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diff --git a/old/67734-0.txt b/old/67734-0.txt deleted file mode 100644 index 8105705..0000000 --- a/old/67734-0.txt +++ /dev/null @@ -1,3403 +0,0 @@ -The Project Gutenberg eBook of Landmarks Medical and Surgical, by -Luther Holden - -This eBook is for the use of anyone anywhere in the United States and -most other parts of the world at no cost and with almost no restrictions -whatsoever. You may copy it, give it away or re-use it under the terms -of the Project Gutenberg License included with this eBook or online at -www.gutenberg.org. If you are not located in the United States, you -will have to check the laws of the country where you are located before -using this eBook. - -Title: Landmarks Medical and Surgical - -Author: Luther Holden - -Release Date: March 29, 2022 [eBook #67734] - -Language: English - -Produced by: deaurider and the Online Distributed Proofreading Team at - https://www.pgdp.net (This file was produced from images - generously made available by The Internet Archive) - -*** START OF THE PROJECT GUTENBERG EBOOK LANDMARKS MEDICAL AND -SURGICAL *** - - - - - -MEDICAL AND SURGICAL LANDMARKS - - - - -_By the same Author._ - - -MANUAL OF DISSECTION OF THE HUMAN BODY. - -With numerous Illustrations. - - -HUMAN OSTEOLOGY. - -Comprising a Description of the Bones with Delineations of the -Attachments of the Muscles. _Sixth Edition in the press._ - - - - - LANDMARKS - - MEDICAL AND SURGICAL - - BY - - LUTHER HOLDEN - - EX-PRESIDENT, MEMBER OF COUNCIL, AND MEMBER OF THE COURT OF EXAMINERS - OF THE ROYAL COLLEGE OF SURGEONS OF ENGLAND: CONSULTING SURGEON - TO SAINT BARTHOLOMEW’S AND THE FOUNDLING HOSPITALS - - _assisted by_ - - JAMES SHUTER, M.A.CAMB., F.R.C.S. - - ASSISTANT SURGEON TO THE ROYAL FREE HOSPITAL: LATE DEMONSTRATOR - OF PHYSIOLOGY, AND LATE ASSISTANT DEMONSTRATOR OF - ANATOMY, AT SAINT BARTHOLOMEW’S HOSPITAL - - _THIRD EDITION_ - - [Illustration] - - LONDON - J. & A. CHURCHILL, NEW BURLINGTON STREET - 1881 - - [_All rights reserved_] - - - - - TO - THE STUDENTS - PAST AND PRESENT - OF - SAINT BARTHOLOMEW’S HOSPITAL - THESE ‘LANDMARKS’ ARE - Dedicated - BY THEIR SINCERE FRIEND - THE AUTHOR - - - - -PREFACE TO THE THIRD EDITION. - - -In the present Edition the author adheres to his decision not to -introduce Diagrams. Additional experience more than ever convinces -him that they would frustrate his original object, which is to teach -Students the habit of making the eye and the hand work together, and to -educate the ‘touch’ upon the normal living body. - -Without such practical training, how can we reasonably expect to form a -correct diagnosis when called upon to examine an injury or to detect a -disease? In truth, the work is intended only for those who are desirous -of acquiring the habit recommended. - - LONDON: _May, 1881_. - - - - -PREFACE TO THE FIRST EDITION. - - -These ‘Landmarks’ have already appeared in Saint Bartholomew’s Hospital -Reports. They are now republished, with some additions, in the hope -that they may be useful to others besides those for whom they were -originally intended. - -My object has been to collect into a compact form the leading landmarks -which help practical surgeons in their daily work. Those relating to -the chest and abdomen have been ascertained, with as much precision as -natural variations permit, by needles introduced in various directions. - -I have to express my acknowledgments to Mr. WALSHAM and to Dr. GODSON -for their contributions. - - 65 GOWER STREET: _March 1876_. - - - - - CONTENTS. - - - PAGE - - THE HEAD 3 - - THE FACE 6 - - THE NECK 14 - - THE CHEST 19 - - THE BACK 25 - - THE ABDOMEN 29 - - THE PERINEUM 40 - - THE THIGH 43 - - THE BUTTOCKS 48 - - THE KNEE 49 - - THE LEG AND ANKLE 52 - - THE FOOT 56 - - THE ARM 59 - - THE FOREARM AND WRIST 64 - - THE HAND 67 - - PALPATION BY THE RECTUM 70 - - EXAMINATION PER VAGINAM 72 - - - - -‘CHIRURGUS MENTE PRIUS ET OCULIS AGAT QUAM MANU ARMATA.’ - - - - -LANDMARKS MEDICAL AND SURGICAL. - - -1. In clinical teaching, we often have occasion to point out, on -the surface of the living body, what may be called ‘medical and -surgical landmarks.’ By ‘landmarks’ we mean surface-marks, such as -lines, eminences, depressions, which are guides to, or indications -of, deeper-seated parts. This practice is not only most useful but -absolutely necessary; because many, even advanced students of anatomy, -are not so ready as they ought to be in their recognition of parts -when covered by skin. Students who may be familiar enough with bones, -muscles, blood-vessels, or viscera in the dissected subject, are often -sadly at fault when they come to put this knowledge into practice in -the living. - -For instance, ask a student to put his finger on the exact place where -he would feel for the head of the radius, the coracoid process of -the scapula, the tubercle of the scaphoid bone in the foot; ask him -to compress effectually one of the main arteries; to chalk the line -of its course; to map on the chest the position of the heart and the -several valves at its base; to trace along the walls of the chest the -outline of the lungs and pleura; to point out the bony prominences -about the joints, and their relative position in the different motions -of the joints; test him about the muscles and tendons which can be -seen or felt as they stand out in relief or remain in repose; let him -introduce his finger into the several orifices of the body, and say -what parts are accessible to the touch:--questions such as these, even -a good anatomist, unaccustomed to deal with the living subject, might -possibly find himself at a loss to answer. - -2. =Object in view.=--Our main object, therefore, is to induce in -students the habit of looking at the living body with anatomical eyes, -and with eyes too at their fingers’ ends. The value of this habit -cannot be too highly estimated. Is it not of the utmost importance -to an operating surgeon that he should have in his mind’s eye the -various structures of the body as they lie grouped, connected, and -working together? Should he not try at least to see them with the same -clearness and accuracy as if they were perfectly transparent? - -Moreover, the habit of examining the living body with ‘anatomical eyes’ -and ‘surgical fingers’ teaches the eye and the hand to act together, -and trains that delicate sense of touch which every surgeon should -possess. - -This habit is within easy reach of any one who has carefully dissected -for himself, and learned what to feel for. Plates will not give him -this knowledge. Let a student examine his own body with a skeleton -before him. Better still that two should work thus together, each -serving as a model to the other. - -Teachers of anatomy should follow the example of Sir C. Bell, who was -in the habit of introducing, from time to time, a powerful muscular -fellow to his class, ‘in order to show how much of the structure of -the body, such as the articulations and the muscles, might be learned -without actual dissection.’[A][1] - -At the same time, it is only fair to say that ‘landmarks’ cannot always -be defined with precision. A considerable latitude must be allowed for -natural variations in different persons. In some, their anatomy stands -out beautifully clear; in others, it is masked by obesity. Selecting, -therefore, for study a moderately lean person, let us begin with the -head. - -[A] The references throughout are to Notes at the end of the book. - - - - -_THE HEAD._ - - -3. =Scalp: its density.=--The great toughness of the scalp, more -especially at the back of the head, is owing to its intimate connection -with the cranial aponeurosis, the scalp vessels and hair bulbs -intervening. This density often obscures the diagnosis of tumours on -the cranium. A tumour growing upon the head may be either above or -below the aponeurosis of the scalp. If below, it will have a firm -resisting feel, being bound down by the aponeurosis. Nevertheless -its firmness and resistance may depend not simply on its confinement -beneath the aponeurosis, but on its having its origin within the -skull. Look with suspicion, then, on every tumour on the head that -will not readily permit you to move it about, so as to be sure of its -connections prior to an attempt at extirpation. - -The scalp moves freely over the pericranium, to which it is very -loosely connected by areolar tissue. When suppuration takes place in -this tissue free incisions through the dense scalp must be made to let -the pus out. - -4. =Arteries of scalp.=--The supra-orbital artery can be felt beating -just above the supra-orbital notch, and traced for some way up the -forehead; the temporal (anterior branch) ascends tortuously about one -inch and a quarter behind the external angular process of the frontal -bone; the occipital can be felt near the middle of a line drawn from -the occipital protuberance to the mastoid process; the posterior -auricular, near the apex of the mastoid process. All these arteries can -be effectually compressed against the subjacent bone. - -5. =Skull-cap.=--The skull-cap is rarely quite symmetrical. This want -of symmetry is often obvious. It may occur in men highly gifted, as -in the celebrated French anatomist Bichat. As to shape and relative -dimensions, no two heads are exactly alike, any more than are two -faces. It is beside my present purpose to go into the question of -craniology more than to say that, although the cranium does not exactly -follow the brain in all its eminences and depressions so as to be like -a cast of its surface, yet it certainly indicates the dimensions of -the great cerebral masses. The prominence of the frontal and parietal -‘eminences’ and of the occipital region may be taken as a general -indication of the development of the corresponding lobes of the brain. -To ascertain the relative proportions of these three regions, let a -thread be passed from one meatus auditorius to the other, across the -frontal, parietal and occipital eminences respectively. - -=Frontal sinuses.=--The ‘frontal sinuses’ formed by the separation of -the two tables of the skull vary much in size in different persons -and at different periods of life. This fact has an important bearing -on wounds in the forehead and on trephining in this situation. These -‘bumps’ do not exist in children, because the tables of the skull do -not begin to separate before puberty. From an examination of many -skulls in the Hunterian Museum, I find that the absence of the ‘bumps,’ -even in middle age, does not necessarily imply the absence of the -sinuses, since they may be formed by a retrocession of the inner wall -of the skull. In old persons, as a rule, when the sinuses enlarge, it -is by the encroachment of the inner table on the brain case. The inner -wall of the skull here follows the shrinking brain. It is, therefore, -important to bear in mind that an adult, and more especially an elderly -person, may have a large frontal sinus without any external indication -of it. - -Neither does a very prominent bump necessarily imply the existence of -a large sinus, or indeed of even a small one. The ‘bump’ may be a mere -heaping up of bone, a degradation, as in some Australian skulls. - -=Mastoid process.=--The mastoid process, which can be felt behind the -ear, contains air-cells, to which the above observations may also be -applied. - -=Occipital protuberance.=--The occipital protuberance, and the superior -curved line, can be distinctly felt at the back of the head. The -protuberance is always the thickest part of the skull-cap, and more -prominent in some than in others. - -The posterior inferior angle of the parietal bone, grooved by the -lateral sinus, is on a level with the zygoma, and a trifle more than -one inch behind the front border of the mastoid process. - -=Lines of cerebral sinuses.=--A line drawn over the head from the root -of the nose to the occipital protuberance corresponds with the superior -longitudinal sinus. Another line drawn from the occipital protuberance -to the front border of the mastoid process corresponds with a part of -the lateral sinus. - -=Middle meningeal artery.=--The trunk of the middle meningeal artery -runs along the front lower corner of the parietal bone, about one inch -and a half behind, and half an inch above, the external angular process -of the frontal. - -A straight line drawn from the front of one mastoid process to the -other would pass through the middle of the condyles of the occiput, -showing how nearly the skull is balanced on the top of the spine in the -erect posture. - -6. =Thickness of skull-cap.=--The average thickness of the cap of -an adult skull is about ⅕ of an inch. The thickest part is at the -occipital protuberance, where it is often ¾ of an inch or more, -even in an otherwise thin skull. The thinnest part is at the temple, -where it may be almost as thin as parchment. Everyone in the habit of -making post-mortem examinations knows how much the skull-cap differs -in thickness in different persons and in different parts of the same -skull. In old persons it is often in some parts not thicker than a -shilling, owing to absorption of the diploë. Another point of interest -is that the inner plane of the cap is not always parallel with the -outer. Hence, in applying the trephine this is not a bad rule--‘Think -that you are operating on the thinnest skull ever seen, and thinner in -one half of the circle than the other.’ - -7. =Levels of the brain.=--The level of the anterior lobes in front -corresponds with a straight line drawn across the forehead, just above -the eyebrows. The lower level of the anterior and middle lobes of -the cerebrum corresponds with a line drawn from the external angular -process of the frontal bone to the upper part of the meatus auditorius. -Another line drawn from the meatus to the occipital protuberance -corresponds with the lower level of the posterior lobe. The lower level -of the cerebellum cannot be defined by external examination. It depends -upon the extent to which the occipital fossæ bulge into the nape of the -neck; and this bulge varies in different skulls. - - -_THE FACE._ - -8. The approaches to the organs of the senses, their ever-varying -expression, their numerous muscles, and their rich profusion of vessels -and nerves, give the face great anatomical importance, which has a -most valuable bearing, not only on the practice of surgery, but on the -physiognomy of health, and in the diagnosis of disease. - -9. =Foramina for branches of fifth nerve.=--As a surgeon may be called -upon to divide any one of the three chief branches of the fifth nerve -upon the face, he looks with interest to the precise situations where -they leave their bony foramina with their corresponding arteries. The -supraorbital notch or foramen can be felt about the junction of the -inner with the middle third of the supraorbital margin. From this point -a perpendicular line drawn with a slight inclination outwards, so as to -cross the interval between the two bicuspid teeth in both jaws, passes -over the infraorbital and the mental foramina. The direction of these -two lower foramina looks towards the angle of the nose. - -10. =Pulley for superior oblique muscle.=--By pressing the thumb -beneath the internal angular process of the frontal bone, the -cartilaginous pulley for the tendon of the superior oblique muscle can -be distinctly felt. We should be careful not to interfere with this -pulley in any operation about the orbit. - -11. =Lower jaw.=--The working of the condyle of the jaw vertically and -from side to side can be distinctly felt in front of the ear. When the -mouth is opened wide, the condyle advances out of the glenoid cavity -on to the eminentia articularis, and returns into its socket when the -mouth is shut. The muscle which causes this advance is the external -pterygoid; and it gives the jaw a greater freedom of grinding motion. - -The posterior margin of the ramus of the lower jaw corresponds with -a line drawn from the condyle to the angle. In opening abscesses in -the parotid region, the knife should not be introduced behind this -line for fear of wounding the external carotid artery. Punctures to -any depth may be safely made in front of it. They are often necessary -where inflammation of the parotid gland ensues after eruptive fevers, -and runs on to suppuration. The swelling, tension, and pain are most -distressing. Owing to the fibrous framework of the gland, the matter -is not circumscribed, but diffused. One puncture is not enough. Three -or more may be requisite. The blade of the knife should be held -horizontally, so as to be less likely to injure the branches of the -facial nerve. We are not to be disappointed if no matter flows. The -punctures give relief, and matter will probably exude the next day. - -12. =Parotid duct.=--A line drawn from the bottom of the lobe of the -ear to midway between the nose and the mouth gives the course of the -parotid duct. Opposite the second upper molar, the duct opens by a -papilla into the mouth. The branch of the facial nerve which supplies -the buccinator runs with the duct. - -13. =Temporal and facial arteries.=--The pulsation of the trunk of -the temporal artery can be felt, between the root of the zygoma and -the ear. This should be well known to and used by chloroformists. It -is also a convenient pulse to feel in a sleeping patient. The facial -artery can be distinctly felt as it passes over the body of the jaw at -the anterior edge of the masseter; again near the corner of the mouth -close to the mucous membrane: and, lastly, by the side of the ala nasi, -up to the inner side of the tendo oculi. By holding the lips between -the finger and thumb the coronary arteries are felt under the mucous -membrane. The facial vein does not accompany the tortuous artery, but -runs a straight course from the inner angle of the eye to the front -border of the masseter, just behind the artery. - -14. =Eyelids and eyes.=--The opening between the eyelids varies in size -in different persons; hence more of the eyeball is seen in some than -in others, and the eye appears larger. Although human eyes do vary a -little in size, yet the actual difference is by no means so great as -is generally supposed. The size of the fissure has much to do with the -apparent size of the eye. Contrast the narrow fissure of the Chinese -and Mongolian races, and the apparent smallness of their eyes with -those of Europeans. As a rule the external angle of the lid is higher -than the internal. When not exaggerated, it gives the face an arch and -pleasing expression. - -Evert the lids to see the Meibomian glands; observe their perpendicular -arrangement, in the substance of the tarsal cartilages. - -The free borders of the lids are not bevelled, as described by J. L. -Petit and most anatomists, ‘so as to form with the globe of the closed -eye a triangular canal for the flow of the tears.’ On the contrary, it -is easily seen that the lid margins, when closed, come into accurate -contact. Their plane is not exactly horizontal, but slightly inclined -upwards. - -Every time the eye is shut, the ball turns upwards and inwards, so that -the cornea is completely covered by the upper lid. This may be well -seen by raising the lid of a sleeping infant; also in cases of low -fever when the lid is not completely closed. This up-turning of the eye -obviously clears the cornea, and protects it from the light. - -A careful examination of the motion of the lower lid in the act of -shutting the eye proves that it is a double motion. The lid is not only -slightly raised, but drawn inwards about ¹⁄₁₂ of an inch. This second -movement sweeps any particles of dust as well as moisture towards the -inner canthus. - -15. =Puncta lachrymalia.