.28, 5.29, 5.30, 5.31 and 6.16 from Rogers
(1992) Textbook of Anatomy. Churchill Livingstone, Edinburgh
Fig. 13.4 from Stevens & Lowe (2000) Pathology, 2nd edn. Mosby, Edinburgh
Figs 15.1 and 15.2, and Boxes 15.1 and 15.2 from Underwood (ed) (2004) General and Systematic
Pathology, 4th edn. Churchill Livingstone, Edinburgh
vii
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SECTION I
Anatomy
1. The Thorax, 2
1
1
The Thorax
Truncus
arteriosus SVC
Aortic
Bulbus arch
cordis Pulmonary
veins
Pulmonary
trunk
Ventricle
Right
atrium Left
Atrium
ventricle
IVC
Sinus
venosus
Left atrium Right ventricle
Primitive heart
tube
Fig. 1.1 The development of the heart. IVC, Inferior vena cava; SVC, superior vena cava.
2
CHAPTER 1 The Thorax 3
• The sinus venosus joins the atria, becoming the two side. On the right, the fifth and sixth arches disappear to
venae cavae on the right and the four pulmonary veins leave the nerve hooked round the fourth, i.e. subclavian
on the left. artery. On the left it remains hooked round the sixth
arch (ligamentum arteriosum in the adult).
Great Vessels (Fig. 1.2)
• Truncus arteriosus gives off six pairs of arches. Fetal Circulation (Fig. 1.3)
• These curve round the pharynx to join the dorsal aortae, • Oxygenated blood travels from the placenta along the
which fuse distally into the descending aorta. umbilical vein.
• First and second arches disappear completely. • Most blood bypasses the liver in the ductus venosus,
• Third arch remains as carotid artery. joining the inferior vena cava (IVC) and then travelling
• Fourth arch becomes subclavian artery on the right to the right atrium.
and aortic arch on the left (giving off the left subclavian • Most of the blood passes through the foramen ovale
artery). into the left atrium so that oxygenated blood can enter
• Fifth arch disappears. the aorta.
• Sixth arch (ventral part) becomes right and left pul- • The remainder goes through the right ventricle with
monary arteries with a connection to dorsal aorta dis- returning systemic venous blood into the pulmonary
appearing on the right, but continuing as the ductus trunk.
arteriosus on the left connecting with the aortic arch. • In the fetus the unexpanded lungs present high resis-
• The above developmental anatomy explains the differ- tance to flow so that blood in the pulmonary trunk
ent positions of the recurrent laryngeal nerves on each tends to pass down the low-resistance ductus arteriosus
into the aorta.
Right and left • Blood returns to the placenta via the umbilical arteries
recurrent
laryngeal
(branches of the internal iliac arteries).
Vagus Vagus • At birth, when the baby breathes, the left atrial pressure
nerves
nerve nerve
Aortic rises, pushing the septum primum against the septum
arch secundum and closing the foramen ovale.
• Blood flow through the pulmonary artery increases and
I
Carotid
becomes poorly oxygenated as it now receives systemic
venous blood.
II
• Pulmonary vascular resistance is abruptly lowered as
lungs inflate and the ductus arteriosus is obliterated
over the next few hours to days.
III
• Ligation of the umbilical cord causes thrombosis of the
umbilical artery, vein and ductus venosus.
Right Left subclavian
subclavian artery Congenital Anomalies
IV Malposition
Arch of • Dextrocardia: mirror image of normal anatomy.
aorta
V • Situs inversus: inversion of all viscera.
VI
Left-to-Right Shunt
Pulmonary
trunk
Atrial septal defect (ASD)
Ductus • Fusion between the septum primum and septum secun-
arteriosus
dum usually takes place about 3 months after birth.
• May be incomplete in 10% of the population.
• If the septum secundum is too short to cover the foramen
secundum in the septum primum and ASD persists after
the primum and septum secundum are pressed together
at birth, this results in an ostium secundum defect, which
allows shunting of blood from the left to the right atrium.
• ASD may also result if the septum primum fails to fuse
Fig. 1.2 The development of the aortic arches. with the endocardial cushions.
4 SECTION I Anatomy
Aortic arch
Ductus
arteriosus
SVC
Septum
secundum
IVC
Liver
Abdominal
Ductus
aorta
venosus
Umbilical vein
Umbilical cord
Common iliac
artery
Umbilical
Placenta
arteries
arising from
the internal
iliac arteries
Fig. 1.3 The fetal circulation. IVC, Inferior vena cava; SVC, superior vena cava.
Right
pleuroperitoneal
membrane Foregut (oesophageal)
mesentery
Body wall
contribution Left
pleuroperitoneal
membrane
Body intercostal
Innermost
• Composed of four pieces (sternebrae). Internal intercostal
• Lateral margins are notched to receive most of the sec- intercostal
ond and third to seventh costal cartilages.
Relations
• On the right side of the median plane, the body is
related to the right pleura and the thin anterior border
of the right lung, which intervenes between it and the
pericardium.
• On the left side of the median plane, the upper two
pieces are related to the pleura and left lung; the lower
two pieces are related directly to the pericardium.
Fig. 1.5 An intercostal space. A needle passed into
Xiphoid the chest immediately above a rib will avoid the neu-
• Small and cartilaginous well into adult life. rovascular bundle.
• May become prominent if patient loses weight.
Clinical Points • The neurovascular bundle lies between the internal and
• Sternal puncture is used to obtain bone marrow from the innermost intercostal.
the body of the sternum; one should be aware of the • The neurovascular bundle consists of (from above
posterior relations! down): the vein, artery and nerve; the vein lying directly
• The sternum is split for access to the heart and occasion- in the groove on the undersurface of the corresponding
ally a retrosternal goitre, thymus or ectopic parathyroid rib.
tissue.
• The xiphoid may become more prominent when a Clinical Points
patient loses weight (naturally or due to disease). The • Insertion of a chest drain should be close to the upper
patient may present in clinic because they have noticed border of the rib below the intercostal space to avoid the
a lump, which was previously covered in fat. neurovascular bundle.
• Irritation of the intercostal nerves (anterior primary
Intercostal Spaces (Fig. 1.5) rami of the thoracic nerves) may give rise to pain
• A typical intercostal space contains three muscles com- referred to the front of the chest wall or abdomen in the
parable to those of the abdominal wall. region of the termination of the nerves.
• External intercostal muscle: passes downwards and
forwards from the rib above to the rib below; deficient
TRACHEA (Fig. 1.6)
in front where it is replaced by the anterior intercostal
membrane. • Extends from lower border of cricoid cartilage (level
• Internal intercostal muscle: passes downwards and of the sixth cervical vertebra) to termination into two
backwards; deficient behind where it is replaced by the main bronchi (level of fifth thoracic vertebra)—11 cm
posterior intercostal membrane. long.
