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 Landmarks, medical and surgical / 
 
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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 J 
 
 CONSULTING BURGEON TO SAINT BARTHOLOMEW'S AND 
 
 THE FOUNDLING HOSPITALS. 
 
 ASSISTED BY 
 
 JAMES jpHUTER., M.A. Camb., F.R..C.S., 
 
 ASSISTANT SURGEON TO THE ROYAL FREE HOSPITAL J LATE DEMONSTRATOR OF 
 
 PHYSIOLOGY, AND LATE ASSISTANT DEMONSTRATOR OF ANATOMY, 
 
 AT SAINT BARTHOLOMEW'S HOSPITAL. 
 
 FHOM THE THIRD ENGLISH EDITION, WITH ADDITIONS, 
 BY 
 
 WILLIAM W. KEEN, M.D., 
 
 PROFESSOR OP ARTISTIC ANATOMY IN THE PENNSYLVANIA ACADEMY OF THE 
 
 FINE ARTS ; FORMERLY LECTURER ON ANATOMY IN THE 
 
 PHILADELPHIA SCHOOL OF ANATOMY, ETC. 
 
 PHILADELPHIA: 
 
 HENRY C. LEA'S SON & CO. 
 
 1881. 
 
J. 33/fi 
 
 /^CORNELI? 
 UNIVERSITY,'! 
 LIBRARY 
 
 41 Chirurgus mente prius et oculis agat quam manu armata." 
 
 Entered according to Act of Congress, in the year 1881, by 
 
 H. C. LEA'S SON & CO., 
 
 in the Office of the Librarian of Congress. All rights reserved. 
 
 ^ 
 
 COLLIHS, PRINTER. 
 
TO 
 
 THE STUDENTS 
 
 PAST AND PRESENT 
 
 OP 
 
 SAINT BARTHOLOMEW'S HOSPITAL 
 
 THESE "LANDMARKS" ARE 
 
 Itbicsttfr 
 
 BY THEIR SINCERE FRIEND 
 
 THE AUTHOR. 
 
PEEFATOHY NOTE. 
 
 At the request of the publishers I have added 
 as much practical matter to the text of Holden's 
 admirable "Landmarks" as the space allowed 
 would permit. All such additions are marked by 
 brackets [ ]. 
 
 Some twelve years ago I began this method of 
 teaching that which I have ventured to call 
 "Clinical Anatomy" (because it is precisely the 
 anatomy that is needed at the bedside), using the 
 living model more and more as the chief means 
 of illustration. Increasing experience has but the 
 more convinced me of its value, and any teacher 
 who has once studied and then tried it faithfully 
 will be very loath ever to give it up. In fact I 
 think the living model is as essential in" teaching 
 anatomy as is the cadaver or the skeleton. One 
 such model the student always has — himself. 
 
 WILLIAM W. KEEN, M.D. 
 
 1729 Chestnut Street, 
 Philadelphia, July 20, 1881. 
 
 1* 
 
PREFACE 
 
 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 " Landmaeks" 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 contribu- 
 tions. 
 
 65 Gower Street : March, 1876. 
 
LANDMAKKS, 
 
 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 land- 
 marks." 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 abso- 
 lutely 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, bloodvessels, 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 ; 
 
12 LANDMARKS, MEDICAL AND SURGICAL. 
 
 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, there- 
 fore, 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, con- 
 nected, 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 
 
LANDMARKS, MEDICAL AND SURGICAL. 13 
 
 body with "anatomical eyes" and "surgical fing- 
 ers " 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." 1 
 
 At the same time, it is only fair to say that 
 "landmarks" cannot always be defined with pre- 
 cision. 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, there- 
 
 1 Some pertinent remarks on this subject have been made 
 by Mr. C. Heath in a pamphlet " On Anatomy in relation to 
 Physic." 
 2 
 
14 THE HEAD. 
 
 fore, for study a moderately lean person, let us 
 begin with the head. 
 