=--The puncta lachrymalia are distinctly -visible at the inner angles of the lids. The lower punctum is larger -and a little more external than the upper, so that they are not exactly -opposite. The direction, too, of the puncta deserves notice. Their open -mouths look a little backwards, ready to imbibe the tears. When their -proper bearing is lost, as in facial paralysis or by a cicatrix near -the lid, the tears overflow the cheek. The length of the lachrymal -canals is from three to four lines. The lower is a little shorter and -wider than the upper. As each makes a little angle in its course, about -a line from its orifice, the lid should be drawn outwards to straighten -the canal when we introduce a probe. - -16. =Lachrymal sac.=--To find the lachrymal sac, draw outwards the -eyelids to tighten the tendo oculi, which crosses the sac a little -above its middle. A knife introduced just below the tendon close to -the edge of the orbit would enter the sac. The angular artery and vein -would be on the inner side of the incision. A probe directed in a line -with the inner edge of the orbit, _i.e._ downwards, outwards, and -backwards, would pass down the nasal duct, and appear in the inferior -meatus of the nose. - -The tendo oculi serves many purposes besides giving attachment to the -cartilages and muscles of the lids. One purpose is said to be to pump -the tears into the lachrymal sac. Place a finger on the tendon, and -feel that it tightens every time the lids are closed. The tendon, being -intimately connected to the sac, draws, as it tightens, the sac wall -outwards and forwards, and in this way it may pump along the lachrymal -canals any fluid collected at the angle of the eye. - -17. =Nasal duct.=--The nasal duct is from six to eight lines long, and -narrowest in the middle of its course. Its termination in the inferior -meatus lies under the inferior spongy bone, about a quarter of an inch -behind the bony edge of the nostril. The appearance of the orifice in -the dry bone conveys no idea of its size and shape in life; for it is -diminished by a valve-like fold of mucous membrane, so that it becomes, -in most cases, a mere slit, not exceeding a line in diameter. - -The facility with which instruments can be introduced into the nasal -opening of the duct depends upon its position as well as its size. This -position varies in different instances. Sometimes it opens directly -into the roof of the inferior meatus, in which case the hole is large -and round, so that tears readily run into the nose. In other instances -the opening is situated on the outer wall of the meatus, and is then -always such a narrow fissure as to be hardly discernible. The practical -conclusion then is, that a probe can be easily introduced when the -opening is in the roof of the meatus, but not without difficulty -and laceration of the mucous membrane when on the outer wall. This -difficulty indeed may be increased by the narrowness of the meatus, -arising from an unusual curvature of the spongy bone. - -18. =Nose and nasal cavities.=--The line where the cartilages of -the nose are attached to the nasal and superior maxillary bones can -be traced with precision. The close connection of the skin to the -cartilages admits of no stretching; hence the acute pain felt in -erysipelas and boils on the nose. The external aperture of the nose is -always placed a little lower than the floor of the nostril, so that the -nose must be pulled up before we can inspect its cavities. - -Looking into the nostrils, we find that the left is, in the majority -of cases, narrower than the right, owing to an inclination of the -septum towards the left. A communication sometimes exists between -them, through a hole in the septum, as in the case of the celebrated -anatomist Hildebrandt. By stretching open the anterior nares we -can get a view of the end of the inferior spongy bone. The middle -spongy bone cannot be seen: its attachment to the ethmoid is high up, -nearly opposite the tendo oculi. The cavities are so much narrowed -transversely by the spongy bones, that in the extraction of polypi it -is better to dilate the blades of the forceps perpendicularly, and near -the septum. - -19. =Mouth.=--What can be seen and felt through the mouth? The upper -surface of the tongue, ‘_speculum primarum viarum_,’ is a study in -itself. We notice, on its under surface, a median furrow, on each side -of which stands out the ranine vein, lying upon the prominent fibres -of the lingualis. In the middle line of the floor of the mouth is the -‘frenum linguæ,’ with the orifice of the duct of the submaxillary -gland on each side of it. The gland itself can be detected immediately -beneath the mucous membrane by feeling further back near the angle of -the jaw, at the same time pressing the gland upwards from below. - -The long ridge of mucous membrane on each side of the floor contains -the sublingual glands. - -We can feel the attachment of the ‘genio-hyo-glossi’ behind the -symphysis of the jaw. The division of this attachment would enable a -surgeon to draw the tongue more freely out of the mouth in any attempt -to remove carcinoma extending far back into its root. - -There is great difference in the shape of the hard palate; this -difference depends upon the depth of the alveolar processes. In some it -forms a broad arch; in others it is narrow, and rises almost to a point -like a Gothic arch, and materially impairs the tone of the voice. - -=Throat.=--To examine the throat well, the nose should be held so as -to compel breathing through the mouth. Thus the soft palate will be -raised, the palatine arches widened, and the tonsils and the back of -the pharynx fairly exposed. Pressing the tongue downwards, provided it -be done very gently, is also of advantage. Rude treatment the tongue -at once resists. The forefinger can be passed into the throat, beyond -the epiglottis, as low as the bottom of the cricoid cartilage, and thus -search the pharynx down to the top of the œsophagus, and the hyoid -space (on each side) where foreign bodies are so apt to lodge. The -greater cornu of the hyoid bone can be felt as a distinct projection -on either side. In introducing a tube into the œsophagus the finger -should keep the instrument well against the back of the pharynx so as -to prevent its slipping into the larynx. - -Pass the finger between the teeth and the cheek and feel the anterior -border of the coronoid process of the jaw. On the inner side of this -process, between it and the tuberosity of the upper jaw, is a recess, -where a deeply-seated temporal abscess might burst, or might be -opened. Behind the last molar on the inner side of the upper jaw we -can distinctly feel the hamular process of the sphenoid bone; also the -lower part of the pterygoid fossa, and the internal pterygoid plate. -Behind, and on the outer side of the last molar, can be felt part of -the back of the antrum and of the lower part of the external pterygoid -plate. - -On the roof of the mouth we can feel the pulsation of the posterior -palatine artery. Hæmorrhage from this vessel can be arrested by -plugging the orifice of the canal, which lies (not far from the -surface) on the inner side of the last molar, about 1/3 of an inch in -front of the hamular process. - -When the mouth is wide open, the pterygo-maxillary ligament forms a -prominent fold readily seen and felt beneath the mucous membrane, -behind the last molar teeth. A little below the attachment of this -ligament to the lower jaw we can easily feel the gustatory nerve, as it -runs close to the bone below the last molar tooth. The exact position -of the nerve can be ascertained in one’s own person by the acute pain -on pressure. A division of the nerve, easily effected by a small -incision, gives much temporary relief in cases of advanced carcinoma of -the tongue. - -To feed a patient in spasmodic closure of the jaw, it is well to know -that there is behind the last molar teeth a space sufficient for the -passage of a small tube into the mouth. - -=Antrum.=--Lift up the upper lip and examine the front wall of the -antrum. The proper place in which to tap it is above the second -bicuspid tooth, about one inch above the margin of the gum. - -20. =Posterior nares.=--A surgeon’s finger should be familiar with the -feel of the posterior nares, and of all that is within reach behind the -soft palate. This is important in relation to the attachment of polypi, -to plugging the nostrils, and to the proper size of the plug. In the -examination of this part of the back of the throat it is necessary to -throw the head well back, because, in this position, nearly all the -pharynx in front of the basilar process comes down below the level of -the hard palate, and can be seen as well as felt. But when the skull -is horizontal, _i.e._ at a right angle with the spine, the hard palate -is on a level with the margin of the foramen magnum, and the parts -covering the basilar process are concealed from view. - -The head then being well back, introduce the forefinger behind the -soft palate, and turn it up towards the base of the skull. You feel -the strong grip of the superior constrictor. Hooking the finger well -forwards, you can feel the contour of the posterior nares. Their size -depends upon the anterior, but rarely exceeds a small inch in the -vertical diameter, and a small half-inch in the transverse. The plug -for the posterior nares should not be larger than this. Their plane -is not perpendicular, but slopes a little forwards. You can feel the -septum formed by the vomer, and also the posterior end of the inferior -spongy bone in each nostril. - -21. =Tonsils.=--Before taking leave of the throat, look well at the -position of the tonsils between the anterior and posterior half arches -of the palate. In a healthy state they should not project beyond the -level of these arches. In all operations upon the tonsils, we should -remember the close proximity of the internal carotid artery to their -outer side. Nothing intervenes but the pharyngeal aponeurosis, and the -superior constrictor of the pharynx. Hence the rule in operating on the -tonsils, always to keep the point of the knife inwards. - -In troublesome hæmorrhage from the tonsils, after an incision or -removal, it is well to know that they are accessible to pressure if -necessary by means of a padded stick, or even a finger. - -22. =Features.=--A word or two on the lines of the face as indicative -of expression. Everyone pays unconscious homage to the study of -physiognomy when, scanning the features of a stranger, he draws -conclusions concerning his intelligence, disposition, and character. -Without discussing how much physiognomy is really worth, there can -be no doubt that it is a mistake to place it in the same category as -phrenology, since the latter lacks that sound basis of physiology which -no one can deny to the former. - -A person fond of observing cannot fail to have arrived at the -conclusion that a man’s daily calling moulds his features. Place a -soldier, a sailor, a compositor, and a clergyman side by side, and who -will not immediately detect a marked difference in their physiognomies? - -The muscles of the features are generally described as arising from the -bony fabric of the face, and as inserted into the nose, the corners of -the mouth, and the lips. But this description gives a very inadequate -idea of their true insertion. They drop fibres into the skin all along -their course, so that there is hardly a point of the face which has not -its little fibre to move it. The habitual recurrence of good or evil -thoughts, the indulgence in particular modes of life, call into play -corresponding sets of muscles which, by producing folds and wrinkles, -give a permanent cast to the features, and speak a language which all -can understand, and which rarely misleads. Schiller puts this well when -he says that ‘it is an admirable proof of infinite wisdom that what is -noble and benevolent beautifies the human countenance; what is base and -hateful imprints upon it a revolting expression.’ - - -_THE NECK._ - -23. =Subcutaneous veins.=--Notice first the direction of the -subcutaneous veins. The chief subcutaneous vein is the external -jugular. Its course corresponds with a line drawn from the angle of the -jaw to the middle of the clavicle, where it joins the subclavian. It -is made more prominent by putting the sterno-mastoid into action, or -by gentle pressure on the lower end of the vein. It is exceptionally -joined by a branch which runs over the clavicle, and is termed -‘jugulo-cephalic.’ The anterior jugular generally runs along the front -border of the sterno-mastoid. - -24. =Parts in central line. Os-hyoides.=--Immediately below and nearly -on a level with the lower jaw we feel the body of the os-hyoides, and -can trace backwards on each side the whole length of the cornua. They -might easily be broken by the grasp of a garotter. Below the body -of the os-hyoides is the gap above the thyroid cartilage. This gap -corresponds with the anterior thyro-hyoid ligament and the apex of the -epiglottis; so that in cases of cut throat in this situation, nearly -the whole of the epiglottis lies above the wound. - -=Thyroid cartilage.=--The projection and depth of the notch in the -thyroid cartilage, or ‘pomum Adami,’ varies in different persons. -Between the notch and the hyoid bone there is a large bursa, which -facilitates the play of the cartilage beneath the bone in deglutition. -The notch does not appear till puberty, and is throughout life much -less distinct in the female than the male. The finger can trace the -upper borders and cornua of the thyroid cartilage: its lower cornua can -be felt by the side of the cricoid. - -On each side of the thyroid cartilage we can recognise the lateral -lobes of the thyroid gland. On the upper and front part of the gland we -can distinctly feel the pulsation of the superior thyroid artery. This -pulsation, coupled with the fact that the gland rises and falls with -the larynx in deglutition, gives the best means of distinguishing a -bronchocele from other tumours resembling it. - -Below the angle of the thyroid cartilage we feel the interval between -it and the cricoid, which is occupied by the cricothyroid membrane. -In laryngotomy we cut through this membrane transversely close to the -upper edge of the cricoid cartilage, in order that the incision may be -as far as possible from the attachment of the vocal cords. - -25. =Cricoid cartilage.=--The projection of the cricoid cartilage is a -point of great interest to the surgeon, because it is his chief guide -in opening the air-passages, and can always be felt even in infants, -however young or fat. It corresponds to the interval between the -fifth and sixth cervical vertebræ. The commencement of the œsophagus -lies behind it: here, therefore, a foreign substance too large to be -swallowed would probably lodge, and might be felt externally. - -Again, a transverse line drawn from the cricoid cartilage horizontally -across the neck would pass over the spot where the omo-hyoid crosses -the common carotid. Just above this spot is the most convenient place -for tying the artery. - -26. Those who have not directed their attention to the subject are -hardly aware what a little distance there is between the cricoid -cartilage and the upper part of the sternum. In a person of the average -height sitting with the neck in an easy position, the distance is -barely one inch and a half. When the neck is well stretched, about -three-quarters of an inch more is gained. Thus, we have (generally) not -more than seven or eight rings of the trachea above the sternum. None -of these rings can be felt externally. The second, third, and fourth -are covered by the isthmus of the thyroid gland. The trachea, it should -be remembered, recedes from the surface more and more as it descends, -so that, just above the sternum in a short fat-necked adult, the front -of the trachea would be quite one inch and a half from the skin. - -27. =Trachea.=--In the dead subject nothing is more easy than to open -the trachea: in the living, this operation may be attended with the -greatest difficulties. In urgent dyspnœa you must expect to find the -patient with his head bent forward, and the chin dropped, so as to -relax as much as possible the parts. On raising his head, a paroxysm -of dyspnœa is almost sure to come on, threatening instant suffocation. -The elevator and depressor muscles draw the trachea and larynx up and -down with a rapidity and a force which may bring the cricoid cartilage -within half an inch of the sternum. The great thyroid veins which -descend in front of the trachea are sure to be distended. There may -be a middle thyroid artery. In children the lobes of the thymus may -extend up in front of the trachea, and the left vena innominata may -cross it unusually high. Thus the air-tube may be covered by important -parts which ought not to be cut. Considering all these possible -complications, the least difficult and the best mode of proceeding -is to open the trachea just below the cricoid cartilage; and if more -room be requisite, to pull down the isthmus of the thyroid gland, or -in children to divide the cricoid itself. It is important that all the -incisions be made strictly in the middle line, the ‘line of safety.’ - -28. =Sterno-mastoid muscle.=--The sterno-mastoid muscle is the great -surgical landmark of the neck. It stands out in bold relief when the -head turns towards the opposite shoulder. Its inner border overlaps -the common carotid, which can be easily compressed for a short time -against the spine about the level of the cricoid cartilage. The -artery extends (generally) as high as the upper border of the thyroid -cartilage and corresponds with a line drawn from the sterno-clavicular -joint to midway between the angle of the jaw and the mastoid process. - -Between the sternal origins of the sterno-mastoid is the fossa above -the sternum, more or less perceptible in different necks. As it heaves -and sinks alternately, especially in distressed breathing, it was -called by the old anatomists ‘fonticulus gutturis.’ In beautiful necks, -as seen in the ‘Venus,’ it is filled up by fat. - -Notice the interval between the sternal and clavicular origins of the -sterno-mastoid. A knife introduced a very little way into this interval -would wound, slanting inwards, the common carotid, slanting outwards, -the internal jugular vein. These facts are of importance in performing -the subcutaneous section of the tendon of this muscle. - -29. =Sterno-clavicular joint.=--Many important parts lie behind -the sterno-clavicular joint. There is the commencement of the vena -innominata; behind this comes the common carotid on the left side, and -the division of the arteria innominata on the right. Deeper still, the -apex of the lung rises into the neck. - -In a child the arteria innominata often lies in front of the trachea -and divides a little higher than the joint: a point to be remembered in -tracheotomy (27). - -30. =Apex of lung in the neck.