• Innermost intercostal muscle: may cover more than one • Composed of fibroelastic tissue and is prevented from
intercostal space. collapsing by a series of U-shaped cartilaginous rings,
8 SECTION I Anatomy
Right main
bronchus Left main bronchus
Right upper
lobe bronchus
Left upper
lobe bronchus
Carina
Right middle Left lower
lobe bronchus lobe bronchus
open posteriorly, the ends being connected by smooth BRONCHI (Fig. 1.6)
muscle (trachealis).
• Lined by columnar ciliated epithelium containing The trachea terminates at the level of the sternal angle,
numerous goblet cells. dividing into right and left bronchi.
Right main bronchus:
Relations • wider, shorter and more vertical than left
In the Neck • approximately 2.5 cm long
• Anteriorly: isthmus of thyroid gland over second to • passes downwards and laterally behind ascending
fourth tracheal rings, inferior thyroid veins, sternohy- aorta and superior vena cava (SVC) to enter hilum of
oid, sternothyroid. lung
• Laterally: lobes of thyroid gland, carotid sheath. • azygos vein arches over it from behind to enter
• Posteriorly: oesophagus, recurrent laryngeal nerves in SVC
the groove between the trachea and oesophagus. • pulmonary artery lies first below and then anterior
to it
In the Thorax • gives off upper lobe bronchus before entering lung
• Anteriorly: brachiocephalic artery and left common • divides into bronchi to middle and inferior lobes
carotid artery, left brachiocephalic vein, thymus. within the lung.
• Posteriorly: oesophagus, recurrent laryngeal nerves. Left main bronchus:
• Right side: vagus nerve, azygos vein, pleura. • approximately 5 cm long
• Left side: aortic arch, left common carotid artery, left • passes downwards and laterally below arch of aorta,
subclavian vein, left recurrent laryngeal nerve, pleura. in front of oesophagus and descending aorta
CHAPTER 1 The Thorax 9
• gives off no branches until it enters hilum of lung, • Each has a blunt apex extending above the sternal end of
where it divides into bronchi to upper and lower lobes the first rib.
• pulmonary artery lies at first anterior to, and then • Each has a concave base related to the diaphragm.
above, the bronchus. • Each has a convex parietal surface related to the ribs.
• Each has a concave mediastinal surface related to the
Clinical Points pericardium.
• The trachea may be displaced or compressed by patho- • Each has a thin anterior border overlapping the pericar-
logical enlargement of adjacent structures, e.g. thyroid, dium and deficient on the left at the cardiac notch.
arch of aorta. • Each has a hilum where the bronchi and vessels pass to
• The trachea may be displaced if the mediastinum is and from the root.
pushed across, e.g. by tension pneumothorax displacing • Each has a rounded posterior border that occupies the
it to the opposite side. groove by the side of the vertebrae.
• Calcification of tracheal rings may occur in the elderly
and be visible on X-ray. Right Lung
• Because the right main bronchus is wider and more ver- • Slightly larger than the left.
tical, foreign bodies are more likely to be aspirated into • Divided into three lobes—upper, middle and lower—by
this bronchus. the oblique and horizontal fissures.
• Distortion and widening of the carina (angle between
the main bronchi), seen at bronchoscopy, usually indi- Left Lung
cates enlargement of the tracheobronchial lymph nodes • Has only an oblique fissure and therefore only two lobes.
at the bifurcation by carcinoma. • The anterior border has a notch produced by the heart
(cardiac notch).
Anatomy of Tracheostomy • The equivalent of the middle lobe of the right lung in the
• Either a vertical or cosmetic transverse skin incision left lung is the lingula, which lies between the cardiac
may be employed. notch and oblique fissure.
• A vertical incision is made downwards from the cricoid
cartilage passing between the anterior jugular veins. Roots of the Lungs
• A transverse cosmetic skin crease incision may be used • Comprise the principal bronchus, the pulmonary artery,
placed halfway between the cricoid cartilage and supra- the two pulmonary veins, the bronchial arteries and
sternal notch. veins, pulmonary plexuses of nerves, lymph vessels,
• The incision goes through the skin and superficial fascia bronchopulmonary lymph nodes.
(in the transverse incision, platysma will be located in • Chief structures composing the root of each lung are
the lateral part of the incision). arranged in a similar manner from before backwards on
• The pretracheal fascia is split longitudinally. both sides, i.e. the upper of the two pulmonary veins in
• Bleeding may be encountered from the anterior rela- front; pulmonary artery in the middle; bronchus behind.
tions at this point, namely anastomosis between ante- • Arrangement differs from above downwards on the two
rior jugular veins across the midline, inferior thyroid sides:
veins, thyroidea ima artery (when present). • right side from above downwards: upper lobe bron-
• In the young child, the brachiocephalic artery, the left chus, pulmonary artery, right principal bronchus,
brachiocephalic vein and the thymus may be apparent lower pulmonary vein
in the lower part of the wound. • left side: pulmonary artery, bronchus, lower pulmo-
• After splitting the pretracheal fascia and retracting the nary vein.
strap muscles, the isthmus of the thyroid will be encoun- • Visceral and parietal pleura meet as a sleeve surround-
tered and may be either retracted upwards or divided ing the structures passing to and from the lung. This
between clamps to expose the cartilages of the trachea. sleeve hangs down inferiorly at the pulmonary liga-
• An opening is then made in the trachea to admit the ment. It allows for expansion of the pulmonary veins
tracheostomy tube. with increased blood flow.
2
3
1 1
2 2
3 3
6
6 5 6
4 4 5
5
7
10 8 10
9 8
9
7
8
10 9
A Lateral Medial
1
1
2 1
3
2
3 2
3
6 6
4 6
4
5 4
8 10 8
5
10 5
9 8
9
8 10
B 9
Lateral Medial
Fig. 1.7 Bronchi and bronchopulmonary segments for the lungs. Divisions of the main bronchi in the centre,
with corresponding pulmonary segments on the surfaces. (A) Right lung upper lobe: 1 = apical, 2 = posterior,
3 = anterior; middle lobe, 4 = lateral, 5 = medial; lower lobe, 6 = apical, 7 = medial basal (cardiac), 8 = ante-
rior basal, 9 = lateral basal, 10 = posterior basal. (B) Left lung upper lobe: 1, 2 = apicoposterior, 3 = anterior;
lingula (middle lobe), 4 = superior, 5 = inferior; lower lobe, 6 = apical, 8 = anterior basal, 9 = lateral basal,
10 = posterior basal.
Inferior vena
cava
Right phrenic
nerve Left phrenic
nerve
Central
tendon
Oesophagus
Left crus of
the diaphragm
Right crus of the
diaphragm
Aorta
Quadratus lumborum
Psoas major
Arch of aorta
Pulmonary trunk
Superior vena cava
Pulmonary trunk
Small cardiac
vein
Fig. 1.9 The heart and great vessels in (A) anterior and (B) posterior view.
14 SECTION I Anatomy
• posterior (base): left ventricle, left atrium with four Left Ventricle
pulmonary veins entering it • Longer and more conical than right with thicker wall
• inferior (diaphragmatic surface): right atrium with (three times thicker).