 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 tumors on the cranium. A tumor 
 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 con- 
 finement beneath the aponeurosis, but on its 
 having its origin within the skull. Look with 
 suspicion, then, on every tumor on the bead 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 
 
THE HEAD. 15 
 
 notch, and traced for some way up to 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 mas- 
 toid process. All these arteries can be effectually 
 compressed against the subjacent bone. 
 
 5. Skullcap. — The skullcap is rarely quite 
 S3 r mmetrical. 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 cor- 
 responding lobes of the brain. To ascertain the 
 relative proportions of these three regions, let a 
 thread be passed from one meatus auditorius to 
 
16 THE HEAD. 
 
 the other, across the frontal, parietal, and occipital 
 eminences respectively. 
 
 [Anterior Fontanelle. — At the junction of the 
 sagittal and the coronal sutures in the new-born 
 child is the anterior fontanelle, caused by the as 
 yet incomplete ossification of the frontal and the 
 parietal bones. It closes at about twelve to eigh- 
 teen months of age. Its condition, as to whether 
 it is a hollow or a hill, is important, for it shows 
 the wasting of the fluids of the body, as in the 
 summer diarrhoeas of children, or the redundancy 
 of fluid within the skull, as in hydrocephalus. The 
 pulse of a sleeping child can often be cbunted at 
 the fontanelle by the eye alone.] 
 
 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 impor- 
 tant 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 neces- 
 sarily 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 
 
THE HEAD. 17 
 
 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 indica- 
 tion of it. 
 
 Neither does a very prominent bump neces- 
 sarily 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. 
 ["Mastoid disease," or suppuration in these cells, 
 which, like the frontal sinuses, are lined by mucous 
 membrane, causes pain, tenderness, and swelling in 
 the process, and often demands early trephining to 
 evacuate the pus.] 
 
 Occipital Protuberance. — The occipital pro- 
 tuberance, and the superior curved line, can be 
 distinctly felt at the back of the head. The pro- 
 tuberance 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 
 
 2* 
 
18 THE HEAD. 
 
 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 supe- 
 rior 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 [or one inch and a 
 half above the zygoma. This is a more definite 
 measuring point vertically]. 
 
 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 Skullcap. — The average 
 thickness of the cap of an adult skull is about J 
 of an inch. The thickest part is at the occipital 
 protuberance, where it is often J of an inch or 
 more, even in an otherwise thin skull. The thin- 
 nest part is at the temple, where it may be almost 
 as thin as parchment. Every one in the habit of 
 
THE HEAD. 19 
 
 making post-mortem examinations knows how 
 much the skullcap differs in thickness in different 
 persons and in different parts of same skull. In 
 old persons it is often in some parts not thicker 
 than a shilling, owing to absorption of the diploe. 
 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 thin- 
 nest skull ever seen, and thinner in one half of the 
 circle than the other." 
 
 7. Levels of the Brain. — The level of the an- 
 terior lobes in front corresponds with a straight 
 line drawn across the forehead, just above the eye- 
 brows. 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 fossae bulge into the nape of 
 the neck ; and this bulge varies in different skulls. 
 
 [Ear. — The axis of the auditory canal is not 
 directly transverse, but inward and forward, to- 
 wards the opposite temple — a fact of importance in 
 
20 THE FACE. 
 
 the use of instruments or of injections into the ear. 
 The canal should always be inspected with care for 
 abscesses, foreign bodies, or impacted wax, and, in 
 cases of possible fracture at the base of the skull, 
 for the escape of cerebro-spinal fluid. About one 
 inch from the external meatus the canal is closed 
 by the membrana tympani. This can be seen best 
 through a speculum by reflected light from a hand 
 or forehead mirror, but not uncommonly it can be 
 seen without the speculum. To examine the au- 
 ditory canal or the membrana tympani, the auricle 
 must be pulled gently, but decidedly, upwards and 
 backwards.] 
 