=--The extent to which the apex of the -lung rises into the neck is greater than is generally supposed. Many -observations in reference to this point lead to the conclusion that -the lung rises behind the sterno-mastoid, on an average, one inch and -a half above the clavicle; in persons with long necks, as much as two -inches. The apex of the lung and pleura is covered by the clavicular -origin of the sterno-mastoid, the sterno-thyroid, and a part of the -scalenus anticus. It is also crossed by the subclavian vessels in -the first part of their course. As this cervical portion of lung is -peculiarly liable to tubercular disease, it should always be carefully -examined. Its condition may be ascertained by percussion near the -sternal end of the clavicle. - -31. =Supra-clavicular fossa.=--The hollow above the clavicle, between -the sterno-mastoid and the trapezius, is very manifest in emaciation -and old age. Notice the termination here of the external jugular vein. -In some necks only a small depression is visible, particularly when -the trapezius has a broad insertion into the clavicle, and comes well -forwards, so that its front border gives a graceful contour to the base -of the neck. - -32. =Subclavian artery.=--In the supra-clavicular fossa, near the outer -border of the sterno-mastoid, and about one inch above the clavicle, we -feel the pulsation of the subclavian artery. Here the artery lies upon -the first rib, and can be effectually compressed. A little pressure is -sufficient. But the pressure must be made in the right direction, or -the artery will be pressed off the rib instead of against it. The plane -of the rib is such that the pressure, to be effectual, must be made in -a direction downwards and a little inwards. It is best to stand behind -the shoulder and make the pressure with one thumb. - -It is worth remembering that the outer border of the sterno-mastoid -corresponds pretty nearly with the outer edge of the scalenus anticus, -which is the surgical guide to the subclavian artery. - -By pressing deeply at the upper part of the supra-clavicular fossa, the -transverse process of the seventh cervical vertebra can be distinctly -felt. - -In long and thin necks, a thin cord is perceptible, running nearly -parallel with and just above the clavicle. It is the posterior belly of -the omo-hyoideus. See it rising and falling in breathing, and making -tense during inspiration that part of the cervical fascia which lies -over the cervical portion of the lung. Thus it may be said to be in all -respects a muscle of inspiration, co-operating with the sterno-mastoid -and scaleni. In the language of transcendental anatomy, we may say that -the central tendon of the omo-hyoid represents a rudimentary cervical -rib. Its posterior belly is analogous to a serration of the serratus -magnus; its anterior belly to a sterno-hyoid. - - -_THE CHEST._ - -33. As a rule, the right half of the chest is slightly larger than the -left. Of ninety-two persons of the male sex and good constitutions, -seventy-one had the right side the larger; eleven the left; ten had -both sides equal. The maximum of difference in favour of the right was -one inch and a quarter. The measurements were made on a plane with the -nipple. - -34. =Peculiarities in the female.=--The chest of the female differs -from that of the male in the following points:--Its general capacity is -less; the sternum is shorter; the upper opening is larger in proportion -to the lower; the upper ribs are more movable, and therefore permit a -greater enlargement of the chest at its upper part, in adaptation to -the requirements of pregnancy. - -35. The top of the sternum is on a level with the second dorsal -vertebra; and the available space between the top of the sternum and -the spine is hardly more than two inches.[2] - -36. =Parts behind first bone of sternum.=--There is little or no lung -behind the first bone of the sternum, the space being occupied by the -trachea and large vessels as follows:-- - -The left vena innominata crosses the sternum just below the upper -border. Next come the great primary branches of the arch of the aorta. -Deeper still is the trachea dividing into its two bronchi opposite the -junction of the first and second bones of the sternum. Deepest of all -is the œsophagus. - -About one inch from the upper border of the sternum is the highest part -of the arch of the aorta, which lies on the bifurcation of the trachea. - -37. The course of the arteria innominata corresponds with a line drawn -from the middle of the junction of the first with the second bone of -the sternum, to the right sterno-clavicular joint. When the artery -rises higher than usual into the neck, its pulsation can be felt in the -fossa above the sternum. - -38. =Rules for counting the ribs.=--In fat persons it is often -difficult to count the ribs; hence the following rules may be useful:-- - -_a._ The finger passed down from the top of the sternum soon comes to a -transverse projection, slight, but always to be felt, at the junction -of the first with the second bone of the sternum. This corresponds with -the level of the cartilage of the second rib. - -_b._ The nipple of the male is placed, in the great majority of cases, -between the fourth and the fifth ribs, about three-quarters of an inch -external to their cartilages. - -_c._ The lower external border of the pectoralis major corresponds with -the direction of the fifth rib. - -_d._ A line drawn horizontally from the nipple round the chest cuts the -sixth intercostal space midway between the sternum and the spine. This -is a useful rule in tapping the chest. - -_e._ When the arm is raised, the highest visible digitation of the -serratus magnus corresponds with the sixth rib. The digitations below -this correspond respectively with the seventh and eighth ribs. - -_f._ The scapula lies on the ribs from the second to the seventh, -inclusive. - -_g._ The eleventh and twelfth ribs can be felt even in corpulent -persons, outside the erector spinæ, sloping downwards. - -_h._ One should remember the fact that the sternal end of each rib -lies on a lower level than its corresponding vertebra. For instance, a -line drawn horizontally backwards from the middle of the third costal -cartilage at its junction with the sternum, to the spine, would touch -the body, not of the third dorsal vertebra, but of the sixth. Again, -the end of the sternum would be on about the level of the tenth dorsal -vertebra. Much latitude must be allowed here for variation in the -length of the sternum, especially in women. - -39. =Interval below clavicle.=--Immediately below the clavicle we -recognise the triangular interval between the pectoralis major and -the deltoid. This space varies in different cases, depending on the -distance between the muscles. It is important as a guide to the -coracoid process and the axillary artery. In a case of injury to the -shoulder, to ascertain whether the coracoid process is broken, carry -the arm outwards, to put the deltoid and pectoral muscles on the -stretch, and make manifest the space between their opposite borders. -Pressing the thumb into the space we can feel the inner side of the -coracoid process, the apex being under the fibres of the deltoid; thus -it is easy to ascertain whether it be broken. Moreover, this space -corresponds with the line of the axillary artery; here its pulsation -can be distinctly felt, and here it can be compressed (but not easily, -or for long) against the second rib. - -40. =Internal mammary artery.=--The line of the internal mammary artery -runs perpendicularly behind the cartilages of the ribs, about half -an inch from the sternum. The perforating branch through the second -intercostal space is generally the largest. - -41. =Outline of heart on chest-wall.=--To have a general idea of the -form and position of the heart, map its outline on the wall of the -chest, as follows:-- - -_a._ To define the base draw a transverse line across the sternum -corresponding with the upper borders of the third costal cartilages: -continue the line half an inch to the right of the sternum and one inch -to the left. - -_b._ To find the apex, mark a point about two inches below the left -nipple, and one inch to its sternal side. This point will be between -the fifth and sixth ribs. - -_c._ To find the lower border (which lies on the central tendon of -the diaphragm), draw a line, slightly curved downwards, from the apex -across the bottom of the sternum (not the ensiform cartilage) as far as -its right edge. - -_d._ To define the right border (formed by the right auricle), continue -the last line upwards with an outward curve, so as to join the right -end of the base. - -_e._ To define the left border (formed by the left ventricle), draw a -line curving to the left, but not including the nipple, from the left -end of the base to the apex. - -Such an outline (seen in the cut, page 22, with the angles rounded -off) shows that the apex of the heart points downwards and towards the -left, the base a little upwards and towards the right; that the greater -part of it lies in the left half of the chest, and that the only part -which lies to the right of the sternum is the right auricle. A needle -introduced in the third, the fourth, or the fifth right intercostal -space close to the sternum would penetrate the lung and the right -auricle. - -A needle passed through the second intercostal space, close to the -right side of the sternum, would, after passing through the lung, enter -the pericardium and the most prominent part of the bulge of the aorta. - -A needle passed through the first intercostal space, close to the right -side of the sternum, would pass through the lung and enter the superior -vena cava above the pericardium. - -[Illustration: OUTLINE OF THE HEART, ITS VALVES, AND THE LUNGS.] - -42. The best definition of that part of the præcordial region which is -less resonant on percussion, was given by Dr. Latham years ago in his -‘Clinical Lectures.’ ‘Make a circle of two inches in diameter round a -point midway between the nipple and the end of the sternum. This circle -will define, sufficiently for all practical purposes, that part of the -heart which lies immediately behind the wall of the chest, and is not -covered by lung or pleura.’ - -=Apex of the heart.=--The apex of the heart pulsates between the fifth -and sixth ribs, two inches below the nipple, and one inch to its -sternal side. The place and extent, however, of the heart’s impulse, -vary a little with the position of the body. Of this anyone may -convince himself by leaning forwards, backwards, on this side and on -that, feeling, at the same time, the heart. Inspiration and expiration -also alter the position of the heart. In a deep inspiration it may -descend half an inch, and can be felt beating at the pit of the stomach. - -43. =Valves of the heart.=--The aortic valves lie behind the third -intercostal space, close to the left side of the sternum. - -The pulmonary valves lie in front of the aortic behind the junction of -the third costal cartilage, on the left side, with the sternum. - -The tricuspid valves lie behind the middle of the sternum, about the -level of the fourth costal cartilage. - -The mitral valves (the deepest of all) lie behind the third intercostal -space, about one inch to the left of the sternum. - -Thus these valves are so situated that the mouth of an ordinary sized -stethoscope will cover a portion of them all, if placed over the -sternal end of the third intercostal space, on the left side. All are -covered by a thin layer of lung; therefore we hear their action better -when the breathing is for a moment suspended. - -44. =Outline of the lungs.=--Now let us trace on the chest the outline -of the lungs, with as much precision as their expansion and contraction -in breathing permit. (See the cut.) - -45. The apex of each lung rises into the neck behind the sternal end of -the clavicle and sterno-mastoid muscle as much as an inch and a half: -in females rather higher than in males (30). From the sternal ends of -the clavicles the lungs converge, so that their thin edges almost meet -in the mesial line on a level with the second costal cartilage. Thus -there is little or no lung behind the first bone of the sternum. From -the level of the second costal cartilage to the level of the fourth, -the margins of the lungs run parallel, or nearly so, close behind the -middle of the sternum: consequently their thin edges overlap the great -vessels and valves at the base of the heart. - -Below the level of the fourth costal cartilage the margins of the -lungs diverge, but not in an equal degree. The margin of the right -corresponds with the direction of the cartilage of the sixth rib: -the margin of the left, being notched for the heart, runs behind the -cartilage of the fourth. A line drawn perpendicularly from the nipple -would find the lung margin about the lowest part of the sixth rib. -Laterally, _i.e._ in the axillary line, the lung margin comes down as -low as the eighth rib: posteriorly, _i.e._ in the dorsal or scapular -line, it descends as low as the tenth. - -It should be remembered that, in a deep inspiration, the lung margins -descend about one inch and a half. - -In children the lungs are separated in front by the thymus gland. -Allowance should be made for this. About the approach of puberty the -thymus disappears. - -46. =Anterior mediastinum.=--The direction of the anterior mediastinum -is not straight down the middle of the sternum, but slants a little to -the left, owing to the position of the heart. The right pleural sac -generally encroaches a little upon the left, behind the middle of the -sternum. A needle introduced through the middle of the sternum opposite -the third or the fourth rib would go through the right pleura. - -47. =Reflection of pleura.=--The reflection of the pleura from the wall -of the chest on to the diaphragm corresponds with a sloping line drawn -from the bottom of the sternum over the cartilages of the ribs down to -the lower border of the last rib. - -Since the pleura lines the inside of the last rib, a musket ball or -other foreign body, loose in the pleural sac, and rolling on the -diaphragm, might fall to the lowest part of the sac, which would be -between the eleventh and twelfth ribs. The ball might be extracted -here. The chest might also be tapped here, but not with a trochar, -since a trochar would penetrate both layers of pleura, and go through -the diaphragm into the abdomen. - -The operation should be done cautiously, by an incision beginning about -two inches from the spine, on the outer border of the ‘erector spinæ,’ -on a level between the spines of the eleventh and twelfth dorsal -vertebræ. The intercostal artery will not be injured if the opening be -made below the middle of the space, which is very wide.[3] - - -_THE BACK._ - -48. =Median furrow.=--In a muscular man, a furrow, caused by the -prominence of the erector spinæ on each side, runs down the middle of -the back. The lower end of the furrow corresponds with the interval -between the spine of the last lumbar and that of the first sacral -vertebra. - -49. =Spines of vertebræ.=--A little friction with the fingers down the -backbone will cause the spines of the vertebræ to be tipped with red, -so that they can be easily counted, and any deviation from the straight -line detected. Still it is worth remembering that the spine of the -third dorsal is on a level with the commencement of the spine of the -scapula--that the spine of the seventh dorsal is on a level with the -inferior angle of the scapula--that the spine of the last dorsal is on -a level with the head of the last rib. - -=Division of the trachea.=--The division of the trachea is opposite the -spine of the third, in some cases the fourth, dorsal vertebra. In front -this division is on the level of the junction of the first with the -second bone of the sternum. - -The root of the spine of the scapula is marked by a slight dimple -in the skin. This is on a level with the third intercostal space. A -stethoscope placed on the inner side of this dimple would cover the -bronchus, more especially the right, since it is nearer to the chest -wall. - -Make a man lean forwards, with his arms folded across the chest; this -will make prominent the spines of the vertebræ. The lower border of the -trapezius will guide you to the spine of the twelfth dorsal vertebra. - -50. The place where the kidney is most accessible to pressure is below -the last rib, on the outer edge of the erector spinæ. - -51. The highest part of the ilium is about the level of the fourth -lumbar spine. The best incision for opening the descending colon is -in a slightly sloping line beginning at the outer edge of the erector -spinæ, midway between the crest of the ilium and the last rib, and -continued across the flank for three inches or more, according to the -amount of subcutaneous fat. - -52. In the pit of the neck we can feel the trapezius and the ligamentum -nuchæ. By pressing deeply we detect the forked and prominent spine of -the second cervical vertebra. - -53. The spines of the third, fourth, and fifth cervical vertebræ recede -from the surface to permit free extension of the neck, and cannot often -be felt. But the spines of the sixth and seventh (v. prominens) stand -out well. - -54. Notice that most of the spines of the dorsal vertebræ, owing to -their obliquity, do not tally with the heads of their corresponding -ribs. Thus, the spine of the second dorsal corresponds with the head -of the third rib; the spine of the third dorsal with the head of the -fourth rib, and so on till we come to the eleventh and twelfth dorsal -vertebræ, which do tally with their corresponding ribs. All this, -however, is best seen in the skeleton. - -55. The spines of the vertebræ may be useful as landmarks indicative -of the levels of important organs. I have therefore arranged them in a -tabular form, thus:-- - - -TABULAR PLAN OF PARTS OPPOSITE THE SPINES OF THE VERTEBRÆ. - - { 5th. Cricoid cartilage. Œsophagus begins. - CERVICAL. { 7th. Apex of lung: higher in the female than in the - { male. (30) - - { 1st. - { 2nd. - { 3rd. Aorta reaches spine. Apex of lower lobe of lung. - { Angle of bifurcation of trachea. (49) - { 4th. Aortic arch ends. Upper level of heart. - { 5th. - { 6th. - DORSAL. { 7th. - { 8th. Lower level of heart. Central tendon of diaphragm. - { 9th. Œsophagus and vena cava through diaphragm. Upper edge - of spleen. - { 10th. Lower edge of lung. Liver comes to surface - posteriorly. Cardiac orifice of stomach. - { 11th. Lower border of spleen. Renal capsule. - { 12th. Lowest part of pleura. Aorta through diaphragm. - Pylorus. - - { 1st. Renal arteries. Pelvis of kidney. (83) - { 2nd. Termination of spinal cord. Pancreas. Duodenum just - below. Receptaculum chyli. - LUMBAR. { 3rd. Umbilicus. Lower border of kidney. - { 4th. Division of aorta. (65) Highest part of ilium. - { 5th. - -56. =Origins of the spinal nerves.=--It is useful to know opposite what -vertebræ the spinal nerves in the different regions arise from the -spinal cord. They arise as follows:-- - -The origins of the eight cervical nerves correspond to the interval -between the occiput and the sixth cervical spine. - -The origins of the first six dorsal nerves correspond to the interval -between the sixth cervical and the fourth dorsal spines. - -The origins of the six lower dorsal nerves correspond to the interval -between the fourth and the eleventh dorsal spines. - -The origins of the five lumbar nerves correspond to the interval -between the eleventh and twelfth dorsal spines. - -The origins of the five sacral nerves correspond to the spines of the -last dorsal and the first lumbar vertebræ. - -57. =Movements of the spine.