IVC entering it and lower part of ventricles. • Communicates with atrium via mitral valve.
Three borders: • Connects with aorta via aortic valve.
• right: right atrium with IVC and SVC • Mitral valve has two cusps: anterior (larger) and
• inferior: right ventricle and apex of left ventricle posterior.
• left: left ventricle, auricle of left atrium. • Chordae tendineae run from the ventricular surfaces of
Chambers of Heart cusps to papillary muscles.
• Aortic valve is stronger than pulmonary valve. Has three
Right Atrium cusps—anterior, right and left posterior—each having a
• Receives blood from IVC, SVC, coronary sinus, anterior central nodule in its free edge and a sinus or dilatation
cardiac vein. in the aortic wall alongside each cusp.
• Crista terminalis runs between cavae–muscular ridge, • The mouths of the right and left coronary arteries are
separating smooth-walled posterior part of atrium seen opening into the anterior and left posterior aortic
(derived from sinus venosus) from rougher area (due to sinuses, respectively.
pectinate muscles) derived from true atrium.
• The fossa ovalis (the site of the fetal foramen ovale) is an Fibrous Skeleton of the Heart
oval depression on the interatrial septum. • The AV orifice is bound together by a figure-of-eight
conjoined fibrous ring.
Right Ventricle • Acts as a fibrous skeleton for attachment of valves and
• Thicker-walled than atrium. muscles of atria and ventricles.
• Communicates with atrium via tricuspid valve. • Helps to maintain shape and position of heart.
• Connects with pulmonary artery via pulmonary valve.
• Tricuspid valve has three cusps: septal, anterior, posterior. Conducting System
• Atrial surface of valve is smooth but ventricular surfaces • Sinoatrial (SA) node situated in right atrial wall at upper
have fibrous cords, the chordae tendineae, which attach end of crista terminalis (SA node = pacemaker of heart).
them to papillary muscles on the ventricular wall. They • From SA node, cardiac impulse spreads to reach AV
prevent eversion of the cusps in the atrium during ven- node.
tricular contraction. • AV node lies in interatrial septum immediately above
• Moderator band is a muscle bundle crossing from the opening of coronary sinus.
interventricular septum to the anterior wall of the heart. • Cardiac impulse is conducted to ventricles via AV
• Moderator band may prevent overdistension of ventri- bundle (of His).
cle. Conducts right branch of the AV bundle to anterior • AV bundle passes through fibrous skeleton of heart to
wall of ventricle. membranous part of interventricular septum, where it
• Infundibulum is the outflow tract of the ventricle. divides into right and left branch.
Directed upwards and to the right towards the pulmo- • Left AV bundle is larger and both run under endocar-
nary trunk. dium to activate all parts of the ventricular muscle.
• Pulmonary orifices guarded by the pulmonary valve • Papillary muscles contract first and then wall and
consisting of three semilunar cusps. septum in a rapid sequence from apex towards outflow
tract, both ventricles contracting together.
Left Atrium • AV bundle is normally the only pathway through which
• Smaller than the right. impulse can reach ventricles.
• Consists of principal cavity and auricle.
• Auricle extends forwards and to the right, overlapping Blood Supply of Heart (see Fig. 1.9)
the commencement of the pulmonary trunk. Right Coronary Artery
• Four pulmonary veins open into the cavity (two from • Arises from anterior aortic sinus.
each lung: superior and inferior). • Passes to the right of the pulmonary trunk between it
• Shallow depression on septal surface corresponds to and the auricle.
fossa ovalis of right atrium. • Runs along the AV groove around the inferior border of
• Largely smooth-walled, except for ridges in the auricle the heart and anastomoses with the left coronary artery
owing to underlying pectinate muscles. at the posterior interventricular groove.
CHAPTER 1 The Thorax 15
Pulmonary trunk
Tranverse sinus 1
Right 2
pulmonary Left pulmonary Superior
veins veins 3 mediastinum
Angle of 4
Louis
5
Anterior
mediastinum 6
7 Posterior
mediastinum
8
Contents: Contents:
• lower end of trachea • heart
• oesophagus • great vessels
• thoracic duct • phrenic nerves
• aortic arch • pericardiophrenic vessels.
• innominate artery
• part of carotid and subclavian arteries Posterior Mediastinum
• innominate veins Boundaries are:
• upper part of SVC • anterior: pericardium, roots of lungs, diaphragm
• phrenic and vagus nerves below
• left recurrent laryngeal nerves • posterior: vertebral column from lower border of fourth
• cardiac nerves to twelfth vertebrae
• lymph nodes • above: horizontal plane drawn through the angle of
• remnants of thymus gland. Louis
• below: diaphragm.
Anterior Mediastinum Contents:
Boundaries are: • descending thoracic aorta
• anterior: sternum • oesophagus
• posterior: pericardium. • vagus and splanchnic nerves
Contents: • azygos vein
• part of the thymus gland in children • hemiazygos vein
• anterior mediastinal lymph nodes. • thoracic duct
• mediastinal lymph nodes.
Middle Mediastinum Fig. 1.12 shows some of the structures in the anterior,
Boundaries are: middle and posterior mediastinum.
• anterior: anterior mediastinum
• posterior: posterior mediastinum.
Body of sternum
Thymic residue
in anterior
mediastinal fat Pulmonary trunk
Ascending aorta
Left pulmonary
artery
Superior vena cava
Descending aorta
Azygos vein
Scapula
Subscapularis
Infraspinatus
Oesophagus
Left subclavian artery Trachea
Sympathetic chain
Azygos vein
Fig. 1.14 The mediastinum seen from the right side.
Fig. 1.13 The mediastinum seen from the left side.
OSCE SCENARIOS
OSCE Scenario 1.1 OSCE Scenario 1.2
A 19-year-old male is admitted with a right-sided spon- A 35-year-old male sustains a crushing upper abdominal
taneous pneumothorax. He has a past history of a treated injury in a road traffic accident. On admission to A&E he
coarctation of the aorta. He requires a chest drain. has a tachycardia of 120 and a systolic blood pressure of
1. Describe the anatomy of a typical intercostal space. 90 mmHg. He is complaining of abdominal and bilateral
2. Why is this knowledge important in your technique of shoulder tip pain. Urgent CT scan reveals liver and splenic
insertion of an intercostal drain? trauma as well as a ruptured left hemidiaphragm.
3. What is the ‘triangle of safety’ when inserting a chest 1. Describe the three origins of the muscular part of the
drain? diaphragm.
4. Explain the anatomical basis for notching of the lower 2. At what vertebral levels do the oesophagus and the IVC
border of a rib seen on a chest X-ray of a patient with pass through the diaphragm?
coarctation of the aorta. 3. What is the nerve supply of the diaphragm?
CHAPTER 1 The Thorax 19
4. Explain why in some cases irritation of the diaphragm 1. Describe the surface anatomy of the heart.
may result in referred pain to the shoulder while in oth- 2. Why does cardiac tamponade result in drop in the blood
ers it may result in referred pain to the abdomen. pressure and clinical shock?
