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.