=--The movements of which the spine -is capable are threefold: 1. Flexion and extension; 2. Lateral -inclination; 3. Torsion. Flexion and extension are freest between the -third and the sixth cervical vertebræ, between the eleventh dorsal -and the second lumbar, and between the last lumbar and the sacrum. -This is well marked in severe cases of opisthotonos, where the body is -supported on the back of the head and heels.[4] - -Still better may it be observed when a mountebank bends backwards, and -touches the ground with his head. - -The lateral movement is freest in the neck and the loins. - -The movement of torsion or rotation round its own axis may be proved by -the following experiment:--Seated upright, with the back and shoulders -well applied against the back of a chair, we can turn the head and neck -as far as 70°. Leaning forwards so as to let the dorsal and lumbar -vertebræ come into play, we can turn 30° more. - -58. =Position and motions of scapula.=--There are a few points worthy -of observation about the scapula. It covers the ribs from the second to -the seventh inclusive. We can feel its superior angle covered by the -trapezius. The inferior angle is covered by the latissimus dorsi, which -keeps it well applied against the ribs in the strong and athletic; but -in weak and consumptive persons the lower angles of the scapulæ project -like wings--hence the term ‘scapulæ alatæ.’ - -A line drawn horizontally from the spine of the sixth dorsal vertebra -over the inferior angle of the scapula gives the upper border of the -latissimus dorsi. Another line drawn from the root of the spine of the -scapula to the spine of the last dorsal vertebra gives the lower border -of the trapezius, which stands a little in relief. - -59. The sliding movement of the scapula on the chest can be properly -understood only on the living subject. It can move not only upwards -and downwards as in shrugging the shoulders--backwards and forwards -as in throwing back the shoulders--but it has a rotatory movement -round a movable centre. This rotation is seen while the arm is being -raised from the horizontal to the vertical position, and is effected -by the co-operation of the trapezius with the serratus magnus. The -glenoid cavity is thus made to look upwards, the inferior angle slides -forwards, and is well held under the latissimus dorsi. - -60. For the medical examination of the back, the patient should sit -with the arms hanging between his thighs, to lower the scapulæ as much -as possible. In this position the spine of the scapula corresponds -(nearly) with the fissure between the upper and lower lobes of the -lung; the apex of the lower lobe being about the level of the third rib. - - -_THE ABDOMEN._ - -The student is assumed to be familiar with the conventional lines -dividing the abdomen into regions. - -61. =Abdominal lines.=--The linea alba, or central line of the abdomen, -marks the union of the aponeuroses of the abdominal muscles. It runs -from the apex of the ensiform cartilage to the symphysis pubis. As this -line is the thinnest and least vascular part of the abdominal wall, we -make our incision along it in ovariotomy, and in the high operation -of lithotomy; in it, we tap the abdomen in ascites, and the distended -bladder in retention of urine. - -The so-called ‘linea semilunaris,’ at the outer border of the sheath of -the rectus, corresponds with a line, drawn slightly curved (with the -concavity towards the linea alba), from the lowest part of the seventh -rib to the spine of the pubes. This line would be in an adult about -three inches from the umbilicus; but in an abdomen distended by dropsy -or other cause, the distance is increased in proportion. - -It is important to know the position of the ‘lineæ transversæ,’ or -tendinous intersections across the rectus abdominis. There are rarely -any below the umbilicus, and generally three above it. The first is -about the level of the umbilicus. The second is about four inches -higher--that is, about the level of the lowest part of the tenth rib. -These are the principal lines, and they divide the upper part of each -rectus into two nearly quadrilateral portions, an upper and a lower: -of these, those on the right side are a trifle larger than on the -left. We see these muscular squares pretty plainly in some athletic -subjects. Much more frequently we see them, too much exaggerated, on -canvas and in marble. Artists are apt to exaggerate them, and make the -front of the belly too much like a chess-board. It is lucky for them -that all the world do not see with anatomical eyes. - -A familiarity with the shape and position of these divisions of the -rectus is of importance, lest we should, in ignorance, make a mistake -in our diagnosis. A spasmodic contraction of one of these divisions, -particularly the upper, or a collection of matter within its sheath, -has been frequently mistaken for deep-seated abdominal disease. - -In the erect position, the anterior superior spines of the ilia are a -little below the level of the promontory of the sacrum. The bifurcation -of the aorta is on about the level of the highest part of the crest of -the ilium. - -62. =Umbilicus.=--The umbilicus is not midway between the ensiform -cartilage and the pubes, but rather nearer to the pubes. In all cases -it is situated above the centre of a man’s height. It is a vulgar error -to say that when a man lies with legs and arms outstretched, and a -circle is drawn round him, the umbilicus lies in the centre of it. This -central point is in most persons just above the pubes. - -In very corpulent persons two deep transverse furrows run across the -abdomen. One runs across the navel and completely conceals it. The -other is lower down, just above the fat of the pubes. In tapping -the bladder above the pubes in such a case, the trochar should be -introduced where this line intersects the linea alba. - -Although the position of the umbilicus varies a little in different -persons, as the abdomen is unusually protuberant or the reverse, still, -as a general rule, it is placed about the level of the body of the -third lumbar vertebra. Now, since the aorta divides a little below the -middle of the fourth lumbar, it follows that the best place to apply -pressure on this great vessel is one inch below the umbilicus, and -slightly to the left of it (65). That the aorta can, under favourable -circumstances, be compressed under chloroform sufficiently to cure -an aneurysm below it, is proved by recorded cases, and by none more -effectually than by a case related in the second volume of the ‘Reports -of St. Bartholomew’s Hospital.’ - -It may be asked, why not apply pressure on the aorta above the -umbilicus? The answer is, that the aorta above the umbilicus is farther -from the surface, and is, moreover, covered by important structures -upon which pressure would be dangerous. - -63. =Parts behind linea alba.=--Let us next consider what viscera lie -immediately behind the linea alba. For two or three fingers’ breadth -below the ensiform cartilage there is the left lobe of the liver, -which here crosses the middle line. Below the edge of the liver comes -the stomach, more or less in contact with the linea alba, according -to its degree of distension. In extreme distension the stomach -pushes everything out of the way, and occupies all the room between -the liver and the umbilicus. When empty and contracted, it retreats -behind the liver, and lies flat in front of the pancreas at the back -of the abdomen; thus giving rise to the hollow termed the ‘pit of -the stomach.’ But as the stomach distends, it makes a considerable -fulness where there was a pit. The middle of the transverse colon lies -above the umbilicus, occupying space (vertically two or three inches) -according to its distension. Behind and below the umbilicus, supposing -the bladder contracted, are the small intestines, covered by the great -omentum. - -64. =Peritoneum.=--The peritoneum is in contact with the linea alba -all the way down to the pubes, when the bladder is empty. But when -the bladder distends, it raises the peritoneum from the middle -line above the pubes; so that with a bladder distended half-way up -to the umbilicus, there is a space of nearly two inches above the -symphysis where the bladder may be tapped without risk of injury to -the peritoneum. For the same reason, we have space sufficient for the -successful performance of the high operation for stone. This fact in -anatomy must have been well understood by Jean de Dot, the smith at -Amsterdam, who, in the seventeenth century, cut himself in the linea -alba above the pubes, and took out of his bladder a stone as large as -a hen’s egg. The stone, the knife, and the portrait of the operator, -may be seen to this day in the museum at Leyden. - -65. =Division of Aorta.=--The aorta generally divides at a point one -inch and a half below the umbilicus. A more reliable guide to this -division than the umbilicus, is a point (a very little to the left) of -the middle line about the level of the highest part of the crest of the -ilium. A line drawn with a slight curve outwards from this point to the -groin, where the pulsation of the common femoral can be distinctly felt -(rather nearer to the pubes than the ilium), gives the direction of the -common iliac and external iliac arteries. About the first two inches of -this line belong to the common iliac, the remainder to the external. -Slight pressure readily detects the pulsation of the external iliac -above ‘Poupart’s ligament.’ - -As a rule, the length of the common iliac is about two inches, but it -should be remembered there are frequent deviations. It may be between -three-quarters of an inch and three inches and a half long. These -varieties may arise either from a high division of the aorta, or a low -division of the common iliac, or both. It is impossible to ascertain -during life what is its length in a given instance, for there is no -necessary relation between its length and the height of the stature. -It is often short in tall men, and _vice versâ_. Anatomists generally -describe the right as a trifle longer than the left; but their average -length is pretty nearly the same. - -66. Mr. Abernethy, who in the year 1796 first put a ligature round -the external iliac, made his incision in the line of the artery. But -the easiest and safest way to reach the vessel is by an incision -(recommended in the first instance by Sir Astley Cooper, and now -generally adopted), beginning just on the inner side of the artery, a -little above Poupart’s ligament, and continued upwards and outwards -a little beyond the spine of the ilium. The same incision extended -farther in the same direction would reach the common iliac. - -67. =Bony prominences.=--The anterior superior spine of the ilium, the -spine of the pubes, and the line of Poupart’s ligament, are landmarks -with which every surgeon should be thoroughly familiar. - -68. =Spine of ilium.=--The spine of the ilium is the spot from which we -measure the length of the lower extremity. It is a valuable landmark in -determining the nature of injuries to the pelvis and the hip. The thumb -easily feels the spine, even in fat persons. Its position with regard -to the trochanter major should be carefully examined. The best way to -do this is to place the thumbs firmly on the opposite spines, and to -grasp the trochanters with the fingers. Any abnormal position on one -side is thus easily ascertained with the sound side as a guide. - -69. =Spine of pubes.=--The spine of the pubes is the best guide to the -external abdominal ring. It cannot easily be felt by placing the finger -directly over it, since it is generally covered by fat. To feel it -distinctly, we should push up the skin of the scrotum and get beneath -the subcutaneous fat. If there be any difficulty in finding it, abduct -the thigh, and the tense tendon of the adductor longus will lead up to -it. - -The position of the spine of the pubes is appealed to as a means of -diagnosis in doubt between inguinal and femoral hernia. The spine lies -on the outer side of the neck of an inguinal hernia, on the inner side -of the neck of a femoral. - -The spine of the pubes is nearly on the same horizontal line as the -upper part of the trochanter major. In this line, about one full -inch external to the spine, is the femoral ring. Here is the seat of -stricture in a femoral hernia. - -70. =Poupart’s ligament, or crural arch.=--The line of Poupart’s -ligament (crural arch) is in most persons indicated by a slight -crescent-like furrow along the skin. It corresponds with a line drawn -not straight, but with a gentle curve downwards from the spine of -the ilium to the spine of the pubes. With the help of the preceding -landmarks it is easy to find the exact position of the external and -internal abdominal rings, and the direction of the inguinal canal. - -71. =Abdominal rings.=--The external abdominal ring is situated -immediately above the spine of the pubes. It is an oval opening with -the long axis directed obliquely downwards and inwards. Though its size -varies a little in different persons, yet as a rule it will admit the -end of the little finger, so that we can tell by examination whether -it be free or otherwise. To ascertain this, the best way is to push up -the thin skin of the scrotum before the finger; then, by tracking the -spermatic cord, the finger readily glides over the crest of the pubes -and feels the sharp margins of the ring. - -The position of the internal ring is about midway between the spine of -the ilium and the symphysis of the pubes, and about two-thirds of an -inch above Poupart’s ligament. - -72. =Inguinal canal.=--The position of the external and internal -abdominal rings being ascertained, it is plain that the direction of -the inguinal canal must be obliquely downwards and inwards, and that -its length in a well-formed adult male is from one and a half to two -inches, according as we include the openings or not. In very young -children the canal is much shorter and less oblique, the inner ring -being behind the outer. With the growth of the pelvis in its transverse -direction, the anterior spines of the ilia become farther apart, and -thus draw the internal ring more and more away from (_i.e._ to the -outer side of) the external. - -73. =Spermatic cord.=--The spermatic cord can be felt as it emerges -through the external ring, and its course can be tracked into the -scrotum. The vas deferens can be distinctly felt at the back of the -cord, and separated from its other component parts. - -74. =Epigastric artery.=--The direction of the deep epigastric artery -corresponds with a line drawn from the inner border of the internal -ring up the middle of the rectus muscle, towards the chest. - -In thin persons the absorbent glands which lie along Poupart’s ligament -can be distinctly felt. They are usually oval, with their long axes -parallel to the line of the ligament. - -75. =Abdominal viscera.=--Now let us see how far we can make out -externally the position and size of the abdominal viscera. - -To make this examination with anything like success, it is desirable to -relax the abdominal muscles. The man should be on his back, the head, -shoulders and thorax being well raised, to relax the recti muscles; and -the thighs bent on the abdomen, to relax the several fasciæ attached to -the crural arch. To induce complete relaxation, where a very careful -examination is desired, chloroform should be given. - -In manipulating the abdomen we should not use the tips of the fingers. -This is sure to excite the contraction of the muscles. The flat hand -should be gently pressed upon it, and with an undulating movement. - -76. It is well to bear in mind that the central tendon of the diaphragm -is about the level of the lower end of the sternum at its junction with -the seventh costal cartilage; that the right half of the diaphragm -rises to about the level of the fifth rib--that is, about an inch below -the nipple; that the left half does not rise quite so high. In tranquil -breathing the diaphragm descends about half an inch. - -The position of the abdominal viscera varies, to a certain extent, -in different persons. In some of them, especially the stomach, their -position varies in the same person at different times. - -Let us take, first, the largest of the abdominal viscera--the liver. - -77. =Liver.=--The liver lies under the right hypochondrium, and passes -across the middle line over the stomach into the left hypochondrium, -generally speaking, as far as the left mammary line. The extent to -which it can be felt below the edges of the ribs depends upon whether -it is enlarged or not, as well as upon its texture, and also upon the -amount of flatus in the stomach and intestines. As a rule, in health -its lower thin border projects about half an inch below the costal -cartilages, and can be felt moving up and down with the action of the -diaphragm; but it requires an educated hand to feel it. An uneducated -hand would miss it altogether. That part of it, however, which crosses -the middle line below the ensiform cartilage is much more accessible -to the feel; here it lies immediately behind the linea alba, and in -front of the stomach, nearly half-way down to the umbilicus. Here, -therefore, is the best place to feel whether the liver be enlarged or -pushed down lower than it ought to be. If it be much enlarged and much -lower, even the most untutored hand could detect its edge. - -Even if the edge of the liver be felt very much lower than is normal -below the ribs, it does not necessarily follow that the liver is -enlarged, since it may be pressed down by other causes--for instance, -the habit of wearing tight stays. - -To what height does the liver ascend? This can only be ascertained by -careful percussion of the chest-wall. The highest part of its convexity -on the right side is about one inch below the nipple, or nearly on a -level with the external and inferior angle of the pectoralis major. -Posteriorly the liver comes to the surface below the base of the right -lung, about the level of the tenth dorsal spine. - -Roughly speaking, the upper border of the liver corresponds with the -level of the tendinous centre of the diaphragm; that is, the level of -the lower end of the sternum. Thus a needle thrust into the right side, -between the sixth and seventh ribs, would traverse the lung, and then -go through the diaphragm into the liver. - -78. =Gall bladder.=--The gall bladder, or rather the fundus of it, is -situated, but cannot be felt, just below the edge of the liver about -the ninth costal cartilage, outside the edge of the right rectus muscle. - -79. =Stomach.=--The stomach varies in size more than any organ in -the body. When empty and contracted (63) it lies at the back of the -abdomen, overlapped by the left lobe of the liver, and in front of the -pancreas. When very full, it turns on its axis and swells up towards -the front, coming close behind the wall of the abdomen, occupying -most of the left hypochondrium and epigastrium, displacing the other -contiguous organs, pushing in every direction, and often interfering -with the action of the heart and left lung. Hence the palpitation and -distressing heart-symptoms in indigestion and flatulence. - -The cardiac orifice of the stomach lies to the left of the middle -line, just below the level of the junction of the seventh costal -cartilage with the sternum. - -80. =Pylorus.=--The pylorus lies under the liver, on the right side, -near the end of the cartilage of the eighth rib; but it cannot be felt -unless occasionally when enlarged and hardened by disease. - -81. =Spleen.