3. Describe how you would treat a cardiac tamponade.
OSCE Scenario 1.3
A 60-year-old female undergoes a right open nephrec- OSCE Scenario 1.5
tomy via a loin approach through the bed of the twelfth An 18-month-old girl developed sudden-onset bouts of
rib. A postoperative chest X-ray shows a small right cough and wheezes. A bowl of peanuts was found nearby
pneumothorax. while she was playing unwitnessed. She was rushed to A&E
1. Describe the surface anatomy of the pleura. and found to be conscious but distressed, tachypnoeic and
2. Why has this patient developed a right pneumothorax? wheezy. A chest X-ray revealed a collapsed lung.
3. At which other site, other than surgery on the thorax, 1. In which main bronchus a foreign body is more likely to
may surgery or trauma result in a pneumothorax? be dislodged and why?
2. In relation to the surface anatomy, where does the tra-
OSCE Scenario 1.4 chea commence and terminate?
A 22-year-old male is brought to A&E with a penetrating 3. Describe briefly how you would treat the patient.
injury in the left third intercostal space, anterior to the mid-
axillary line. His blood pressure is 80/40, pulse rate 140 Answers in Appendix pages 431–433
beats/min and has muffled hear sounds and distended neck
veins. A diagnosis of cardiac tamponade is established.
Please check your eBook at https://studentconsult.inkling.com/ for more self-assessment questions. See inside cover for
registration details.
2
The Abdomen, Pelvis and Perineum
DEVELOPMENT
Development of the Gut
The gut develops from a primitive endodermal tube. It is
divided into three parts:
• foregut: extends to the entry of the bile duct into the
duodenum (supplied by the coeliac axis)
• midgut: extends to distal transverse colon (supplied by
superior mesenteric artery)
• hindgut: extends to ectodermal part of anal canal (sup-
plied by inferior mesenteric artery).
A B
Foregut
• Starts to divide into the oesophagus and the laryngotra- Fig. 2.1 Types of oesophageal atresia. (A) Oeso
cheal tube during the 4th week. pha geal atresia with distal tracheo-oesophageal
• If it fails to do so correctly, there may be pure oesopha- fistula—most common type, with an incidence of
geal atresia (8% of cases), or atresia associated with 80%. (B) Isolated oesophageal atresia—second com
tracheo-oesophageal fistula (the commonest, 80% of monest, with an incidence of about 8%.
cases), the fistula being between the lower end of the
trachea and the distal oesophagus (Fig. 2.1). artery, bringing the third and fourth parts of the duode-
• Distal to the oesophagus, the foregut dilates to form the num across to the left of the midline behind the supe-
stomach. rior mesenteric artery; this part of the duodenum is now
• Rotates so that the right wall of the stomach now fixed retroperitoneally.
becomes its posterior surface, forming the lesser sac • The midgut returns to the abdomen at the 10th week
behind. and during this time it continues to rotate counterclock-
• Vagus nerves rotate with the stomach so that the right wise through a further 180°, bringing the ascending
vagus nerve becomes posterior and the left anterior. colon to the right side of the abdomen with the caecum
• As the stomach rotates to the left, so the duodenum lying immediately below the liver.
swings to the right, its mesentery fusing with the peri- • The caecum descends into its definitive position in the
toneum of the posterior abdominal wall, leaving all but right iliac fossa, pulling the colon with it.
the first inch retroperitoneal. • The mesenteries of the ascending and descending colon
blend with the posterior abdominal wall, except for the
Midgut (Fig. 2.2) sigmoid colon, which retains a mesentery.
• Enlarges rapidly in early fetal life, becoming too big for
the developing abdominal cavity, and herniates into the Clinical Points
umbilical cord. • In early fetal life, growth obliterates the lumen of the
• The apex of the herniated bowel is continuous with the developing gut. It then recanalizes. If recanalization is
vitellointestinal duct into the yolk sac. incomplete, areas of atresia or stenosis may result.
• While the midgut is within the cord it rotates 90° coun- • The communication between the primitive midgut and
terclockwise around the axis of the superior mesenteric yolk sac may persist as a Meckel’s diverticulum. This
20
CHAPTER 2 The Abdomen, Pelvis and Perineum 21
Ventral mesentery
Stomach developing from foregut
Spleen developing
Liver (in the in the dorsal mesentery
ventral mesentery)
Coeliac trunk
Dorsal mesentery
Aorta
Caecum
Superior
mesenteric
artery
Inferior
mesenteric
artery
Umbilical
Hindgut
cord
Midgut loop
Fig. 2.2 The developing gut and mesentery seen from the left. The midgut is in the umbilical cord. The arrows
show the direction of rotation for the foregut and midgut.
may occasionally be attached to the back of the umbi- • At its caudal end, the urorectal septum reaches the cloa-
licus by a fibrous cord, a remnant of the vitellointesti- cal membrane and divides it into anal and urogenital
nal duct (this may act as a fixed point for small bowel membranes.
volvulus). • The anal membrane separates the hindgut from the
• Rarely, the Meckel’s diverticulum may open onto the proctodeum (anal pit).
skin at the umbilicus.
• Malrotation occurs when the sequence described above
fails to occur or is incomplete. The duodenojejunal
(DJ) flexure may not become fixed retroperitoneally
and hangs freely from the foregut, lying to the right of
the abdomen. The caecum may also be free and may
obstruct the second part of the duodenum because of
peritoneal bands (of Ladd) passing across it. The base
of the mesentery is then very narrow as it is not fixed Allantois
at either end, and the whole of the midgut may twist
around its own blood supply, i.e. volvulus neonatorum.
Urorectal
• Persistence of midgut herniation at the umbilicus may septum
occur after birth, i.e. exomphalos. Cloaca
Anal Canal
Mesonephric
• Rectum, anus and genitourinary tracts develop at the duct
end of the 9th week by separation of these structures Common
excretory duct Metanephric
within the cloaca (Fig. 2.3). duct
• Urorectal septum divides the cloaca into bladder anteri- Hindgut
orly and rectum (hindgut) posteriorly. Fig. 2.3 The connections between cloaca (rudimen
• Anal canal develops from the end of the hindgut (endo- tary bladder) and allantois. The urachus is the embry
derm) and an invagination of ectoderm, the proctodeum. onic remnant of this connection.
22 SECTION I Anatomy
• Eventually the anal membrane breaks down and conti- • The kidney may fail to migrate cranially, resulting in
nuity is established between the anal pit and the hindgut. pelvic kidney.
• Failure of the anal membrane to rupture or anal pit to • One or more of the distal arteries may persist, giving
develop results in imperforate anus. rise to aberrant renal arteries (occasionally one may
persist from the common iliac artery).
The Kidneys and Ureter (Fig. 2.4) • The two metanephric masses may fuse in the midline,
• Pronephros develops at the 3rd week; it is transient and resulting in a horseshoe kidney.
never functions. • The ureteric bud may branch early, giving rise to dou-
• Mesonephros develops at the 4th week; this also degen- ble ureter. Rarely, the extra ureter may open ectopi-
erates but its duct persists in the male to form the epi- cally into the vagina or urethra, resulting in urinary
didymis and vas deferens. incontinence.
