Part 2

=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.

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.’