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.