• Metanephros develops at the 5th week in the pelvis. • The metanephros may fail to develop on one side, result-
Metanephric duct arises as a diverticulum from the ing in congenital absence of the kidney.
lower end of the mesonephric duct.
• Metanephric duct (ureteric bud) invaginates the meta-
Bladder and Urethra
nephros, undergoing repeated branching to develop Bladder
into the ureter, pelvis, calyces and collecting tubules. • Urinary bladder is formed partly from the cloaca and
• Collecting tubules fuse with the proximal part of the partly from the ends of the mesonephric ducts.
tubular system and glomeruli which are developing • The anterior part of the cloaca is divided into three parts:
from the metanephros. • cephalic: vesicourethral
• The mesonephric duct loses its connection with the • middle: pelvic portion
renal tract. • caudal: phallic portion.
• The kidney develops in the pelvis, eventually migrating • The latter two constitute the urogenital sinus.
upwards, its blood supply moving cranially with it, initially • The ureter and mesonephric duct come to open sepa-
being from the iliac arteries and eventually from the aorta. rately into the vesicourethral portion.
• The mesonephric duct participates in the formation of
Development Anomalies the trigone and dorsal wall of the prostatic urethra.
• Failure of fusion of the derivatives of the ureteric bud • The remainder of the vesicourethral portion forms the
with the derivatives of the metanephros may give rise to body of the bladder and part of the prostatic urethra.
autosomal recessive form of polycystic kidney. • The apex of the bladder is prolonged to the umbilicus
as the urachus (where the primitive bladder joins the
allantois).
Urethra
Pronephros • In the female, the whole of the urethra is derived from
the vesicourethral portion of the cloaca.
Urogenital
sinus • In the male, the prostatic part of the urethra cranial to
the prostatic utricle is derived from the vesicourethral
part of the cloaca and the incorporated caudal ends of
the mesonephric duct.
Cloaca • The remainder of the prostatic urethra and the membra-
Mesonephros
nous urethra are derived from the urogenital sinus.
• The succeeding portion as far as the glans is formed by
fusion of the genital (urethral) folds enclosing the phal-
Mesonephric lic portion of the urogenital sinus (Fig. 2.5).
Common
duct • The terminal part of the urethra develops within the
excretory glans, which in turn develops from the genital tubercle.
duct
Metanephros
Metanephric Clinical Points
duct • Failure of fusion of the genital folds results in persis-
Fig. 2.4 Development of the pronephros, mesoneph tence of the urethral groove. This is known as hypo-
ros, metanephros and their ducts. spadias and occurs in varying degrees, e.g. complete
CHAPTER 2 The Abdomen, Pelvis and Perineum 23
Clinical Points
• Testis develops on posterior abdominal wall and its
Epithelial tag at blood supply, lymphatic drainage and nerve supply
site of definitive remain associated with the posterior abdominal wall.
meatus • The testis may descend into an ectopic position and may
Glans penis
be found at the root of the penis, in the perineum or in
the upper thigh.
Urethral groove • The testis may fail to descend and may be found any-
eventually closes where along its course, either intra-abdominally, within
– hypospadias results the inguinal canal or at the external ring.
if failure to close
• Processus vaginalis may fail to obliterate or may become
Scrotal swelling partially obliterated, resulting in a variety of hydroceles
(Fig. 2.6).
B Anus
Fig. 2.5 Development of the penis and urethra. (A) ANTERIOR ABDOMINAL WALL
Undifferentiated stage of development of external
genitalia. (B) Fusion of the urethral folds and penis Superficial Fascia of Abdominal Wall
development. The glans develops from the genital • Only superficial fascia on abdominal wall.
tubercle. • Two layers in lower abdomen:
• superficial fatty layer (Camper’s fascia)
• deep fibrous layer (Scarpa’s fascia).
groove, open or just a narrow urethral orifice on the • Superficial fascia extends onto penis and scrotum.
undersurface of the penile shaft. • Scarpa’s fascia is attached to the deep fascia of thigh
• Epispadias occurs where the dorsal wall of the urethra 2.5 cm below the inguinal ligament.
is partially or completely absent and is caused by failure • Extends into perineum as Colles’ fascia.
of infraumbilical mesodermal development. In extreme • Colles’ fascia is attached to the perineal body, perineal
cases this results in ectopia vesicae where the trigone membrane and laterally to the rami of the pubis and
of the bladder and ureteric orifices are exposed on the ischium.
abdominal wall and is associated with cleft pelvis, e.g.
no symphysis pubis. Clinical Points
• In rupture of the bulbous urethra, urine tracks into the
Testis scrotum, perineum and penis and into abdominal wall
• Develops as a mesodermal ridge on the posterior abdomi- deep to Scarpa’s fascia. It does not track into the thigh
nal wall medial to the mesonephros (urogenital ridges). because of the attachment of Scarpa’s fascia to the deep
• Links with mesonephric duct, which forms the epididy- fascia of the thigh.
mis, vas deferens and ejaculatory ducts. • An ectopic testis in the groin cannot descend any lower
• Undergoes descent from the posterior abdominal wall into the thigh because of the attachment of Scarpa’s fas-
to the scrotum. cia to the deep fascia of the thigh.
24 SECTION I Anatomy
Internal ring
External ring
Spermatic Hydrocele of
cord the cord
Hydrocele
connecting with Hydrocele
peritoneal cavity
A B C
Fig. 2.6 Types of hydrocele. (A) Congenital. (B) Vaginal. (C) Hydrocele of the cord (a similar lesion exists in the
female—a hydrocele of the canal of Nuck).
External oblique
A Xiphisternum
Sixth and seventh
costal cartilage
Linea alba
External oblique
Internal oblique
Transversus Transversalis
fascia
B Peritoneum
External oblique
Internal oblique
Transversus
Transversalis
fascia
C Peritoneum
Fig. 2.7 The formation of the rectus sheath. (A) Above the costal margin. (B) Above the arcuate line. (C) Below
the arcuate line.
these with violent contraction of the rectus muscle leads • Incision 2.5 cm below and parallel to costal margin
to a rectus sheath haematoma. extending laterally to lateral border of rectus or further.
• Structures encountered:
THE ANATOMY OF ABDOMINAL INCISIONS • skin
• subcutaneous fat
Midline • superficial fascia
• Through linea alba skirting the umbilicus. • anterior rectus sheath
• Excellent for routine and rapid access. • rectus abdominis
• Linea alba virtually bloodless. • posterior rectus sheath
• Structures encountered: • extraperitoneal fat
• skin • peritoneum.
• subcutaneous fat • Ninth intercostal nerve is present in lateral part of
• superficial fascia (two layers in lower abdomen) wound. Damage to it may result in weakness and atro-
• linea alba phy of upper rectus with predisposition to incisional
• extraperitoneal fat hernia.