 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 
 
THE FACE. 21 
 
 with their corresponding arteries. The supra- 
 orbital notch or foramen can be felt about the 
 junction of the inner with the middle third of 
 the supraorbital margin. From this point a per- 
 pendicular 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 direc- 
 tion of these two lower forainina looks towards the 
 angle of the nose. [The canal in the lower jaw for 
 the inferior dental nerve, it must be remembered, 
 in persons who have lost the alveolar process by 
 absorption, lies by so much nearer the upper 
 margin of the jaw. A trephine must, therefore, 
 in such persons be applied well above the middle 
 of the bone, or the canal may be missed entirely.] 
 
 10. Pulley for Superior Oblique Muscle. — 
 By pressing the thumb beneath the internal an- 
 gular 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 [and seen] in front of the ear. When 
 the mouth is opened wide, the condyle advances 
 out of the glenoid cavity on to the eminentia 
 
22 THE FACE. 
 
 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 con- 
 dyle 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 neces- 
 sary where inflammation of the parotid gland 
 ensues after eruptive fevers, and runs on to suppu- 
 ration. 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 proba- 
 bly exude the next day. 
 
 [Zygoma. — In front of the ear lies the zygoma, 
 one of the most marked and important landmarks 
 to the touch, and in lean persons to the eye. 
 
 Seventh Nerve. — This nerve, after emerging 
 from the stylo-mastoid foramen, passes into the 
 
THE FACE. 23 
 
 parotid gland and is distributed to the facial 
 muscles, its branches running towards the temple, 
 the eye, the cheek, and the jaw. It can always 
 readily be galvanized in facial palsy, etc., by 
 placing one pole at the lobule of the ear and the 
 other at the desired points of the face.] 
 
 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 mem- 
 brane [and can be compressed here either by the 
 finger and thumb, or by a spring clip, in hare-lip 
 
24 THE FACE. 
 
 and other similar operations]. The facial vein 
 does not accompany the tortuous artery, hut runs 
 a straight course from the inner angle of the eye 
 to the front border of the masse ter, 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. [Eversion of 
 the upper lid is best done while the patient is 
 looking down, by placing a pencil on the lid, next 
 seizing the eyelashes, and then pushing the pencil 
 gently downwards, while by the lashes the free 
 border of the lid is lifted over it. In case of a 
 suspected foreign body, if it be not found on the 
 
THE PACE. "25 
 
 lid, it must be remembered that it may easily be 
 in the cornea and have been overlooked on the iris 
 as a background. Oblique light will best reveal it 
 if there.] 
 
 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. The 
 plane is not exactly horizontal, but slightly in- 
 clined upwards. 
 
 Every time the eye is shut, the ball turns up- 
 wards 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. The upturning 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 ^ of 
 an inch. This second movement sweeps any 
 particles of dust as well as moisture towards the 
 inner canthus. 
 
 15. Puncta Lachrymalia. — The puncta lach- 
 rymalia are distinctly visible [as two little black 
 3 
 
26' THE FACE. 
 
 dots] 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 
 
THE PACE. 27 
 
 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 quar- 
 ter of an inch behind the bony edge of the nostril. 
 The appearance of the orifice in the dry bone con- 
 veys no idea of its size and shape in life; for it is 
 diminished by a valve-like fold of mucous mem- 
 brane, 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 in- 
 
28 THE FACE. 
 
 troduced 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 eases, 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 sep- 
 tum, 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. [With the head 
 thrown well back this middle turbinated bone can 
 
THE FACE. 29 
 
 be seen. It is important not to mistake these 
 spongy bones for polypi.] 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. 
 
 [Lips. — The color of the vermilion border the 
 doctor ought always, and even unconsciously, to 
 notice, as a means of judging of the condition of 
 the circulation and the character of the blood.] 
 
 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 linguae," 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 press- 
 ing 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 
 
 3* 
 
30 THE 'PACE. 
 
 to draw the tongue more freely out of the mouth 
 in any attempt to remove carcinoma extending far 
 back into its root. c 
 
 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. 
 