=--The spleen, if healthy, cannot be felt, so completely is -it sheltered by the ribs. It lies on the left side, connected to the -great end of the stomach, beneath the ninth, tenth, and eleventh ribs, -between the axillary lines--lines drawn vertically downwards from the -anterior and posterior margins of the axilla. Its upper edge is on a -level with the spine of the ninth dorsal vertebra, its lower with the -spine of the eleventh. - -Its position and size, therefore, in health can only be ascertained, -and not very accurately, by the extent of dulness on percussion. -The greatest amount of dulness would be over the tenth and eleventh -ribs; above this the thin edge of the lung would intervene between -the spleen and the abdominal wall. If, therefore, the spleen can be -distinctly felt below the ribs, it must be enlarged. In proportion to -its enlargement, so can its lower rounded border be detected below the -tenth and eleventh ribs, especially when forced downwards by a deep -inspiration.[5] - -82. =Pancreas.=--The pancreas lies transversely behind the stomach, -and crosses the aorta and the spine about the junction of the -first and second lumbar vertebræ. The proper place to feel for it, -therefore, would be in the linea alba about two or three inches above -the umbilicus. Is it perceptible to the touch?--only under very deep -pressure, and very favourable circumstances, such as an emaciated and -empty abdomen. It is worth remembering that it may be felt under such -conditions. The pancreas of normal size, in thin persons, has been -mistaken for disease--disease of the transverse arch of the colon, or -aneurysm of the abdominal aorta. - -83. =Kidney.=--The kidney lies at the back of the abdomen, on the -quadratus lumborum and psoas muscles, opposite the two lower dorsal and -two upper lumbar spines. The right, owing to the size of the liver, -is a trifle--say, three-quarters of an inch--lower than the left. The -pelvis of the kidney is on about the level of the spine of the first -lumbar vertebra: the upper border is on about the level of the space -between the eleventh and twelfth dorsal spines; the lower border comes -as low as the third lumbar spine. During a deep inspiration both -kidneys are depressed by the diaphragm nearly half an inch. - -Can we feel the normal kidney? The only place where it is accessible to -pressure is just below the last rib, on the outer edge of the ‘erector -spinæ.’ I say accessible to pressure, for I have never succeeded in -satisfying myself that I have distinctly felt its rounded lower border -in the living subject, nor even in the dead, with the advantage of -flaccid abdominal walls and the opportunity of making hard pressure -with both hands, placed simultaneously, one in front of the abdomen, -the other on the back. For these reasons, although we can easily -ascertain its degree of tenderness, we cannot actually feel it unless -it be considerably enlarged. - -We must be on our guard not to mistake for the kidney an enlarged liver -or spleen, or an accumulation of fæces in the lumbar part of the colon. - -84. =Large intestine.=--Let us now trace the large intestine and see -where it is accessible to pressure. The ‘cæcum,’ or ‘caput coli,’ and -the ileo-cæcal valve lie in the right iliac fossa. The ascending colon -runs up the right lumbar region over the right kidney. The transverse -colon crosses the abdomen two or three inches above the umbilicus. The -descending colon lies in the left lumbar region in front of the left -kidney. The sigmoid flexure occupies the left iliac fossa. - -Throughout this tortuous course, except at the hepatic and splenic -flexures, the colon is accessible to pressure, and we could, under -favourable circumstances, detect hardened fæces in it. In a case which -occurred in St. Bartholomew’s Hospital, a collection of fæces in the -transverse colon formed a distinct tumour in the abdomen. All the -symptoms yielded to large and repeated injections of olive oil. In -another case an accumulation of fæcal matter in the sigmoid flexure -during life was mistaken for a malignant disease. - -85. =Colotomy.=--The operation of opening the colon (colotomy) may be -done in the right or left loin, below the kidney, in that part of the -colon not covered by peritoneum. - -The landmarks of the operation are:--(1) The last rib, of which feel -the sloping edge; (2) the crest of the ilium; (3) the outer border of -the ‘erector spinæ.’ The incision should be about three inches long, -midway between the rib and the ilium. It should begin at the outer -border of the ‘erector spinæ,’ and should slope downwards and outwards -in the direction of the rib. The edge of the ‘quadratus lumborum,’ -which is the guide to the colon, is about one inch external to the edge -of the ‘erector spinæ,’ or three full inches from the lumbar spines. -The line of the gut is vertical, and runs for a good two inches between -the lower border of the kidney and the iliac crest on the left side; -rather less on the right. - -=Small intestines.=--All the room below the umbilicus is occupied -by the small intestines. The coils of the jejunum lie nearer to the -umbilicus (one reason of the great fatality of umbilical herniæ). Those -of the ilium are lower down. - -On the right side, a little below the ninth rib, the colon lies close -to the gall bladder, and is, after death, sometimes tinged with bile. -Posteriorly, this part of the colon is in contact with the kidney and -duodenum. - -86. =Bladder.=--When the bladder distends, it gradually rises out of -the pelvis into the abdomen, pushes the small intestines out of the -way, and forms a swelling above the pubes, reaching in some instances -up to the navel. The outline of this swelling is perceptible to the -hand as well as to percussion. More than this, fluctuation can be -felt through the distended bladder by tapping on it in front with the -fingers of one hand, while the forefinger of the other passed up the -rectum feels the bottom of the ‘trigone.’ - - - - -_THE PERINEUM._ - - -The body is supposed to be placed in the usual position for lithotomy. - -87. =Bony framework.=--We can readily feel the osseous and ligamentous -boundaries of the perineum; namely, the rami of the pubes and ischia, -the tuberosities of the ischia, the great sacro-ischiatic ligaments, -and the apex of the coccyx. This framework forms a lozenge-shaped -space. If we draw an imaginary line across it from the front of one -tuber ischii to the other, we divide this space into an anterior and -a posterior triangle. The anterior is nearly equilateral, and, in a -well-formed pelvis, its sides are from three to three and a half inches -long. It is called the urethral triangle. The posterior, containing the -greater part of the anus and the ischio-rectal fossa on each side, is -called the anal triangle. - -88. =Raphé.=--A slight central ridge of skin, called the ‘raphé,’ -runs from the anus up the perineum, scrotum, and penis. This ‘raphé,’ -or middle line of the perineum, is the ‘line of safety’ in making -incisions to let out matter or effused urine, or to divide a stricture. - -89. =Central point of perineum.=--It is very important to know that -a point of the raphé about midway between the scrotum (where it -joins the perineum) and the centre of the anus, corresponds with the -so-called ‘central tendon’ where the perineal muscles meet. The bulb -of the urethra lies above this point, and never, at any age, comes -lower down. The artery of the bulb, too, never runs below this level. -Therefore the incision in lithotomy should never commence above it. -A knife introduced at this point, and pushed backwards with a very -slight inclination upwards, would enter the membranous part of the -urethra just in front of the prostate gland; pushed still farther it -would enter the neck of the bladder. This point, then, is a very good -landmark to the urethra in lithotomy, or, indeed, in any operations on -the perineum. - -The incision in the lateral operation of lithotomy, beginning below -the point indicated, should be carried downwards and outwards between -the anus and the tuberosity of the ischium, a little nearer to the -tuberosity than the anus. The lower end of the incision should reach a -point just below the anus. - -90. =Triangular ligament.=--In a thin perineum, we can feel the lower -border of the deep perineal fascia or the ‘so-called’ triangular -ligament of the urethra. The urethra passes through it about one inch -below the lower part of the symphysis pubis, and about three-quarters -of an inch higher than the central tendon of the perineum. It is -important to bear in mind these landmarks in introducing a catheter. -If the catheter be depressed too soon, its passage will be resisted by -the triangular ligament; if too late, it will be likely to make a false -passage by running through the bulb. - -91. =Anus.=--One of the most important landmarks which guide a -surgeon in his operations about the anus, is a white line[6] at the -junction of the skin and mucous membrane. It is easily recognised and -is of especial interest, because it marks with great precision the -linear interval between the external and internal sphincter muscles. -From this line the internal sphincter extends upwards, beneath the -mucous membrane, for about an inch, becoming gradually more and more -attenuated. - -The wrinkled appearance of the anus is caused by the contraction of the -external sphincter. At the bottom of these cutaneous folds, especially -towards the coccyx, we look for ‘fissure of the anus.’ - -92. =Landmarks in the rectum.=--Many valuable landmarks may be felt -by introducing the finger into the rectum, with a catheter at the -same time in the urethra. The principal of these landmarks are the -following:-- - -_a._ The finger can feel the extent and powerful grasp of the internal -sphincter for about one inch up the bowel. (91) - -_b._ =Urethra.=--Through the front wall of the bowel it can most -distinctly feel the track of the membranous part of the urethra, -exactly in the middle line. This is very important, because you can -ascertain with precision whether the catheter has deviated from the -proper track. - -_c._ =Prostate gland.=--About an inch and a half or two inches from -the anus, the finger comes upon the prostate gland. The gland lies in -close contact with the bowel, and can be detected by its shape and hard -feel. The finger, moved from side to side, can examine the size of its -lateral lobes, their consistence and sensibility. - -_d._ The finger, introduced still farther, can reach beyond the -prostate, as far as the apex of the trigone of the bladder. More than -this, it can feel the angle between the ‘ductus communes ejaculatorii,’ -which forms the apex of the trigone. This is the precise spot where -the distended bladder should be punctured through the rectum. The more -distended the bladder, the easier can this spot be felt. Fluctuation -is at once detected by a gentle tap on the bladder above the pubes -(86). The trochar must be thrust in the direction of the axis of the -distended bladder; that is, roughly speaking, in a line drawn from the -anus through the pelvis to the umbilicus. - -_e._ The fold of peritoneum, called the recto-vesical pouch, is about -four inches from the anus, therefore it is not within reach of the -finger; and we run no risk of wounding it in tapping the bladder if the -trochar be introduced near the angle of the trigone. - -_f._ The finger can feel one of the ridges or folds of mucous membrane -which are situated at the lower part of the rectum. This fold projects -from the side, and sometimes from the upper part of the rectum, near -the prostate. When thickened or ulcerated, this fold occasions great -pain in defæcation; and great relief is afforded by its division. - -_g._ Lastly, the finger can examine the condition of the spaces filled -with fat on either side of the rectum, called the ischio-rectal fossæ, -with a view to ascertain the existence of deep-seated collections of -matter, or the internal communications of fistulæ. - -=Introduction of catheters.=--In the introduction of catheters the -following are good rules. Keep the point of the instrument well -applied against the upper surface of the urethra;--depress the handle -at the right moment (90);--keep the umbilicus in view;--in cases of -difficulty feel the urethra through the rectum, to ascertain whether -the instrument be in the right direction. Attention to these rules -diminishes the risk of making a false passage, an injury which under -great delicacy in manipulation ought never to happen. - -=Urethra in the child.=--In children the membranous part of the -urethra is, relatively speaking, very long, owing to the smallness of -the prostate. It is also more sharply curved, because the bladder in -children is more in the abdomen than in the pelvis. It is, moreover, -composed of thin and delicate walls. The greatest gentleness, -therefore, should be used in passing a catheter; else the instrument -is likely to pass through the coats and make a false passage. Hence -the advantage of being able to ascertain through the rectum whether -the instrument be in the right track and moving freely in the bladder, -which can also be easily felt in children. - - - - -_THE THIGH._ - - -93. =Poupart’s ligament, or crural arch.=--Mark the anterior superior -spine of the ilium, the spine of the pubes, and define the line of -‘Poupart’s ligament’ which extends between them. This line is one of -our guides in the diagnosis of inguinal and femoral herniæ. If the bulk -of the tumour be above the line, the hernia is probably inguinal; if -below it, femoral. The line is not a straight one drawn from the spine -of the ilium to the spine of the pubes, but slightly curved, with the -convexity downwards, owing to its close connection with the fascia lata -of the thigh. In many persons it can be distinctly felt; in nearly all -its precise course is indicated by a slight furrow in the skin. - -For the points about the spine of the pubes, refer to paragraph 69. - -94. =Furrow at the bend of the thigh.=--When the thigh is even slightly -bent, there appears a second furrow in the skin below that at the -crural arch. This second furrow begins at the angle between the -scrotum and the thigh, passes outwards, and is gradually lost between -the top of the trochanter and the anterior superior spine of the ilium. -It runs right across the front of the capsule of the hip-joint. For -this reason it is a valuable landmark in amputation at the hip-joint. -The point of the knife should be introduced externally where the furrow -begins, should run precisely along the line of it, and come out where -it ends; so that the capsule of the joint may be opened with the first -thrust. In suspected disease of the hip pressure made in this line, -just below the spine of the ilium, will tell us if the joint be tender. -Effusion into the joint obliterates all trace of the furrow, and makes -a fulness when contrasted with the opposite groin. - -95. =Saphenous opening.=--In most persons there is a natural depression -over the saphenous opening in the fascia lata, where the saphena vein -joins the femoral. The position of this opening is just below the inner -third of Poupart’s ligament, and about an inch and a half external -to the spine of the pubes. This is the place where the swelling of -a femoral hernia first appears: therefore it ought to be carefully -examined in cases of doubt. - -96. =Femoral ring.=--The position of the femoral ring, through which -the hernia escapes from the abdomen, is on a deeper plane, about half -an inch higher than the saphenous opening, and immediately under -Poupart’s ligament. As the plane of the ring is vertical in the supine -position of the body, the way in which we should try to reduce a -femoral hernia is by pressure, applied first in a downward direction, -afterwards in an upward. The intestine protruded has to pass back under -a sharp edge of fascia, namely, the upper horn of the saphenous opening -(known as Hey’s ligament). At the same time we bend the thigh, to relax -the fascia as much as possible. - -A good way to find the seat of the femoral ring with precision is the -following:--Feel for the pulsation of the femoral artery on the pubes; -allow half an inch (on the inner side) for the femoral vein; then comes -the femoral ring. - -In performing the operation for the relief of the stricture in femoral -hernia the incision through the skin should be about an inch and a half -external to the spine of the pubes. Its direction should be vertical, -and its middle should be just over the femoral ring. - -97. =Lymphatic glands in the groin.=--The cluster of inguinal and -femoral lymphatic glands can sometimes be felt in thin persons. The -inguinal lie for the most part along the line of Poupart’s ligament: -they receive the absorbents from the wall of the abdomen, the urethra, -the penis, the scrotum, and the anus. The femoral glands lie chiefly -over the saphenous opening and along the outer side of the saphena -vein: they receive the absorbents of the lower extremity; they receive -some also from the scrotum--of which we have practical evidence in -cases of chimney-sweepers’ cancer. - -98. =Trochanter major.=--The trochanter major is a most valuable -landmark, to which we are continually appealing in injuries and -diseases of the lower extremity. There is a natural depression over the -hip (in fat persons) where it lies very near the surface, and can be -plainly felt, especially when the thigh is rotated. Nothing intervenes -between the bone and the skin except the strong fascia of the gluteus -maximus and the great bursa underneath it. - -The top of the trochanter lies pretty nearly on a level with the spine -of the pubes, and is about three-fourths of an inch lower than the top -of the head of the femur. A careful examination of the bearing of the -great trochanter to the other bony prominences of the pelvis, and a -comparison of its relative position with that of the opposite side, are -the best guides in the diagnosis of injuries about the hip, and the -position of the head of the femur. - -99. =Nélaton’s line.=--‘If in the normal state you examine the -relations of the great trochanter to the other bony prominences of the -pelvis, you will find that the top of the trochanter corresponds to a -line drawn from the anterior superior spine of the ilium to the most -prominent part of the tuberosity of the ischium. This line also runs -through the centre of the acetabulum. The extent of displacement in -dislocation or fracture is marked by the projection of the trochanter -behind and above this line.’[7] - -‘Nélaton’s line,’ as it is termed, theoretically holds good. But in -stout persons it is not always easy to feel these bony points so as -to draw the line with precision. A surgeon must, after all, in many -cases trust to measurement by his eyes and his flat hands--his best -guides. Thus, let the thumbs be placed firmly on the spines of the -ilia, while the fingers grasp the trochanters on each side. Having the -sound side as a standard of comparison, the hand will easily detect -any displacement on the injured side. Hippocrates bids us compare the -sound parts with the parts affected (in fractures) and observe the -inequalities. - -The top of the great trochanter is the guide in an operation recently -introduced by Mr. Adams, namely, the ‘subcutaneous section of the neck -of the femur.’ ‘The puncture should be made one inch above and nearly -one inch in front of the top of the trochanter. The neck of the bone -is to be sawn through at right angles to its axis, the saw working -parallel to Poupart’s ligament, and about one inch below it.’ - -=Spine of the ilium.=--The anterior superior spine of the ilium is the -point from which we measure the length of the lower limb. By looking -at the spines of opposite sides we can detect any slant in the pelvis. -By pressure on both spines simultaneously we examine if there be a -fracture of the pelvis, or disease at the sacro-iliac joint. - -100. ‘In reducing a dislocation of the hip by manipulation it is -important to bear in mind that, in every position, the head of the -femur faces nearly in the direction of the inner aspect of its internal -condyle.’[8] - -101. =Compression of femoral artery.=--About a point midway between -the spine of the ilium and the symphysis pubis, the femoral artery -can be felt beating, and effectually compressed, against the pubes. -How should the pressure be applied when the patient lies on the back? -In accordance with the slope of the bone--that is, with a slight -inclination upwards. A want of attention to this point is the reason -why so many fail when they undertake to command the circulation -through the femoral artery in an amputation, or to cure an aneurysm by -digital compression. - -If the Italian tourniquet be used, we should be careful to adjust -the counter-pad well under the tuberosity of the ischium. If digital -pressure be used, it is easy to command the femoral by slight pressure -of the thumb, provided the fingers have a firm hold on the great -trochanter. - -102. =Sartorius.=--The sartorius is the great fleshy landmark of the -thigh, as the biceps is of the arm, and the sterno-cleido-mastoideus of -the neck. Its direction and borders may easily be traced by asking the -patient to raise his leg, a movement which puts the muscle in action. -The same action defines the boundaries of the triangle (of Scarpa) -formed by Poupart’s ligament, the adductor longus and sartorius. - -=Line of femoral artery.=--To define the course of the femoral artery, -draw a line from midway between the anterior superior spine of the -ilium and the symphysis pubis to the (spur-like) tubercle for the -adductor magnus on the inner side of the knee. The femoral artery lies -under the upper 2/3 of this line. - -The sartorius begins to cross the artery, as a rule, from three to -four inches below Poupart’s ligament. The point at which the profunda -artery arises is about one and a half or two inches below the ligament. -Therefore the incision for tying the femoral in Scarpa’s triangle -should commence about a hand’s breadth below Poupart’s ligament, and be -continued for three inches in the line of the artery. - -To command the femoral in Scarpa’s triangle, the pad of the tourniquet -should be placed at the apex, and the direction of the pressure should -be, not backwards, but outwards, so that the artery may be compressed -against the femur. - -In the middle third of the thigh the femoral artery lies in Hunter’s -canal, overlapped by the sartorius. About the commencement of the lower -third the artery leaves the canal through the oval opening in the -adductor magnus, and, under the name of popliteal, enters the popliteal -space. The line for finding the artery in Hunter’s canal has been -already traced (102). The incision to reach the artery in this part of -its course would fall in with the outer border of the sartorius. - -To command the femoral artery in Hunter’s canal, the pressure should be -directed outwardly, so as to press the vessel against the bone. - - - - -_THE BUTTOCKS._ - - -103. =Buttocks.--Bony landmarks.=--The bony landmarks of the buttocks -which can be distinctly felt are: 1, the posterior superior spines of -the ilia; 2, the spines of the sacral vertebræ; 3, the two tubercles of -the last sacral vertebra; 4, the apex of the coccyx in the deep groove -leading to the anus; 5, the tuberosities of the ischia on each side of -the anus. - -The posterior spines of the ilia are about the level of the second -sacral spine, and correspond with the middle of the sacro-iliac -symphysis. - -The third sacral spine marks the lowest level to which the membranes of -the cord and the cerebro-spinal fluid descend in the spinal canal. - -The tuberosities of the ischia, in the erect position, are covered by -the gluteus maximus. In the sitting position they support the weight of -the body, and are only covered by a thick pad of coarse fat. Between -this pad and the bones there is a bursa, which becomes occasionally -enlarged and inflamed in coachmen. - -The prominence of the nates is one of the characteristics of man in -connection with his erect attitude. ‘Les fesses n’appartiennent qu’à -l’espèce humaine.’ They are formed of an accumulation of fat over the -great muscle of the buttock (gluteus maximus). From their appearance -we may gather some indication of the state of the constitution. They -are firm and globose in the vigorous; loose and flaccid in the infirm. -Wasting and flattening of one, compared with the other, is an early -symptom of disease in the hip. - -104. =Fold of the buttock.=--The deep furrow, termed ‘the fold of -the buttock,’ which separates the nates from the back of the thigh, -corresponds with the lower border of the gluteus maximus. Its altered -direction in disease of the hip is very characteristic. This is the -best place to feel for the great ischiatic nerve. We find it by -pressing deeply between the trochanter and the tuber ischii, rather -nearer to the latter. When we sit upright, the nerve is not liable to -pressure; but it becomes numbed when we sit long sideways. - -105. =Gluteal artery.=--To find at what point the gluteal artery comes -out of the pelvis, draw a line from the posterior superior spine of the -ilium to the top of the trochanter major, rotated inwards. The junction -of the inner with the middle third of this line lies over the artery as -it emerges from the upper border of the great ischiatic notch. - -The point of exit of the ischiatic artery from the pelvis is about half -an inch lower than that of the gluteal. - -106. =Pudic artery.=--The pudic artery crosses the spine of the -ischium. To find it, draw a line from the outer side of the tuber -ischii to the posterior superior spine of the ilium. The junction of -the lower with the middle third gives the position of the artery. The -ischiatic artery lies close to it, but nearer the middle line. - -Looking at the course of these arteries it appears that when we sit -on hard seats the pressure is sustained by the bones; when we recline -on soft seats the pressure is sustained more by the soft parts, and -reaches the arteries; hence the tendency of modern modes of reposing -to drive the blood into the interior of the pelvis and favour the -production of piles and uterine disorders. A celebrated French -accoucheur used to say that the fashion of high waists, tight lacing, -and easy chairs brought him many thousands a year. - - - - -_THE KNEE._ - - -107. =Bony points.=--The patella; the tuberosities of the two condyles; -the tubercle of the tibia for the attachment of the ligamentum patellæ; -another (the lateral) tubercle, on the outer side of the head of the -tibia; and the head of the fibula are the chief bony landmarks of the -knee. - -Observe that the head of the fibula lies at the outer and back part of -the tibia, and that it is pretty nearly on a level with the tubercle -for the attachment of the ligamentum patellæ. - -We can also feel the adductor tubercle or spur-like projection of bone -above the internal condyle which gives attachment to the tendon of the -adductor magnus. This spur-like projection corresponds with the level -of the epiphysis of the lower end of the femur, and also with the level -of the highest part of the trochlea for the patella: facts worth notice -in performing excision of the knee. - -‘In reducing a dislocation of the hip, it is important to bear in mind -that the inner aspect of the internal condyle in every position of the -limb faces nearly in the direction of the head of the femur.’ (100) - -The tubercle on the outer side of the head of the tibia gives -attachment to the broad and strong aponeurosis (tendon of the tensor -fasciæ), which, acting like a brace for the support of the pelvis, -is well seen in emaciated persons down the outer side of the thigh. -This tubercle indicates the level to which the condyles of the femur -descend, and the lower level of the synovial membrane. - -The patella, in extension of the knee, is nearly all above the -condyles; in flexion, it lies in the inter-condyloid fossa (more on the -external condyle), and thus protects the joint in kneeling. Its inner -border is thicker and more prominent than the outer, which slopes down -towards its condyle. - -108. =Ligamentum patellæ.=--The line of the ligamentum patellæ is -vertical. Hence any deviation from this line, one way or the other, -indicates more or less dislocation of the tibia. There is a pellet of -fat under the ligament, which answers a ‘packing’ purpose--sinking in -when the knee is bent; rising when the knee is extended, and bulging -on either side of the tendon, almost enough to give the feel of -fluctuation. - -In a well-formed leg the ligamentum patellæ, the tubercle of the -tibia, and the middle of the ankle should be in the same straight line. -A useful point in the adjustment of fractures. - -Behind the upper half of the ligamentum patellæ is the synovial -membrane of the knee-joint; behind the lower half is a synovial bursa -and a pad of fat. It is well to remember this in cases of injury to the -ligamentum patellæ. - -109. =Patellar bursa.=--The patellar or housemaids’ bursa is situated -not only over the patella, but over the upper part of the ligament. -This is plain enough when the bursa becomes enlarged. There is another -subcutaneous bursa over the insertion of the ligament into the tubercle -of the tibia. This is quite independent of the deep bursa between the -tendon and the bone. - -110. =Synovial membrane of knee.=--The synovial membrane of the knee, -when the joint is extended, rises like a cul-de-sac above the upper -border of the patella about two inches. It ascends, too, a little -higher under the vastus internus than the vastus externus--a fact -very manifest when the joint is distended. When the knee is bent -this cul-de-sac is drawn down--hence the rule of bending the knee in -operations near the lower end of the femur. - -The lower level of the synovial membrane of the knee is just above the -level of the upper part of the head of the fibula. The tibio-fibular -synovial membrane is, with rare exceptions, independent of that of the -knee. - -111. =Popliteal tendons.=--The tendons forming the boundaries of the -popliteal space can be distinctly felt when the muscles which bend the -knee are acting. On the outer side, we have the biceps running down -to the head of the fibula. On the inner side we feel three tendons, -disposed as follows:--nearest to the middle of the popliteal space -is the semitendinosus, very salient and traceable high up the thigh; -next comes the thick round tendon of the semimembranosus; still more -internally is the gracilis. The sartorius, which forms a graceful -muscular prominence on the inner side of the knee, does not become -tendinous until it gets below it. - -112. =Popliteal bursa.=--The precise position of the bursa in the -popliteal space, which sometimes enlarges to the size of a hen’s -egg, is between the tendon of the inner head of the gastrocnemius and -the tendon of the semimembranosus, just where they rub one against -the other. The bursa is from one and a half to two inches long. When -enlarged, it makes a swelling on the inner side of the popliteal space, -which bulges and becomes tense when the knee is extended, and _vice -versâ_. I examined 150 bodies with a view to ascertain how often this -bursa communicates with the synovial membrane of the knee. There was -a communication about once in five instances. This should make us -cautious in interfering too roughly with the bursa when enlarged. - -113. =Popliteal artery.=--The popliteal artery can be felt beating -and can be compressed against the back of the femur, close to which -it lies. But pressure, sufficient to stop the blood, should be firm, -and should be made against the bone nearer to the inner than the outer -hamstrings. The line of the artery corresponds with the middle of the -ham. It lies under cover of the fleshy belly of the semimembranosus, -and the outer border of this muscle is the guide to it. An incision -down the middle of the ham would fall in with the vessel just above the -condyles. - -114. =Peroneal nerve.=--The peroneal nerve runs parallel with and close -to the inner border of the tendon of the biceps. It can be felt in thin -persons. There is a risk of dividing it in tenotomy of the biceps, -unless the knife be carefully introduced from within outwards. Below -the knee the nerve can be felt close to the fibula just below the head, -and when pressed upon in this situation causes a sensation to run down -its branches to the foot. - - - - -_THE LEG AND ANKLE._ - - -115. =Bony points.=--The tubercle of the tibia (for the attachment of -the ligamentum patellæ), the sharp front edge called the shin, and the -broad flat subcutaneous surface of the bone can be felt all the way -down. The inner edge can be felt too, but not so plainly. The lower -third is the narrowest part of the bone and the most frequent seat of -fracture. - -The head of the fibula is a good landmark on the outer side of the leg, -about one inch below the top of the tibia and nearly on a level with -the tubercle. Observe that it is placed well back, and that it forms no -part of the knee-joint, and takes no share in supporting the weight. - -The shaft of the fibula arches backwards, the reverse of the shaft of -the tibia. The fact of the bones not being on the same plane should be -remembered in flap amputations. The shaft of the fibula is so buried -amongst the muscles, that the only part to be distinctly felt is the -lower fourth. Here there is a flat triangular subcutaneous surface, -between the peroneus tertius in front, and the two peronei (longus and -brevis) behind. Here is the most frequent seat of fracture. - -116. =Malleoli.=--The shape and relative position of the malleoli -should be carefully studied, as the great landmarks of the ankle. The -inner malleolus does not descend so low as the outer, and advances more -to the front: at the same time, owing to its greater antero-posterior -depth, it is on the same plane as the outer behind. The lower border of -the inner malleolus is somewhat rounded, and the slight notch in it for -the attachment of the lateral ligament can be felt. The outer malleolus -descends lower than the inner, thus effectually locking the joint on -the outer side. Its shape is not unlike the head of a serpent. Viewed -in profile, it lies just in the middle of the joint. - -In Syme’s amputation of the foot at the ankle, the line of the incision -should run from the apex of the outer malleolus, under the sole to the -centre of the inner. - -In a well-formed leg, the inner edge of the patella, the inner ankle, -and the inner side of the great toe, should be in the same vertical -plane. Look to these landmarks in adjusting a fracture or dislocation, -keeping at the same time an eye upon the conformation of the opposite -limb. - -There are several strong tendons to be seen and felt about the ankle. - -117. =Tendo Achillis.=--Behind is the tendo Achillis. It forms a high -relief, with a shallow gutter on each side of it. The narrowest part -of the tendon, where it should be divided in tenotomy, is about the -level of the inner ankle; below this it expands again to be attached to -the lower and back part of the os calcis. Seen in profile, the tendon -is not straight,but slightly concave--being drawn in by an aponeurosis -which forms a sort of girdle round it. This girdle proceeds from -the posterior ligament of the ankle; and, though most of its fibres -encircle the tendon, some of them adhere to and draw in its sides. All -this disappears when the tendon is laid bare by dissection. - -118. =Tendons behind inner ankle.=--Above and behind the malleolus -internus we can feel the broad flat tendon of the tibialis posticus and -upon it that of the flexor longus digitorum. The tendon of the tibialis -posticus lies nearest to the bone and comes well up in relief in -adduction of the foot. It lies close to, and parallel with, the inner -edge of the tibia, so that this edge is the best guide to it. Therefore -in tenotomy the knife should be introduced first perpendicularly -between the tendon and the bone, and then turned at right angles to cut -the tendon. The tendon has a separate sheath and synovial membrane, -which commences about one inch and a half above the apex of the -malleolus, and is continued to its insertion into the tubercle of the -scaphoid bone. The proper place, then, for division of the tendon, is -about two inches above the end of the malleolus. - -In a young and fat child, where the inner edge of the tibia cannot be -distinctly felt, the best guide to the tendon is a point midway between -the front and the back of the ankle. An incision in front of this -point might injure the internal saphena vein; behind this point, the -posterior tibial artery. - -119. =Tendons behind outer ankle.=--Behind the malleolus externus we -feel the two peroneal (long and short) tendons. They lie close to the -edge of the fibula, the short one nearer to the bone. In dividing these -tendons, the knife should be introduced perpendicularly to the surface, -and about two inches above the apex of the ankle, so as to be above the -synovial sheaths of the tendons. - -=Tendons in front of ankle.=--Over the front of the ankle, when -the muscles are in action, we can see and feel, beginning on the -inner side, the tendons of the tibialis anticus, the extensor longus -pollicis, the extensor longus digitorum, and the peroneus tertius. They -start up like cords when the foot is raised, and are kept in their -proper relative position by strong pulleys formed by the anterior -annular ligament. Of these pulleys the strongest is that of the -extensor communis digitorum. When the ankle is sprained, the pain and -swelling arise from a stretching of these pulleys and effusion into -their synovial sheaths. A laceration of one of the pulleys and escape -of the tendon is extremely rare. - -The place for the division of the tendon of the tibialis anticus, so as -to divide it below its synovial sheath, is about one inch before its -insertion into the cuneiform bone. The knife should be introduced on -the outer side, so as to avoid the dorsal artery of the foot. - -Now trace the lines of the arteries, and the landmarks near which they -divide. - -120. =Popliteal artery.=--About one inch and a quarter below the head -of the fibula, or say one inch below the tubercle of the tibia, the -popliteal artery divides into the anterior and posterior tibial. The -peroneal comes off from the posterior tibial about three inches below -the head of the fibula. - -Consequently we may lay down, as a general rule, that, in amputations -one inch below the head of the fibula, only one main artery, the -popliteal, is divided. In amputations two inches below the head of -the fibula, two main arteries, the anterior and posterior tibial, -are divided. In amputations three inches below the head, three main -arteries, the two tibials and the peroneal, are divided. - -121. =Anterior tibial artery.