• peritoneum.
Gridiron Incision (Muscle-Splitting)
Subcostal (Kocher’s) • Used for appendicectomy.
• Right side (cholecystectomy), left side (elective sple- • Centred on McBurney’s point (two-thirds of the way
nectomy), both sides connected (kidneys: anterior along a line drawn from the umbilicus to the anterior
approach). superior iliac spine).
26 SECTION I Anatomy
Oesophagus
Inferior layer of the
coronary ligament
Lienorenal ligament
Root of mesentery
Sigmoid mesocolon
Fourth part of duodenum
Rectum
Fig. 2.9 The posterior abdominal wall. The lines of reflexion of the peritoneum are shown. The liver, stomach,
spleen and intestines have been removed.
CHAPTER 2 The Abdomen, Pelvis and Perineum 29
Common bile
Clinical Points
duct Hepatic artery • Subphrenic abscesses may result from perforated peptic
ulcers, perforated appendicitis, perforated diverticulitis.
Free edge of • On the right side, infected fluid tracks along the right
lesser omentum
paracolic gutter into the right subhepatic space when
Fig. 2.10 A transverse section through the foramen of the patient is recumbent.
Winslow (epiploic foramen). IVC, Inferior vena cava. • The left subhepatic space (lesser sac) may distend with
fluid with perforated posterior gastric ulcer or acute
pancreatitis (pseudocyst of the pancreas).
Lesser Sac (Omental Bursa) • Most subphrenic abscesses are drained percutaneously
Relations nowadays under ultrasound or computerized tomogra-
• Anteriorly: lesser omentum and stomach. phy (CT) control.
• Superiorly: superior recess whose anterior border is the • If surgery is required, posterior abscesses can be
caudate lobe of the liver. accessed by an incision below or through the bed of the
• Inferiorly: projects downwards to transverse mesocolon. 12th rib; anterior abscesses can be accessed by an inci-
• To the left: spleen, gastrosplenic and lienorenal ligaments. sion below and parallel to the costal margin.
• To the right: opens into the greater sac via the epiploic
foramen.
POSTERIOR ABDOMINAL WALL
Epiploic Foramen (Foramen of Winslow; Fig. 2.10) The posterior abdominal wall is made up of bony and mus-
• Anteriorly: free edge of lesser omentum containing bile cular structures. The bones are:
duct to the right, hepatic artery to the left and portal • bodies of the lumbar vertebrae
vein behind. • the sacrum
• Posteriorly: inferior vena cava (IVC). • the wings of the ilium.
• Inferiorly: first part of duodenum. The muscles are:
• Superiorly: caudate process of the liver. • the posterior part of the diaphragm
• psoas major
Clinical Points • quadratus lumborum
• The hepatic artery can be compressed between fin- • iliacus.
ger and thumb in the free edge of the lesser omentum Important structures on the posterior abdominal wall
(Pringle’s manoeuvre). This is useful if the cystic artery include:
is torn during cholecystectomy or if there is gross haem- • abdominal aorta
orrhage following liver trauma. • IVC
• kidneys
• suprarenal glands
SUBPHRENIC SPACES • lumbar sympathetic chain.
• Potential spaces below liver in relation to diaphragm, The diaphragm has been described in the section on
which may be site of collections or abscesses (sub- the thorax, and the kidneys and suprarenal glands are dealt
phrenic abscesses). with elsewhere in this chapter.
30 SECTION I Anatomy
Aorta
Splenic artery
Coeliac axis
Fig. 2.11 Magnetic resonance angiogram showing the main branches of the abdominal aorta.
CHAPTER 2 The Abdomen, Pelvis and Perineum 31
Levator prostatae
(sphincter vaginae)
Puborectalis
Coccygeus
Median fibrous raphe
Insertion Insertion
• Forms a sling around the prostate (levator prostatae) or • Side of coccyx and lowest part of sacrum.
vagina (sphincter vaginae) inserting into the perineal body. • Muscle has same attachments as sacrospinous ligament.
• Forms a sling around the rectum and anus inserting into Nerve supply
and reinforcing the deep part of the anal sphincter at the • Perineal branch of S4.
anorectal ring (puborectalis). Action
• Into the sides of the coccyx and to a median fibrous • Holds the coccyx in its natural forwards position.
raphe stretching between the apex of the coccyx and the • Pelvic fascia.
anorectal junction. • Parietal pelvic fascia is a strong membrane covering the
Nerve supply muscles of pelvic wall and is attached to bones at mar-
• Perineal branch of S4 on pelvic surface, and branch of gins of muscles.
the inferior rectal and perineal division of the pudendal • Visceral pelvic fascia is loose and cellular over movable
nerve on the perineal surface. structures, e.g. levator ani, bladder, rectum.
Actions • It is strong and membranous over fixed or nondisten-
• Acts as principal support of pelvic floor. sible structures, e.g. prostate.
• Supports pelvic viscera and resists downwards pressure
of abdominal muscles.
PERINEUM
• Has a sphincter action on the rectum and vagina.
• Assists in increasing intra-abdominal pressure during The perineum comprises:
defecation, micturition and parturition. • The anterior (urogenital) perineum.
• The posterior (anal) perineum.
Coccygeus
• Small triangular muscle behind and in the same plane as Urogenital Triangle (The Anterior Perineum)
levator ani. • Triangle formed by the ischiopubic inferior rami and a
line joining the ischial tuberosities which passes just in
Origin front of the anus (Fig. 2.13).
• Spine of ischium.
Corpus cavernosum
Crus of penis
Bulbospongiosus
Perineal membrane
Bulb of penis
Levator ani
Superficial transverse
perineal muscle
External anal sphincter
Gluteus maximus
Coccyx
Fig. 2.13 The male perineum viewed from below. On the right side the muscles have been removed to display
the crus and bulb of the penis.
34 SECTION I Anatomy
Clitoris
Crus of the clitoris
Urethra
Bulb Bulbospongiosus
Ischiocavernosus
Gluteus maximus
Coccyx
Fig. 2.14 The female perineum. On the right side the muscles have been removed to display the bulb of the
vestibule and Bartholin’s glands.
• The perineal membrane (the inferior fascia of the uro- • The crura of the penis, which are attached at the angle
genital diaphragm) is a strong fascial sheath attached to between the insertion of the perineal membrane and
the sides of this triangle. ischiopubic rami; each crus is surrounded by an ischio-
• The perineal membrane is pierced by: cavernous muscle.
• urethra in the male • Superficial transverse perineal muscle running trans-
• urethra and vagina in the female. versely from the perineal body to the ischial ramus.
• Deep to the perineal membrane is the external urethral • The same muscles are present in the female but are less
sphincter composed of striated muscle fibres which sur- well developed (Fig. 2.14).
rounds the membranous urethra.