 [Teeth. — In young children the question of the 
 impending eruption of any tooth should always 
 be settled by inspection. The secondary incisor 
 teeth should be examined if any possibility of 
 syphilis exist. Before giving any anaesthetic, arti- 
 ficial teeth should invariably be removed.] 
 
 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, feude 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 
 cesophagus, and the hyoid space (on each side) 
 where foreign bodies are so apt to lodge. The 
 
THE FACE. 31 
 
 greater cornu of the hyoid bone can be felt as a 
 distinct projection on either side. In introducing a 
 tube into the oesophagus 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 pulsa- 
 tion of the posterior palatine artery. Hemorrhage 
 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 
 £ 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, be- 
 hind the last molar teeth. A little below the 
 
32 THE FACE. 
 
 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 examina- 
 tion 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 
 
THE FACE. 33 
 
 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 con- 
 cealed 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 prox- 
 imity of the external 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 
 
34 THE FACE. 
 
 tonsils, always to keep the point of the knife 
 inwards. 
 
 In troublesome hemorrhage 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. Every one 
 pays unconscious homage to the study of physiog- 
 nomy 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 base 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 de- 
 scribed 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. 
 
THE NECK. 35 
 
 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 pro- 
 ducing 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 admira- 
 ble proof of infinite wisdom that what is noble 
 and benevolent beautifies the human countenance ;, 
 what is base and hateful imprints upon it a revolt- 
 ing expression." 
 
 THE NECK. 
 
 [Skin. — In no part of the body can the differ- 
 ing thickness of the skin be more readily perceived 
 than by pinching up a fold at the front and back 
 of the neck.J 
 
 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 
 
36 THE NECK. 
 
 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 gene- 
 rally runs along the front border of the sterno- 
 mastoid. [The condition of these veins should 
 be examined in all . diseases causing respiratory 
 disturbance, especially dyspnoea. In case of tri- 
 cuspid regurgitation there will be a venous pulse 
 seen. The stethoscope will also reveal a venous 
 hum or musical note over these veins in anaemia.] 
 , 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 NECK. 37 
 
 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 
 recognize 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 thy- 
 roid artery. This pulsation, coupled with the 
 fact that the gland rises and falls with the larynx 
 in deglutition, gives the best means of distinguish- 
 ing a bronchocele from other tumors resembling it. 
 
 Below the angle of the thyroid cartilage we 
 feel the interval between it and the cricoid, which 
 is occupied by the crico-thyroid 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 
 vertebrae. The commencement of the oesophagus 
 4 
 
38 THE NECK. 
 
 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, 
 
THE NECK. 39 
 
 this operation may be attended with the greatest 
 difficulties. In urgent dyspnoea you must expect 
 to find the patient with his head bent forward, and 
 the chin dropped, so as to relax as much as possi- 
 ble the parts. On raising his head, a paroxysm of 
 dyspnoea 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 inci- 
 sions 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 
 
40 THE NECK. 
 
 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 corre- 
 sponds with a line drawn from the sterno-clavicu- 
 lar joint to midway between the angle of the jaw 
 and the mastoid process, i 
 
 Between the sternal origins of the sterno-mas- 
 toid is the fossa above the sternum, more or less 
 perceptible in different necks. As it heaves and 
 sinks alternately, especially in distressed breath- 
 ing, it was called by the old anatomists "fonti- 
 culus 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 perform- 
 ing the subcutaneous section of the tendon of this 
 muscle. 
 
 29. Sterno-clavieular Joint. — Many impor- 
 tant parts lie behind the sterno-clavieular joint. 
 There is the commencement of the vena innomi- 
 
THE NECK. 41 
 
 nata ; 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 ob- 
 servations 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 sca- 
 lenus 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 stern o- mastoid 
 and the trapezius, is very manifest in emaciation 
 and old age. [Shrugging the shoulders makes it 
 
42 THE NECK. 
 
 exceedingly pronounced.] 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-clavicu- 
 lar fossa, near the outer border of the sterno-mas- 
 toid, 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 effect- 
 ually compressed. A little pressure is sufficient. 
 But the pressure must be made in the right direc- 
 tion, 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. [As 
 the phrenic nerve passes over the scalenus anticus, 
 it can now be readily located. If it is to be gal- 
 vanized, one pole of the battery should be placed 
 in this fossa and the other over the diaphragm.] 
 