=--The anterior tibial artery comes in -front of the interosseous membrane, one inch and a quarter below the -head of the fibula, and here lies close to this bone. Its subsequent -course is defined by a line drawn from the front of the head of the -fibula to the middle of the front of the ankle. This line corresponds -pretty nearly with the outer border of the tibialis anticus all -the way down. If this muscle be put in action, its outer border -(the intermuscular line) is plainly seen, and the incision for the -ligature of the artery in any part of its course may be defined with -the greatest precision. The artery can be felt beating and can be -compressed where it crosses the front of the tibia and ankle. - -122. =Posterior tibial artery.=--The posterior tibial commences about -one inch and a quarter below the head of the fibula. Its subsequent -course corresponds with a line drawn from the middle of the upper part -of the calf to the hollow behind the inner ankle, where it can be felt -beating distinctly about half an inch behind the edge of the tibia. A -vertical incision down the middle of the calf would reach the artery -under cover of the gastrocnemius and soleus. A vertical incision along -the middle third of the leg, about half an inch from the inner edge of -the tibia, would enable the operator to reach the artery sideways, by -detaching from the bone the tibial origin of the soleus. - -123. =Saphena veins.=--The subcutaneous veins on the dorsum of the foot -form an arch convex towards the toes (as on the back of the hand), -from which issue the two main subcutaneous trunks of the lower limb, -the internal and external saphena veins. The internal saphena vein can -be always plainly seen over the front of the inner ankle. Its further -course up the inner side of the leg, knee, and thigh to its termination -in the femoral is not in all persons manifest. - -The external saphena vein runs behind the outer ankle and up the middle -of the calf to empty itself (generally) into the popliteal vein. - - - - -_THE FOOT._ - - -What are the bony landmarks which guide us in the surgery of the foot? - -124. =Points of bone.=--Along the inner side of the foot, beginning -from behind, we can feel--1, the tuberosity of the os calcis; 2, the -projection of the internal malleolus; 3, the projection of the os -calcis, termed ‘sustentaculum tali,’ about one full inch below the -malleolus; 4, about one inch in front of the malleolus internus, and a -little lower, is the tubercle of the scaphoid bone; the gap between -it and the sustentaculum tali being filled by the calcaneo-scaphoid -ligament and the tendon of the tibialis posticus, in which there -is often a sesamoid bone; 5, the internal cuneiform bone; 6, the -projection of the first metatarsal bone; 7, the sesamoid bones of the -great toe. - -Along the outer side of the foot we can feel--1, the external -tuberosity of the os calcis; 2, the external malleolus; 3, the peroneal -tubercle of the os calcis, one inch below the malleolus, with the long -peroneal tendon below it, and the short one above it; 4, the projection -of the base of the fifth metatarsal bone. - -125. =Lines of joints.=--In fat persons the following rules for finding -the joints may be of service as regards the surgery of the foot:-- - -The level of the ankle joint lies about half an inch above the end of -the inner malleolus. This is worth remembering in performing ‘Syme’s’ -amputation. - -The tubercle of the scaphoid bone is the best guide to the -astragalo-scaphoid joint which lies immediately behind it; and the -plane of this joint is in the same line as that of the calcaneo-cuboid. -Thus a line drawn transversely over the dorsum of the foot, behind -the tubercle of the scaphoid, would strike both the joints opened in -‘Chopart’s’ operation. - -Place your thumb on the tubercle of the scaphoid, and measure about one -inch and a half in front: here you find the joint between the internal -cuneiform bone and the metatarsal bone of the great toe. This point is -useful in Lisfranc’s operation, which consists in the removal of the -metatarsal bones. - -The line of the calcaneo-cuboid joint lies midway between the external -malleolus and the (tarsal) end of the metatarsal bone of the little toe. - -The projection of the fifth metatarsal bone is the guide to the joint -between it and the cuboid. - -Notice that the line of the joints between the metatarsal bones and the -first phalanges lies a full inch farther back than the interdigital -folds of the skin. This is a point to be remembered in amputating the -toes. - -126. =Dorsal artery.=--The line of the dorsal artery of the foot is -from the middle of the ankle to the interval between the first and -second metatarsal bones. The artery can be felt beating over the bones -along the outer side of the extensor longus pollicis, which is the best -guide to it. - -127. =Bursa.=--The synovial sheath of the extensor longus pollicis -extends from the front of the ankle, over the instep (apex of the -internal cuneiform bone) as far as the metatarsal bone of the great -toe. There is generally a bursa over the instep, above, or it may be, -below, the tendon. - -There is often a large irregular bursa between the tendons of the -extensor longus digitorum, and the projecting end of the astragalus, -over which the tendons play. There is much friction here. It is well to -be aware that this bursa sometimes communicates with the joint of the -head of the astragalus. - -128. =Plantar arteries.=--The course of the external plantar artery -corresponds with a line drawn from the hollow behind the inner ankle -obliquely across the sole nearly to the base of the fifth metatarsal -bone; from thence the artery turns transversely across the foot, lying -(deeply) near the bases of the metatarsal bones, till it inosculates -with the dorsal artery of the foot in the first interosseous space. - -The course of the internal plantar corresponds with a line drawn from -the inner side of the os calcis to the middle of the great toe. - -129. =Plantar fascia.=--To divide the plantar fascia subcutaneously, -the best place is about one inch in front of its attachment to the -os calcis. This is the narrowest part of it. The knife should be -introduced on the inner side; and the incision will be behind the -plantar artery. - -The subcutaneous section of the tendon of the abductor pollicis should -be made about one inch before its insertion. - - - - -_THE ARM._ - - -130. =Clavicle.=--The line of the clavicle and the projection of the -joint at either end of it can always be felt, even in the fattest -persons. Its direction is not perfectly horizontal, but slightly -inclined downwards, when the arm hangs quietly by the side. When the -body lies flat on the back, the shoulder not only falls back, but rises -a little, the weight of the limb being taken off. Hence the modern -practice of treating fractures of the clavicle (in the early stage) by -the supine position. - -On the front surface of the clavicle, not far from its acromial end, -there is in many persons of mature age a spine-like projection of bone. -So far as I know, it has not been described. A gentleman, himself a -surgeon, showed me an instance in his own person. He suspected it was -an exostosis. - -As a rule the acromio-clavicular joint forms an even plane. But there -is sometimes a knob of bone at the acromial end of the clavicle; or it -may be only a thickening of the fibro-cartilage, sometimes existing -in the joint. In either case this relief might be mistaken for a -dislocation, or even for a fracture. A reference to the other shoulder -might settle the question. - -131. =Bony points of the shoulder.=--We can distinctly feel the spine -of the scapula and the acromion, more especially at the angle where -they join behind the shoulder. This angle is the best place from which -to measure in taking the comparative length of the arms. - -In some shoulders, though very rarely, there is an abnormal symphysis -between the spine of the scapula and the acromion. There may indeed -be two symphyses and two acromial bones, the acromion having two -centres of ossification. These abnormal symphyses might be mistaken for -fractures, until we have examined the opposite shoulder, which is sure -to present a similar conformation.[9] - -=Tuberosities.=--Projecting beyond the acromion (the arm hanging -by the side), we can feel, through the fibres of the deltoid, the -upper part of the humerus. It distinctly moves under the hand when -the arm is rotated. It is not the head of the bone which is felt, but -the tuberosities, the greater externally, the lesser in front. These -tuberosities form the convexity of the shoulder. When the arm is -raised, this convexity disappears; there is a slight depression in its -place. The head of the bone can be felt by pressing the fingers high up -in the axilla. - -The absence of this prominence formed by the upper part of the humerus -under the deltoid, and the presence of a prominence low in the hollow -of the axilla, or in front, below the coracoid process, or behind, on -the back of the scapula, bespeak dislocation of the head of the bone. - -In examining obscure injuries about the shoulder, it is worth -remembering that, in the normal relation of the bones, and in every -position, the great tuberosity faces in the direction of the external -condyle. The head of the bone faces very much in the direction of the -internal condyle. - -It is worth remembering also that the upper epiphysis of the humerus -includes the tuberosities; and that it does not unite by bone to the -shaft, till about the 20th year. - -By making deep pressure in front of the shoulder, when the arm is -pendent and supine, we can feel the bicipital groove. It looks directly -forwards, and runs in a line drawn vertically downwards through the -middle of the biceps to its tendon at the elbow. We should be aware of -this, lest it be mistaken for a fracture. - -132. =Coraco-acromial ligament.=--Under the anterior fibres of the -deltoid, we can distinctly feel the position and extent of the -coraco-acromial ligament. A knife, passed vertically through the middle -of it, goes at once into the shoulder joint and strikes the bicipital -groove with the tendon, a point to be remembered in excision. - -In persons of an athletic build the triangular form and beautiful -structure of the deltoid become conspicuous when the muscle is in -action. The depression on the outer side of the arm, indicating its -insertion, is the place selected for issues or setons. - -The arm being held up by an assistant, the anterior and posterior -borders of the relaxed deltoid admit of being raised so that in -amputation at the shoulder the knife can be introduced beneath the -muscle to make the flap. - -133. =Axilla.=--The anterior border of the axilla, formed by the -pectoralis major, follows the line of the fifth rib. In counting the -ribs, or in tapping the chest, it is worth remembering that the highest -visible digitation of the serratus magnus is attached to the sixth rib. -The angle of the digitation is directed forwards, and corresponds to -the upper edge of the rib. The second visible digitation corresponds -to the seventh rib; the interval between these digitations, therefore, -corresponds to the sixth intercostal space--a convenient place for -tapping the chest. (38) - -In the normal state no glands can be felt in the axilla. - -134. =Axillary artery.=--When the arm is raised to a right angle with -the body, and the head of the humerus thereby depressed, the axillary -artery is plainly felt beating, and can be perfectly compressed on the -inner side of the coraco-brachialis. This muscle stands out in relief -along the humeral side of the axilla, and is the best guide to the -artery. A line drawn along its inner border--that is, down the middle -of the axilla--corresponds with the course of the artery. - -The depth and form of the axilla alter in different positions of the -arm. In the arm raised and abducted the axilla becomes nearly flat; -hence this position is always adopted in operations. - -In opening abscesses in the axilla, the incision should be made midway -between the borders, and the point of the knife introduced from above -downwards. - -135. =Brachial artery.=--When the arm is extended and supinated, a line -drawn from the deepest part of the middle of the axilla down the inner -side of the biceps to the middle of the bend of the elbow, corresponds -with the course of the brachial artery. The artery can be felt and -compressed all the way down; but nowhere so effectually as midway, -where it lies on the tendon of the coraco-brachialis close to the -inner side of the humerus. The only direction to apply the pressure -effectually is outwards and a little backwards, else the artery will -slip off the bone. - -The musculo-spiral nerve and superior profunda artery wind round -the back of the humerus about its middle, and come to the front of -the external condyloid ridge. Thus, for full three inches above the -condyles, there is nothing to interfere with operations on the back of -the bone, which is here broad and flat. - -136. =Bend of elbow.=--At the bend of the elbow, the tendon of the -biceps can be plainly felt, as well as the pulsation of the brachial -artery close to its inner side, before dividing into the radial and -ulnar. - -=Cutaneous veins.=--The bend of the elbow in young children and in -persons with fat and round arms, presents a semicircular fold of which -the curve embraces the lower part of the biceps; but in muscular -persons we see the distinct boundaries of the triangular space, formed -by the pronator teres on the inner side, and the supinator longus on -the outer. Here can be traced, standing out in strong relief under -the thin white skin, the superficial veins, which, in days gone by, -when bloodletting was the fashion, were of such great importance. -Their arrangement, although subject to variety, is very much like the -branches of the letter M, the middle of the M being at the middle -of the elbow. Of these branches the median basilic, which runs over -the tendon of the biceps, is the largest and most conspicuous, and -is generally selected for venesection; it crosses the course of the -brachial artery, nothing intervening but the semilunar aponeurosis from -the tendon of the biceps. - -137. =Landmarks of elbow.=--It is of great importance to be familiar -with the relative positions of the various bony prominences about the -elbow. We can always feel the internal and external condyles. The -internal is the more prominent of the two, and a trifle higher. - -=Olecranon.=--We can always feel the olecranon. This is somewhat nearer -to the inner than to the outer condyle. Between the olecranon and the -internal condyle is a deep depression in which lies the ulnar nerve -(vulgarly called the ‘funny bone’). - -On the outer side of the olecranon, just below the external condyle, -is a pit in the skin, constant even in fat persons (when the elbow is -extended). This pit is considered one of the beauties of the elbow in a -graceful arm; it is seen in a child as a pretty little dimple. To the -surgeon it is most interesting, as in this valley behind the supinator -longus and the radial extensors of the wrist he can distinctly feel the -head of the radius rolling in pronation and supination of the forearm. -It is, therefore, one of the most important landmarks of the elbow, -since it enables us to say whether the head of the radius is in its -right place, and whether it rotates with the shaft. - -Can the tubercle of the radius be felt? Yes, but only on the back of -the forearm in extreme pronation. Its projection is then distinctly -perceptible just below the head of the bone. - -=Relations of olecranon and condyles.=--To examine the relative -positions of the olecranon and condyles in the different motions of -the elbow joint, place the thumb on one condyle, the tip of the middle -finger on the other, and the tip of the forefinger on the olecranon. In -extension, the highest point of the olecranon is never above the line -of the condyles; indeed, it is just in this line. With the elbow at -right angles the point of the olecranon is vertically below the line -of the condyles. In extreme flexion the point of the olecranon lies in -front of the line of the condyles. - -All these relative positions would be altered in a dislocation of the -ulna, but not (necessarily) in a fracture of the lower end of the -humerus. - -Sometimes, though rarely, we meet with a hook-like projection of bone -above the internal condyle. It is called a ‘supra-condyloid’ process; -it can be felt through the skin, with its concavity downwards, and is -a rudiment of the bony canal which, in many mammalia, transmits the -median nerve and ulnar artery. A third origin of the pronator teres is -always attached to it; this origin covers the brachial artery.[10] - -=Bursæ.=--The subcutaneous bursa over the olecranon, if distended, -would be as large as a walnut. A second bursa sometimes exists a little -lower down upon the ulna. There is also a small subcutaneous bursa -over each of the condyles. - -The vertical extent of the elbow joint is limited, above by a line -drawn from one condyle to the other; below, by a line corresponding to -the lowest part of the head of the radius. - -138. =Interosseous arteries.=--About one inch below the head of the -radius, the ulnar artery gives off the common interosseous; and this -divides, about half an inch lower, into the anterior and posterior -interosseous. Thus, in amputating the forearm, say two inches below the -head of the radius, four arteries at least would require ligature. - -By flexion of the elbow to the utmost, the circulation through the -brachial artery can be arrested; but the position is painful, and can -be tolerated only for a short time. - -=Lymphatic gland.=--There is a small lymphatic gland just above the -inner condyle, in front of the intermuscular septum. It is the first to -take alarm in poisoned wounds of the hand. - - - - -_THE FOREARM AND WRIST._ - - -139. =Ulna.=--The edge of the ulna can be felt subcutaneous from the -olecranon to the styloid process (in supination). Any irregularity -could be easily detected. The styloid process of the ulna does not -descend so low as the styloid process of the radius, or it would -impede the free abduction of the hand. Its apex is on a level with -the radio-carpal joint. The head of the ulna is plainly felt and seen -projecting at the back of the wrist, especially in pronation of the -forearm. It then lies between the tendons of the extensor carpi ulnaris -and extensor minimi digiti. There is often a subcutaneous bursa over it. - -140. =Radius.=--The upper half of the shaft of the radius is so covered -by muscles that we cannot feel it; the lower half is more accessible to -the touch, especially just above and just below the part where it is -crossed by the extensors of the thumb. Its styloid process is readily -felt, and made all the more manifest by being covered by the first -two extensor tendons of the thumb. It descends lower, and lies more -to the front than the corresponding process of the ulna. The relative -positions of these styloid processes can be best examined by placing -the thumb on one and the forefinger on the other. - -Feel for the little bony pulley on the back of the radius near the -wrist, which keeps in place the third extensor tendon of the thumb. -This and the bone just above it is the place which we examine for a -suspected fracture (termed Colles’s) near the lower end of the radius. - -141. =Carpus.