• The deep perineal pouch encloses the external urethral Perineal Body
sphincter. • Fibromuscular nodule lying in the midline between
• Below the external urethral sphincter is the perineal anterior and posterior perineum.
membrane, while above is an indefinite layer of fascia, • Attached to it are:
i.e. the superior fascia of the urogenital diaphragm. • anal sphincter
• In the male, the deep perineal pouch contains the • levator ani
bulbourethral glands (of Cowper) whose ducts pierce • bulbospongiosus
the perineal membrane to open into the bulbous • transverse perineal muscles.
urethra. • Important site of insertion of levator ani; tearing of per-
• The pouch also contains the deep transverse perineal ineal body during childbirth will considerably weaken
muscles. the pelvic floor.
• Superficial to the perineal membrane is the superficial
perineal pouch. The Posterior (Anal) Perineum
• Triangular area lying between the ischial tuberosities on
Superficial Perineal Pouch each side and the coccyx.
In the male, this contains: • It contains the following:
• The bulb of the penis, which is attached to the undersur- • anus and its sphincters
face of the perineal membrane; bulbospongiosus muscle • levator ani
covers the corpus spongiosum. • ischiorectal fossa.
CHAPTER 2 The Abdomen, Pelvis and Perineum 35
Ischiorectal Fossa • The skin of the penis is attached to the neck of the glans
This is a space between the anal canal and side wall of the and doubles up on itself forming the prepuce or foreskin.
pelvis.
• Its boundaries are: Body
• medially: fascia over levator ani and the external anal • Part of the penis between the root and glans. The body
sphincter comprises:
• laterally: fascia over obturator internus • corpora cavernosa
• anteriorly: extends forwards as a prolongation deep • corpus spongiosum.
to the urogenital diaphragm Corpora cavernosa
• posteriorly: limited by the sacrotuberous ligaments • Placed dorsally.
and the origin of gluteus maximus from this ligament. • Connected together in anterior three-quarters with sep-
• Floor is formed from skin and subcutaneous fat. tum of penis intervening.
• Contains mainly fat and is crossed by the inferior rectal • Separated behind to form the two crura, which are
vessels and nerves from lateral to medial side. attached along the medial margins of the ischial and
• The internal pudendal vessel and pudendal nerve lie on pubic rami.
the lateral wall of the fossa in the pudendal canal (of • Anteriorly, the corpora cavernosa fit into the base of the
Alcock), a tunnel of fascia which is continuous with the glans.
fascia overlying obturator internus. • There is a groove on the upper surface for the dorsal
vein of the penis and another groove on the lower sur-
Clinical Points face for the corpus spongiosum.
• Infection of the ischiorectal space may occur from boils • Corpora cavernosa are attached to the pubic symphysis
or abscesses on the perianal skin, from lesions within by the suspensory ligament.
the rectum and anal canal, from pelvic collections Corpus spongiosum
bursting through levator ani. • Commences at the perineal membrane by an enlarge-
• The fossae communicate with one another behind the ment, i.e. the bulb.
anus, allowing infection to pass readily from one fossa • Runs forward in the groove on the undersurface of the
to another. corpora cavernosa, expanding over their extremities to
• The pudendal nerves can be blocked in Alcock’s canal form the glans.
on either side, giving regional anaesthesia in forceps • The bulb lies below the perineal membrane and is sur-
delivery. rounded by the bulbospongiosus muscle.
• The urethra pierces the bulb on its upper surface and
Penis runs forwards in the middle of the corpus spongiosum.
The penis is divided into:
• root URETHRA
• body
• glans. Male Urethra
The male urethra is 20 cm long and is divided into:
Root • prostatic urethra
• The root is attached at: • membranous urethra
• perineal membrane • spongy urethra.
• the pubic rami by two strong processes, the crura
• the symphysis pubis by the suspensory ligament. Prostatic Urethra
• Passes through the prostate gland from base to apex.
Glans • Three centimetres long.
• Forms the extremity of the penis. • Bears the urethral crest on the posterior wall, on each
• At its summit is the opening of the urethra—the exter- side of which is the shallow depression, the prostatic
nal meatus. sinus, into which 15–20 prostatic ducts empty.
• Passing from the lower margin of the glans is a fold of • In the centre of the urethral crest is a prominence (veru-
mucous membrane continuous with the prepuce called montanum), into which opens the prostatic utricle.
the frenulum. • The ejaculatory ducts formed by the union of the duct
• At the base of the glans is a projecting edge or corona, of the seminal vesicle and the terminal part of the vas
behind which is a constriction. deferens open on either side of the prostatic utricle.
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“Oh, shucks,” said Laurie. “That doesn’t sound like sense. Does it,
Bob?”
“Well, I guess whoever owns this little strip wouldn’t object to a
person landing on it.”
“Of course not,” said Polly. “Besides, I don’t believe it belongs to
any one—except the town or the State of New York or some one like
that!”
“Guess we can find that out easy enough,” said Laurie, recovering
confidence. “Now, what’s the verdict? Think there’s anything in the
scheme?”
CHAPTER XV
ROMANCE AND MISS COMFORT
T hey parted from Brose Wilkins half an hour later. The work of
fixing up the Pequot Queen for Miss Comfort’s accommodation
seemed shorn of all difficulties. They were to start in the morning on
the gangway between boat and shore, Bob supplying the material
and Brose the tools. “Better get that up first,” said the latter, “so’s you
can get aboard without wading. You don’t need to bring much
material, fellers. There’s a pile of second-hand stuff over on our
wharf we can make use of. Don’t forget the spikes, though. I ain’t got
any spikes. Well, see you fellers again.”
Brose pushed off the launch with a foot, jumped nimbly aboard,
and waved a long, lean hand. And just then Laurie remembered
something.
“Hold on,” he called. “We haven’t paid you!”
“To-morrow,” said Brose. “It won’t be but seventy-five cents,
anyway; just the worth of that hawser. That tow ain’t going to cost
anything now I know who I done it for!”
The launch broke into sound and disappeared momentarily around
the stern of the Pequot Queen. When they saw it again Brose was
draped over the little engine, squirting oil.
I fear that Laurie begrudged Kewpie the two sessions of pitching-
practice that day. Certain it is that the afternoon session was
shortened to a scant thirty minutes, after which four boys set forth on
a shopping expedition, armed with a list that Laurie had made after
dinner. Still later they joined Polly and Mae at the shop. Progress
was reported and plans for the next day laid. Then Bob treated the
crowd, Kewpie virtuously choosing a ginger-ale.
To their disappointment, a light rain was falling that Thursday
morning when the four boys set forth for the Pequot Queen. Ned
trundled a wheelbarrow laden with lumber, and the others each
carried a couple of two-by fours or planks. Ned’s load also included a
paper bag of iron spikes, two hammers, and a hatchet. They chose
Ash Street in preference to the busier thoroughfares and, because
the lumber on the wheelbarrow was continually falling off and the
burdens on the boys’ shoulders required frequent shifting, their
progress was slow. The rain wasn’t hard, but it was steady, and Ned,
who had arisen in a depressed state of mind, grumbled alternately at
the weather and the wheelbarrow. They scarcely expected to find
Brose Wilkins on hand when they reached the boat, but there he was
awaiting them. Laurie introduced Ned and Kewpie, and work began.