THE CHEST. 43 
 
 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 percepti- 
 ble, 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 lan- 
 guage of transcendental anatomy, we may say 
 that the central tendon of the omo-hyoid repre- 
 sents 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 per- 
 sons 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 favor of the right was one inch 
 and a quarter. The measurements were made on 
 a plane with the nipple. 
 
44 THE CHEST. 
 
 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. 1 
 
 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 
 
 1 In several adult normal skeletons measured in the Hun- 
 terian Museum, the average diameters of the upper opening of 
 the chest were — antero-posterior, about 2\ inches ; transverse, 
 about 4£ inches. In the skeleton of O'Brien, the Irish giant, 
 the antero-posterior diameter measures 4 inches, the trans- 
 verse 6j. 
 
THE CHEST. 45 
 
 second bones of the sternum. Deepest of all is 
 the oesophagus. 
 
 About one inch from the vipper border of the 
 sternum is the highest part of the aorta, which lies 
 on the bifurcation of the trachea. 
 
 37. The course of the arteria innominata corre- 
 sponds 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. 
 
46 THE CHEST. 
 
 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. 
 
 /. 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 
 spinse, 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 recognize the triangular 
 interval between the pectoralis major and the 
 
THE CHEST. 47 
 
 deltoid. This space varies in different cases, de- 
 pending 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 oppo- 
 site 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 dis- 
 tinctly 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 perpendicu- 
 larly 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 
 
48 THE CHEST. 
 
 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, below, 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 
 
THE CHEST. 
 
 49 
 
 right intercostal space close to the sternum would 
 penetrate the lung and the right auricle. 
 
 Fig. 1. 
 
 Outline of the Heart, its Valves, and the Lungs. 
 
 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. 
 5 
 
50 THE CHEST. 
 
 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 pras- 
 cordial region which is less resonant on percus- 
 sion, 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 any one may convince him- 
 self 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 CHEST. 51 
 
 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. 
 
 [Where to Auscult the Valves of the 
 Heart. — The valves being so close together, it is 
 evident that, to discriminate the sound of one from 
 that of the others, we must be able to auscult 
 them separately ; and accordingly we follow the 
 diverging course of the blood-currents they trans- 
 mit. Hence, 
 
 The aortic valve is best ausculted over the 
 second intercostal space at the right border of the 
 sternum ; it can also be heard over the aorta in 
 the back, from the third to the ninth dorsal spines, 
 especially if there be any murmur ; 
 
52 THE OHEST. 
 
 The pulmonary valve, over the second space at 
 the left border of the sternum ; 
 
 The tricuspid valve, over the middle of the 
 sternum above the ensiform cartilage ; and 
 
 The mitral valve, over the apex of the heart.] 
 
 44. Outline of the Lungs. — Now let us trace 
 on the chest the outline of the lungs, with as 
 much precision as their expansion and contraction 
 in breathing permit. (See the cut, p. 49.) 
 
 45. The apex of each lung rises into the neck 
 behind the sternal end of the clavicle and sterno- 
 mastoid muscle as much as an inch and a half: in 
 females rather higher than in males (30). From 
 the sternal ends of the clavicles the lungs con- 
 verge, so that their thin edges almost meet in the 
 mesial line on a level with the second costal car- 
 tilage. Thus there is little or no lung behind the 
 first bone of the sternum. From the level of the 
 second costal cartilage to the level of the fourth, 
 the margins of the lungs run parallel, or nearly 
 so, close behind the middle of the sternum: con- 
 sequently their thin edges overlap the great vessels 
 and valves at the base of the heart. 
 
