Part 7

154. =Sesamoid bones.=--The sesamoid bones of the thumb can be distinctly felt. Just above them--that is, nearer to the wrist--lies the joint between the metacarpal bone and the first phalanx. We should remember the position of these bones in amputation at this joint. _Mutatis mutandis_ the same observations apply to the sesamoid bones of the great toe.

The extensor tendon of the last joint of the thumb crosses the apex of the first interosseous space. Under the tendon, and in the angle between the bones, we feel the radial artery just before it sinks into the palm.

155. =Subcutaneous veins.=--The veins on the back of the hand, and their arrangement in the form of arches which receive the digital veins, is sufficiently obvious. The number and arrangement of the arches may vary, but in all hands it is interesting to notice that the veins from the fingers run up between the knuckles and are out of harm’s way.

156. =Interosseous arteries.=--Since the dorsal interosseous arteries, like the palmar, run along the interosseous spaces, incisions to let out pus should always be made along the lines of the metacarpal bones.

157. =Digital bursæ.=--Small subcutaneous bursæ are sometimes developed over the knuckles and the backs of the joints of the fingers. They often become enlarged and unseemly in persons of a rheumatic or gouty tendency.

158. =Knuckles and digital joints.=--The three rows of projections called ‘the knuckles’ are formed by the proximal bones of the several joints: thus the first row is formed by the ends of the metacarpals; the second by the ends of the first phalanges, and so forth. In amputations of the fingers it is well to remember that in all cases the line of the joints is a little in advance of the knuckles, that is, nearer the end of the fingers.

Long and graceful fingers, coupled with thickness and breadth of the sentient pulp at their ends, and too great arching of the nails, have been regarded, ever since the days of Hippocrates, as not unlikely indications of a tendency to pulmonary disease.

_PALPATION BY THE RECTUM._

The following report is from Mr. Walsham, of St. Bartholomew’s Hospital, who, having a small hand (somewhat less than seven and a half inches round), has had opportunities of introducing it up the rectum, in the living subject, for the purpose of diagnosis:--

‘It is possible to introduce the hand (if small) into the rectum; in many cases into the sigmoid flexure, and in rare instances into the descending colon.

‘Once beyond the sphincter, the hand enters a capacious sac, and the following important parts can be felt through its walls:--

‘Through the anterior wall the hand first recognises the prostate, which feels like a moderately large chestnut. Immediately behind the prostate, the vesiculæ seminales may be distinguished as two softish masses situated one on either side of the middle line. Internal to them, the whipcord-like feel of the vasa deferentia can be readily traced over the bladder to the sides of the pelvis.

‘The bladder is easily recognised, when moderately distended, as a soft fluctuating tumour behind the prostate; when empty it cannot be distinguished from the intestines, which then descend between the rectum and the pubes. The arch of the pubes can well be defined when the bladder is empty.

‘Through the posterior wall of the bowel the coccyx and sacrum can be felt, the curve of the sacrum being readily followed by the hand.

‘The projecting spine of the ischium on each side of the pelvis is a valuable landmark. From this point the outlines of the greater and lesser sacro-ischiatic foramina can be traced by the fingers; and any new growth, encroaching on the pelvic cavity through these apertures, could be easily detected.

‘If the hand be now pushed farther up the gut, the promontory of the sacrum is reached; the pulsation of the iliac vessels becomes manifest, and the course of the external iliac can be traced along the brim of the pelvis to the crural arch, the loose attachments of the rectum permitting very free movement in this direction. The internal iliac artery can also be followed to the upper part of the great sacro-ischiatic foramen.

‘By semi-rotatory movement, and alternately flexing and extending the fingers, the hand can gradually be insinuated into the commencement of the sigmoid flexure. In the sigmoid flexure the fingers can explore the whole of the lower part of the abdomen, the loose attachment of this portion of the gut permitting the hand to travel freely over the iliac and hypogastric regions.

‘The parts that can here be felt are the bifurcation of the aorta, the division of the common iliac arteries, the iliac fossa, and the crest of the ilium.

‘In the female, the uterus in the middle line, and the ovaries on either side, can be readily distinguished.

‘In the introduction of the hand into the rectum, in a patient under chloroform, the dilatation of the sphincter ani should be very gradual: first two fingers, then four, and finally the thumb should be passed. It is necessary to use considerable force, and unless care be taken, not only the integumentary edge of the anus, but the sphincter itself, may be lacerated. The introduction is facilitated by the application of the other hand upon the abdomen.

‘When the dilatation has been gradual and the hand not too large, no incontinence of fæces and no very considerable amount of pain has resulted.

‘We have been informed on reliable authority that permanent incontinence of fæces has occasionally followed these examinations.’