=--Below the styloid process of the radius, just on the -inner side of the extensors of the thumb, we feel the tubercle of the -scaphoid bone. Between the styloid process and the tubercle is the -level of the radio-carpal joint. A little lower we feel the trapezium. - -Just below the ulna on the palm of the hand we feel the pisiform bone; -and on the inner side of this, the cuneiform. - -There are several transverse furrows on the palmar aspect of the -wrist. The lowest of these, which is slightly convex downwards, -corresponds with the upper edge of the anterior annular ligament and -the intercarpal joint. The line of the radio-carpal joint, as already -stated, is on a level with the apex of the styloid process of the ulna. - -In forcible flexion of the wrist, the tendon of the flexor carpi -radialis and that of the palmaris longus come up in relief. On the -outer side of the first-named tendon we feel the pulse, the radial -artery here lying close to the radius. - -The tendon of the palmaris longus runs near the middle of the wrist, -and close to its inner border runs the median nerve. In letting out -deep-seated matter near the wrist, the incision should be made close to -and parallel with the inner edge of the radial flexor tendon, so as to -avoid injury to the median nerve. - -We can feel the tendon of the flexor carpi ulnaris for some distance -above the wrist. It overlies the ulnar artery, and somewhat masks its -pulsation. - -142. =Pulse.=--The ‘pulse at the wrist’ is felt just outside the -tendon of the flexor carpi radialis. In feeling the pulse it should -be remembered that, in some cases, the superficialis volæ arises -higher and is larger than usual. In such cases it runs by the side of -the radial artery, and gives additional volume to the pulse. The old -writers call it ‘pulsus duplex.’ When in doubt, therefore, it is well -to feel the pulse in each wrist. - -143. =Great carpal bursa.=--The great synovial sheath under the annular -ligament common to the flexor tendons of the fingers and the long -flexor of the thumb, extends, upwards, about an inch and a half above -the edge of the ligament, and, downwards, as low as the middle of -the palm. This general synovial sheath communicates with the special -sheaths of the thumb and the little finger; not with that of the index, -middle, and ring fingers. - -144. ‘=Tabatière anatomique.=’--On the outer side of the wrist we can -distinctly see and feel, when in action, the three extensor tendons of -the thumb. Between the second and third there is deep depression, at -the root of the thumb, which the French humorously call the ‘tabatière -anatomique.’ In this depression we can make out--1, the relief of the -superficial radial vein; 2, the radial artery, in its passage to the -back of the hand; 3, the upper end of the metacarpal bone of the thumb. - -145. =Tendons on back of wrist.=--The relative positions of the several -extensor tendons of the wrist and fingers, as they play in their -grooves over the back of the radius and ulna, can all be distinctly -traced when the several muscles are put in action. The length of their -synovial sheaths should be remembered. They vary from one inch and a -half to two inches and a half. The longest of all are those of the -extensors of the thumb. When these sheaths are inflamed and swollen, -the motion of the tendons becomes painful and gives rise to a feeling -of crepitus, called ‘tenalgia crepitans’ by some writers. It is said to -be met with sometimes in pianists. - -146. =Lines of arteries.=--The course of the radial artery corresponds -with a line drawn from the outer border of the tendon of the biceps at -the bend of the elbow down the front of the forearm to the front of -the styloid process of the radius. In the upper third of its course the -artery is overlapped by the supinator longus. To make allowance for -this, the incision for the ligature of the artery in this situation -should be made, not precisely in the line of its course, but rather -nearer the middle of the forearm. - -The line of the ulnar artery runs from the middle of the bend of the -elbow (slightly curving inwards) to the outer side of the pisiform -bone. The radial and ulnar arteries can, in most cases, be effectually -commanded by pressure well applied at the wrist, in wounds of the -palmar arch. - -Before we make incisions along the forearm, it is always desirable -to ascertain whether the ulnar artery, which usually runs under the -superficial muscles, may not run abnormally over them; in which case -its pulsations can be felt all down the forearm. - - - - -_THE HAND._ - - -147. It is beside the purpose here to examine the question whether the -hand can tell more than the arm, the leg, or any other part of the -body, about the physical constitution of its owner, and to what use -it has been put. Those who are interested in this subject should read -a very elaborate treatise by Carus,[11] ‘On the Reason and Meaning of -the Different Forms of the Hand.’ Still less would I indulge curiosity -by inquiring whether the professors of chiromancy, relying on the text -‘erit signum in manu tua et quasi monumentum ante oculos tuos,’ can -advance any reasonable pretensions for their assertion that they can -read in the furrows of the palm the future destiny of its master. - -148. =Furrow in palm.=--The only furrow in the palm useful as a -surgical landmark is that which runs transversely across its lower -third, and is well seen when the fingers are slightly bent. This -transverse furrow corresponds pretty nearly with the metacarpal joints -of the fingers, with the upper limit of the synovial sheaths of the -flexor tendons of the fingers (that of the little finger excepted -(143)); also with the splitting of the palmar fascia into its four -slips. The transverse metacarpal ligament lies in the same line with -it. Again, a little below this furrow, the digital arteries bifurcate -to run along the opposite sides of the fingers. - -149. =Interdigital folds.=--By pressing upon the interdigital folds -of skin, we can feel the transverse ligament of the fingers, which -prevents their too wide separation. The skin of these folds is much -thinner on the dorsal than the palmar aspect; hence deep-seated -abscesses in the palm very frequently burst on the back of the hand. - -150. =Digital furrows.=--Concerning the transverse furrows on the -palmar surface of the fingers, notice that the first furrows, close to -the palm, do not correspond with the metacarpal joints. The second and -third furrows do correspond with their respective joints. - -The slight depression observable between the ball of the thumb and -that of the little finger corresponds with the middle of the anterior -annular ligament. - -151. =Palmar arterial arches.=--In opening abscesses in the palm, it -is important to bear in mind the position of the large arterial arches -which lie beneath the palmar fascia. The line of the superficial palmar -arch crosses the palm about the junction of the upper with the lower -two-thirds--that is, in the line of the thumb separated widely from -the fingers. From this, the digital arteries run straight between the -shafts of the metacarpal bones towards the clefts of the fingers. -Incisions, therefore, to let out pus beneath the palmar fascia may -safely be made in the lower two-thirds of the palm, provided they run -in the direction of the middle line of the fingers. The deep palmar -arch lies half an inch nearer the wrist than the superficial. - -152. =Digital arteries.=--As the digital arteries run along the sides -of the fingers, the incision to open a thecal abscess should be made -strictly in the middle line. It should be made not over but between the -joints, since the sheath is strongest and thickest over the shafts of -the phalanges, and therefore more likely to produce strangulation of -the enclosed tendons. - -153. =Metacarpal joint of thumb.=--The joint of the metacarpal bone -of the thumb with the trapezium can be distinctly felt by tracing the -dorsal surface of the bone upwards till we come to the prominence which -indicates the joint at the bottom of the ‘tabatière anatomique’ (144). -Supposing, however, there be much swelling, the knife introduced at the -angle between the first and second metacarpal bones readily finds the -joint if the blade be directed outwards. - -154. =Sesamoid bones.=--The sesamoid bones of the thumb can be -distinctly felt. Just above them--that is, nearer to the wrist--lies -the joint between the metacarpal bone and the first phalanx. We should -remember the position of these bones in amputation at this joint. -_Mutatis mutandis_ the same observations apply to the sesamoid bones of -the great toe. - -The extensor tendon of the last joint of the thumb crosses the apex -of the first interosseous space. Under the tendon, and in the angle -between the bones, we feel the radial artery just before it sinks into -the palm. - -155. =Subcutaneous veins.=--The veins on the back of the hand, and -their arrangement in the form of arches which receive the digital -veins, is sufficiently obvious. The number and arrangement of the -arches may vary, but in all hands it is interesting to notice that -the veins from the fingers run up between the knuckles and are out of -harm’s way. - -156. =Interosseous arteries.=--Since the dorsal interosseous arteries, -like the palmar, run along the interosseous spaces, incisions to let -out pus should always be made along the lines of the metacarpal bones. - -157. =Digital bursæ.=--Small subcutaneous bursæ are sometimes developed -over the knuckles and the backs of the joints of the fingers. They -often become enlarged and unseemly in persons of a rheumatic or gouty -tendency. - -158. =Knuckles and digital joints.=--The three rows of projections -called ‘the knuckles’ are formed by the proximal bones of the several -joints: thus the first row is formed by the ends of the metacarpals; -the second by the ends of the first phalanges, and so forth. In -amputations of the fingers it is well to remember that in all cases the -line of the joints is a little in advance of the knuckles, that is, -nearer the end of the fingers. - -Long and graceful fingers, coupled with thickness and breadth of the -sentient pulp at their ends, and too great arching of the nails, have -been regarded, ever since the days of Hippocrates, as not unlikely -indications of a tendency to pulmonary disease. - - - - -_PALPATION BY THE RECTUM._ - - -The following report is from Mr. Walsham, of St. Bartholomew’s -Hospital, who, having a small hand (somewhat less than seven and a half -inches round), has had opportunities of introducing it up the rectum, -in the living subject, for the purpose of diagnosis:-- - -‘It is possible to introduce the hand (if small) into the rectum; in -many cases into the sigmoid flexure, and in rare instances into the -descending colon. - -‘Once beyond the sphincter, the hand enters a capacious sac, and the -following important parts can be felt through its walls:-- - -‘Through the anterior wall the hand first recognises the prostate, -which feels like a moderately large chestnut. Immediately behind the -prostate, the vesiculæ seminales may be distinguished as two softish -masses situated one on either side of the middle line. Internal to -them, the whipcord-like feel of the vasa deferentia can be readily -traced over the bladder to the sides of the pelvis. - -‘The bladder is easily recognised, when moderately distended, as a -soft fluctuating tumour behind the prostate; when empty it cannot be -distinguished from the intestines, which then descend between the -rectum and the pubes. The arch of the pubes can well be defined when -the bladder is empty. - -‘Through the posterior wall of the bowel the coccyx and sacrum can be -felt, the curve of the sacrum being readily followed by the hand. - -‘The projecting spine of the ischium on each side of the pelvis is a -valuable landmark. From this point the outlines of the greater and -lesser sacro-ischiatic foramina can be traced by the fingers; and any -new growth, encroaching on the pelvic cavity through these apertures, -could be easily detected. - -‘If the hand be now pushed farther up the gut, the promontory of -the sacrum is reached; the pulsation of the iliac vessels becomes -manifest, and the course of the external iliac can be traced along the -brim of the pelvis to the crural arch, the loose attachments of the -rectum permitting very free movement in this direction. The internal -iliac artery can also be followed to the upper part of the great -sacro-ischiatic foramen. - -‘By semi-rotatory movement, and alternately flexing and extending the -fingers, the hand can gradually be insinuated into the commencement of -the sigmoid flexure. In the sigmoid flexure the fingers can explore the -whole of the lower part of the abdomen, the loose attachment of this -portion of the gut permitting the hand to travel freely over the iliac -and hypogastric regions. - -‘The parts that can here be felt are the bifurcation of the aorta, the -division of the common iliac arteries, the iliac fossa, and the crest -of the ilium. - -‘In the female, the uterus in the middle line, and the ovaries on -either side, can be readily distinguished. - -‘In the introduction of the hand into the rectum, in a patient under -chloroform, the dilatation of the sphincter ani should be very gradual: -first two fingers, then four, and finally the thumb should be passed. -It is necessary to use considerable force, and unless care be taken, -not only the integumentary edge of the anus, but the sphincter itself, -may be lacerated. The introduction is facilitated by the application of -the other hand upon the abdomen. - -‘When the dilatation has been gradual and the hand not too large, no -incontinence of fæces and no very considerable amount of pain has -resulted. - -‘We have been informed on reliable authority that permanent -incontinence of fæces has occasionally followed these examinations.’ - -Lastly, we think it right to insist upon the important fact that, in -some subjects, even a small hand cannot be passed up the rectum beyond -the reflection of the peritoneum over the second part of the gut. In -such instances the peritoneum offers a resistance like a tight garter, -and prevents the farther advance of the hand without great risk of -laceration of the parts.[12] - - - - -_EXAMINATION PER VAGINAM._ - - -For this report I am indebted to Dr. Godson, of St. Bartholomew’s -Hospital:-- - -‘The finger introduced into the vagina comes upon the carunculæ -myrtiformes, which are vascular membranous processes independent of the -hymen, variable in number, size, and form. It also feels the transverse -ridges known as “rugæ.” - -‘Along the anterior wall of the vagina the finger readily detects the -track of the urethra, which feels like a prominent cord and forms an -excellent guide to the orifice of the meatus urinarius in passing a -catheter. The orifice is indicated by a slight semicircular prominence, -situated about one-third of an inch above the orifice of the vagina. -Behind the urethra the finger comes upon the posterior wall of the -bladder. But the bladder is not perceptible, as such, to the touch -unless distended. With a catheter previously introduced it is much more -readily explored. - -‘The septum between the vagina and the rectum is so thin that, should -the rectum contain fæcal matter, its presence becomes at once apparent -to the finger. - -‘The cervix uteri is felt protruding from the roof of the vagina in -a direction downwards and backwards--that is, in a line from the -umbilicus to the coccyx. The os uteri is felt, small and round, in the -centre of the cervix. The posterior lip feels a little lower than the -anterior. The cul-de-sac formed by the vagina in front and behind the -cervix should be perfectly elastic to the touch, and not communicate -the sensation of a resisting body. Any resistance here bespeaks an -abnormal condition. - -‘The bony landmarks within reach of a finger, or perhaps two, in a -woman who has not borne a child, are the symphysis pubis, the rami -of the pubes and ischia. The coccyx and part of the hollow of the -sacrum may also be felt, but not without exerting much pressure on the -posterior wall of the vagina, which gives considerable pain. If the -promontory of the sacrum can be felt, it is a sign that the conjugate -diameter of the pelvis is abnormal. - -‘The finger in the rectum can detect almost everything which has been -mentioned in connection with the vagina. The shape and direction of -the cervix uteri are almost as perceptible, and the posterior wall of -the uterus can be examined. The peritoneal fold termed recto-vaginal -(Douglas’s space) can also be well explored, and anything abnormal -detected in this direction--a point of great importance in the -diagnosis of diseases and displacements of the uterus. - -‘The ovary in its normal state and position cannot be detected by -the touch even with the hand firmly pressed on the hypogastrium. If -a movable body be felt through the vaginal roof on one side of the -cervix, if this body be exquisitely tender and recede at once from the -finger, it is an ovary in a state of prolapse. - -‘The fundus of a healthy unimpregnated uterus never rises above the -level of the brim of the pelvis, and cannot therefore be felt by -pressing the hand on the hypogastrium. - -‘The direction of the uterus is subject to changes which cannot be -looked upon as abnormal. The fundus may be thrown backwards by a -distended bladder, or forwards by a distended rectum. The axis of its -cavity is not a straight but a curved line; and uterine sounds should -be shaped to suit it.’ - - - - -NOTES. - - -[1] Some pertinent remarks on this subject have been made by Mr. C. -Heath in a pamphlet ‘On Anatomy in relation to Physic.’ - -[2] In several adult normal skeletons measured in the Hunterian -Museum, the average diameters of the upper opening of the chest -were--antero-posterior, about 2¼ inches; transverse, about -4½ inches. In the skeleton of O’Brien, the Irish giant, the -antero-posterior diameter measures 4 inches, the transverse 6¼. - -[3] Special experiments upon this subject were made many years ago by -the late Professor Quekett in the work-rooms of the College of Surgeons. - -[4] See a beautiful illustration of this in Sir C. Bell’s ‘Anatomy of -Expression,’ p. 160. - -[5] See some good observations on the position of the enlarged spleen, -by Sir W. Jenner, ‘Brit. Med. Journ.,’ Jan. 16, 1869. - -[6] ‘Lectures on Rest and Pain,’ by John Hilton, F.R.S. London, 1863. -p. 280. - -[7] Nélaton, ‘Pathologie chirurgicale,’ t. iv. p. 441. 1848. - -[8] Bigelow, ‘Mechanism of Dislocation and Fracture of the Hip.’ -Philadelphia, 1869. - -[9] See Pruge on ‘Ossa Acromialia’ (‘Zeitschrift für rationelle -Medizin’), 3. Reihe, Bd. vii. 1859. - -[10] See on this subject a monograph, ‘Canalis Supra-Condyloideus -Humeri.’ By W. Grüber. Petersburg, 1856. - -[11] ‘Ueber Grund und Bedeutung der verschiedenen Formen der Hand.’ -Stuttgart, 1846. - -[12] For further information on this subject, see a paper by Mr. -Walsham, in St. Bartholomew’s Hospital Reports, vol. xii. - - -_Spottiswoode & Co., Printers, New-street Square, London._ - - - - -Transcriber’s Notes - -A few obvious errors in punctuation have been fixed. - -The reference in section 153 to tabatière anatomique in section 140 has -been corrected to 144. - -*** END OF THE PROJECT GUTENBERG EBOOK LANDMARKS MEDICAL AND -SURGICAL *** - -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. 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