 Below the level of the fourth costal cartilage 
 the margins of the lungs diverge, but not in an 
 equal degree. The margin of the right corre- 
 sponds with the direction of the cartilage of the 
 sixth rib: the margin of the left, being notched 
 
THE CHEST. 53 
 
 for the heart, runs behind the cartilage of the 
 fourth. A line drawn perpendicularly from the 
 nipple would find the lung margin about the 
 lowest part of the sixth rib. Laterally, i. e., in 
 the axillary line, the lung margin comes down as 
 low as the eighth rib : posteriorly, i. e., in the 
 dorsal or scapular line, it descends as low as the 
 tenth. 
 
 It should be remembered that, in a deep inspira- 
 tion, the lung margins descend about one inch and 
 a half. 
 
 In children the lungs are separated in front by 
 the thymus gland. Allowance should be made 
 for this. About the approach of puberty the 
 thymus disappears. 
 
 46. Anterior Mediastinum. — The direction 
 of the anterior mediastinum is not straight down 
 the middle of the sternum, but slants a little to 
 the left, owing to the position of the heart. The 
 right pleural sac generally encroaches a little upon 
 the left, behind the middle of the sternum. A 
 needle introduced through the middle of the ster- 
 num opposite the third or the fourth rib would 
 go through the right pleura. 
 
 47. Reflection of Pleura. — The reflection of 
 the pleura from the wall of the chest on to the 
 diaphragm corresponds with a sloping line drawn 
 from the bottom of the sternum over the cartilages 
 
 5* 
 
54 THE BACK. 
 
 of the ribs down to the lower border of the last 
 rib. 
 
 Since the pleura lines the inside of the last rib, 
 a musket ball or other foreign body, loose in the 
 pleural sac, and rolling on the diaphragm, might 
 fall to the lowest part of the sac, which would be 
 between the eleventh and twelfth ribs. The ball 
 might be extracted here. The chest might also 
 be tapped here, but not with a trocar, since a 
 trocar would penetrate both layers of pleura, and 
 go through the diaphragm into the abdomen. 
 
 The operation should be done cautiously, by an 
 incision beginning about two inches from the 
 spine,' on the outer border of the "erector spinse," 
 on a level between the spines of the eleventh and 
 twelfth dorsal vertebras. The intercostal artery 
 will not be injured if the opening be made below 
 the middle of the space, which is very wide. 1 
 
 THE BACK. 
 
 48. Median Furrow. — In a muscular man, a 
 furrow, caused by the prominence of the erector 
 spinae on each side, runs down the middle of the 
 
 1 Special experiments upon this subject were made many 
 years ago by the late Professor Quekett in the work-rooms 
 of the College of Surgeons. 
 
THE BACK. 55 
 
 back. The lower end of the furrow corresponds 
 with the interval between the spine of the last 
 lumbar and that of the first sacral vertebra. [It 
 must be observed that in the skeleton and the 
 body furrows and prominences, hills and hollows, 
 are, as a general rule, reversed. Bony projections 
 in the skeleton, as a rule, are for muscular origins. 
 As, at a little distance from the origin, the mus- 
 cular bellies swell out, such prominences lie at the 
 bottom of depressions. But when long sickness 
 wastes the soft parts, the form of the skeleton 
 reappears, and such bony prominences then be- 
 come the favorite seats of bedsores.] 
 
 49. Spines of Vertebrae. — A little friction 
 with the fingers down the backbone will cause 
 the spines of the vertebrae to be tipped with red, 
 so that they can be easily counted, and any devia- 
 tion from the straight line detected. Still it is 
 worth remembering that the spine of the third 
 dorsal is on a level with the commencement of the 
 spine of the scapula — that the spine of the seventh 
 dorsal is on a level with the inferior angle of the 
 scapula — that the spine of the last dorsal is on a 
 level with the head of the last rib. 
 
 Division of the Trachea. — The division of 
 the trachea is opposite the spine of the third, in 
 some cases the fourth, dorsal vertebra. In front 
 
56 THE BACK. 
 
 this division is on the level of the junction of the 
 first with the second bone of the sternum. 
 