Lastly, we think it right to insist upon the important fact that, in some subjects, even a small hand cannot be passed up the rectum beyond the reflection of the peritoneum over the second part of the gut. In such instances the peritoneum offers a resistance like a tight garter, and prevents the farther advance of the hand without great risk of laceration of the parts.[12]

_EXAMINATION PER VAGINAM._

For this report I am indebted to Dr. Godson, of St. Bartholomew’s Hospital:--

‘The finger introduced into the vagina comes upon the carunculæ myrtiformes, which are vascular membranous processes independent of the hymen, variable in number, size, and form. It also feels the transverse ridges known as “rugæ.”

‘Along the anterior wall of the vagina the finger readily detects the track of the urethra, which feels like a prominent cord and forms an excellent guide to the orifice of the meatus urinarius in passing a catheter. The orifice is indicated by a slight semicircular prominence, situated about one-third of an inch above the orifice of the vagina. Behind the urethra the finger comes upon the posterior wall of the bladder. But the bladder is not perceptible, as such, to the touch unless distended. With a catheter previously introduced it is much more readily explored.

‘The septum between the vagina and the rectum is so thin that, should the rectum contain fæcal matter, its presence becomes at once apparent to the finger.

‘The cervix uteri is felt protruding from the roof of the vagina in a direction downwards and backwards--that is, in a line from the umbilicus to the coccyx. The os uteri is felt, small and round, in the centre of the cervix. The posterior lip feels a little lower than the anterior. The cul-de-sac formed by the vagina in front and behind the cervix should be perfectly elastic to the touch, and not communicate the sensation of a resisting body. Any resistance here bespeaks an abnormal condition.

‘The bony landmarks within reach of a finger, or perhaps two, in a woman who has not borne a child, are the symphysis pubis, the rami of the pubes and ischia. The coccyx and part of the hollow of the sacrum may also be felt, but not without exerting much pressure on the posterior wall of the vagina, which gives considerable pain. If the promontory of the sacrum can be felt, it is a sign that the conjugate diameter of the pelvis is abnormal.

‘The finger in the rectum can detect almost everything which has been mentioned in connection with the vagina. The shape and direction of the cervix uteri are almost as perceptible, and the posterior wall of the uterus can be examined. The peritoneal fold termed recto-vaginal (Douglas’s space) can also be well explored, and anything abnormal detected in this direction--a point of great importance in the diagnosis of diseases and displacements of the uterus.

‘The ovary in its normal state and position cannot be detected by the touch even with the hand firmly pressed on the hypogastrium. If a movable body be felt through the vaginal roof on one side of the cervix, if this body be exquisitely tender and recede at once from the finger, it is an ovary in a state of prolapse.

‘The fundus of a healthy unimpregnated uterus never rises above the level of the brim of the pelvis, and cannot therefore be felt by pressing the hand on the hypogastrium.

‘The direction of the uterus is subject to changes which cannot be looked upon as abnormal. The fundus may be thrown backwards by a distended bladder, or forwards by a distended rectum. The axis of its cavity is not a straight but a curved line; and uterine sounds should be shaped to suit it.’

NOTES.

[1] Some pertinent remarks on this subject have been made by Mr. C. Heath in a pamphlet ‘On Anatomy in relation to Physic.’

[2] In several adult normal skeletons measured in the Hunterian Museum, the average diameters of the upper opening of the chest were--antero-posterior, about 2¼ inches; transverse, about 4½ inches. In the skeleton of O’Brien, the Irish giant, the antero-posterior diameter measures 4 inches, the transverse 6¼.

[3] Special experiments upon this subject were made many years ago by the late Professor Quekett in the work-rooms of the College of Surgeons.

[4] See a beautiful illustration of this in Sir C. Bell’s ‘Anatomy of Expression,’ p. 160.

[5] See some good observations on the position of the enlarged spleen, by Sir W. Jenner, ‘Brit. Med. Journ.,’ Jan. 16, 1869.

[6] ‘Lectures on Rest and Pain,’ by John Hilton, F.R.S. London, 1863. p. 280.

[7] Nélaton, ‘Pathologie chirurgicale,’ t. iv. p. 441. 1848.

[8] Bigelow, ‘Mechanism of Dislocation and Fracture of the Hip.’ Philadelphia, 1869.

[9] See Pruge on ‘Ossa Acromialia’ (‘Zeitschrift für rationelle Medizin’), 3. Reihe, Bd. vii. 1859.

[10] See on this subject a monograph, ‘Canalis Supra-Condyloideus Humeri.’ By W. Grüber. Petersburg, 1856.

[11] ‘Ueber Grund und Bedeutung der verschiedenen Formen der Hand.’ Stuttgart, 1846.

[12] For further information on this subject, see a paper by Mr. Walsham, in St. Bartholomew’s Hospital Reports, vol. xii.

_Spottiswoode & Co., Printers, New-street Square, London._

Transcriber’s Notes

A few obvious errors in punctuation have been fixed.

The reference in section 153 to tabatière anatomique in section 140 has been corrected to 144.