By eleven o’clock a gangway led from the bank to the deck of the
Pequot Queen. Or, if you liked, you could call it a bridge. It was
twenty-six feet in length and thirty-two inches wide, and it was
supported midway by two posts which Brose had driven into the
sand. It was railed on each side so that, even in the dark, Miss
Comfort could traverse it safely. Later it was to be painted, the
planking green and the hand-rails white. At least, that was what
Brose said, and since Brose seemed to have taken command of
operations no one doubted the assertion. Ned and Kewpie, who had
been to Walnut Street on an errand, arrived just as the last plank
was laid, and the five drew up on the bank and admired the
gangway. Of course, as the material was all second-hand, the job
didn’t possess the fine appearance that new lumber lends. A stern
critic might even have sneered at the joinery, for Brose Wilkins
worked with speed rather than accuracy, and the gangway reminded
Laurie a little of Brose’s launch. But it was strong and practical, and
none of the admirers were inclined to be fastidious. On the contrary
the boys were loud in commendation, even Laurie and Bob, who had
wielded saw and hammer under Brose’s direction, praised the result
highly. Then they all walked along it to the deck and solemnly and
approvingly walked back again to the shore. As Bob said proudly, it
didn’t even creak.
They spent an hour clearing the boat of the worst of the dirt and
rubbish, preparatory to the more careful going over to follow in the
afternoon, and finally they parted from Brose and climbed the hill
again.
There was no pitching-practice that forenoon.
Shortly after half-past one they went to Mrs. Deane’s, reported
progress to Miss Comfort, borrowed two pails, a broom, a scrubbing-
brush, and a mop, and returned to the scene of their labors. Brose
was again ahead of them. He had taken down the smoke-stack and
was covering the hole in the roof with a piece of zinc sheeting. “I was
thinking,” he explained, “that she might want to use this place for
something, and there was a lot of water coming in around that old
funnel. After I paint around the edges of this it’ll be tight.” Brose
drove a last flat-headed nail and swung his legs over the side of the
boiler-room. “I was thinking that maybe she’d like to keep a few hens
in here.”
“Hens!” cried the quartet below in incredulous chorus.
Brose nodded. “Yeah, she was always fond of hens, Miss Pansy.
Used to have quite a lot of ’em until her fences got sort of bad and
they took to wandering into other folks’ yards. There wouldn’t be
much trouble here, I guess. They could go ashore and wander as
much as they pleased and not hurt anything.”
Ned broke into laughter. “Can’t you see Miss Comfort’s hens filing
ashore every morning with a big red rooster in the lead?”
“Sure,” agreed Brose. “Put up half a dozen nests and a couple of
roosts across here and you’d have a fine chicken-house. Anyhow, no
harm in stopping the leak.”
“I dare say she can use it for something, anyhow,” said Laurie.
“If it was me,” said Kewpie, “I’d keep ducks. Look at all the water
they’d have!”
For better than an hour dust flew from bow to stern on the Pequot
Queen, and the scrape of the scrubbing-brush and the slap of the
mop sounded from cabin, deck, and wheel-house. To introduce
water into the boiler room would have made matters only worse
there, for the floor and even the walls were black with coal-dust.
They cleaned out the fire-box and used the broom repeatedly and
closed the doors on the scene. But by four o’clock the rest of the
boat was thoroughly clean, and only sunlight and warmth were
needed to complete the work. The rather worn linoleum on the cabin
floor looked very different after Bob’s scrubbing brush and Kewpie’s
mop had got through with it. Even the paint in there had been won
back to a fair semblance of whiteness. By that time Polly and Mae,
released from school, had also arrived, and the Pequot Queen
resounded to eager voices. The rain had ceased and beyond the
hills westward the gray clouds were breaking when, carrying pails
and mop, broom and brush, the party of six went back to the shop in
merry mood.
It had been very hard to keep Miss Comfort away from her new
home thus far, and, since they wanted to have everything in shape
before she saw it, they didn’t recount to her all that had been
accomplished. “You see, ma’am,” said Laurie, “she was pretty dirty,
and—”
“But I’ll attend to the cleaning,” declared Miss Comfort eagerly.
“Land sakes, I don’t expect you boys to do that!”
“No, ma’am, well, now you take that hen—I mean boiler-room.
That wouldn’t be any sort of work for you.”
“But it doesn’t seem right to let you young folks do so much. Why,
just look at the boy’s shoes! They’re soaking wet!”
“Oh, Kewpie doesn’t mind that, Miss Comfort. Besides, I guess it’s
just outside that’s wet. Isn’t it, Kewpie?”
Kewpie moved his foot once or twice experimentally and obtained
a gentle squishing sound. He nodded. “That’s all,” he said.
“But,” resumed Laurie, “I guess we’ll have everything ready for you
by Saturday noon. I thought we might get the stove down that
morning and put it up. Then, maybe, on Monday you could move in!”
“You don’t think I could get settled Saturday?” pleaded Miss
Comfort. “I’d so love to spend Sunday in my—my new home.”
Laurie silently consulted the others and read assent. “Why, yes,
ma’am, I think we could have everything all ready by, say, half-past
ten or eleven.”
“That would be much nicer,” exclaimed Polly, “for then we could all
help get the things arranged.”
“Oh, thank you,” cried Miss Comfort gratefully. “To-morrow I’ll
engage Peter Brown to move my things Saturday morning. And to
think that it won’t be to the poor-farm! I told Mr. Grierson yesterday
about it. He’s one of the overseers, you know. He seemed—almost
—almost put out, and I thought for a moment he was going to insist
on my going to that place after all.” Miss Comfort laughed softly. “He
said he had been ‘counting on me.’”
“Yes, ma’am,” said Laurie, “you go ahead and arrange for the team
for Saturday at about ten thirty, and we’ll see that the place is all
ready, won’t we, Polly?”
“Yes, indeed, we will, Miss Comfort, even if we have to—to work
all night! Mae and I don’t have to go to school again for a week after
to-morrow, and we can do lots of things for you, I’m sure.”
“You’ve done so much already, my dear, all of you!” Miss Comfort
sighed, but it was a happy sigh. “I don’t know how to thank you, I’m
sure. It does seem as if—as if—” She faltered then, and before she
could continue Laurie got to his feet somewhat noisily and the others
followed suit.
“Got to go along,” he said hurriedly. “Change Kewpie’s feet—
shoes, I mean. Might take cold. See you in the morning, folks.”
Laurie made his escape, followed by the others, sighing relief.
Outside on the bricks, Kewpie’s shoes squished beautifully, but
Kewpie was frowning. “I like the old soul,” he announced, “but, say,
she’s awful leaky around the eyes!”
“So you’d be if you were seventy years old and folks were—were
kind to you and—and all that sort of thing,” replied Laurie gruffly and
vaguely. “Folks get that way when they’re old; sort of grateful and
tearful. They can’t help it, I guess!”