Part 1

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_

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.