 The root of the spine of the scapula is marked 
 by a slight dimple in the skin. This is on a level 
 with the third intercostal space. A stethoscope 
 placed on the inner side of the dimple would 
 cover the bronchus, more especially the right, 
 since it is nearer to the chest wall. 
 
 Make a man lean forwards, with his arms folded 
 across the chest; this will make prominent the 
 spines of the vertebrae. The lower border of the 
 trapezius will guide you to the spine of the twelfth 
 dorsal vertebra. 
 
 50. The place where the kidney is most ac- 
 cessible to pressure is below the last rib, on the 
 outer edge of the erector spinae. 
 
 51. The highest part of the ilium is about the 
 level of the fourth lumbar spine. The best in- 
 cision for opening the descending colon is in a 
 slightly sloping line beginning at the outer edge 
 of the erector spinas, midway between the crest of 
 the ilium and the last rib, and continued across 
 the flank for three inches or more, according to 
 the amount of subcutaneous fat. [This ilio-costal 
 space varies very much in its vertical measure- 
 ment. I have seen it only a finger's breadth, and 
 again a whole hand's breadth. The line of the 
 colon passes through it vertically about half an 
 
THE BACK. 57 
 
 inch behind the middle of the crest of the ilium 
 (Heath).] 
 
 52. In the pit of the neck we can feel the tra- 
 pezius and the ligamentum nuchse. By pressing 
 deeply we detect the forked and prominent spine 
 of the second cervical vertebra. 
 
 53. The spines of the third, fourth, and fifth 
 cervical vertebrae recede from the surface to per- 
 mit free extension of the neck, and cannot often 
 be felt. But the spines of the sixth and seventh 
 (v. prominens) stand out well. 
 
 , 54. Notice that most of the spines of the dorsal 
 vertebra?, owing to their obliquity, do not tally 
 with the heads of their corresponding ribs. Thus, 
 the spine of the second dorsal corresponds with 
 the head of the third rib ; the spine of the third 
 dorsal with the head of the fourth rib, and so on 
 till we come to the eleventh and twelfth dorsal 
 vertebra?, which do tally with their correspond- 
 ing ribs. All this, however, is best seen in the 
 skeleton. 
 
 55. The spines of the vertebrae may be useful as 
 landmarks indicative of the levels of important 
 organs. I have therefore arranged them in a 
 tabular form, thus : — 
 
58 THE BACK. 
 
 Tabular Plan of Parts opposite the Spines 
 of the Vertebra. 
 
 M 
 
 ■< 
 
 2 J 
 
 S 
 <! 
 
 GO 
 
 K 
 O 
 
 A 
 
 PS 
 
 ■«! 
 
 M 
 
 p 
 A 
 
 7th. Apex of lung : higher in the female than in 
 the male. (30) 
 
 1st. 
 
 2d. 
 
 3d. Aorta reaches spine. Apex of lower lobe of 
 lung. Angle of bifurcation of trachea. (49) 
 
 4th. Aortic arch ends. Upper level of heart. 
 
 5th. 
 
 6th. 
 
 7th. 
 
 8th. Lower level of heart. Central tendon of dia- 
 phragm. 
 
 9th. (Esophagus and vena cava through diaphragm. 
 Upper edge of spleen. 
 
 10th. Lower edge of lung. Liver comes to surface 
 posteriorly. Cardiac orifice of stomach. 
 
 11th. Lower border of spleen. Renal capsule. 
 
 12th. Lowest part of pleura. Aorta through dia- 
 phragm. Pylorus. 
 
 1st. Renal arteries. Pelvis of kidney. (83) 
 
 2d. Termination of spinal cord. Pancreas. Duo- 
 denum just below. Receptaculum chyli. 
 
 3d. Umbilicus. Lower border of kidney. 
 
 4th. Division of aorta. (65) Highest part of ilium. 
 
 5th. 
 
 56. Origins of the Spinal Nerves. — It is 
 
 useful to know opposite what vertebrae the spinal 
 nerves in the different regions arise from the spinal 
 cord. They arise as follows: — 
 
THE BACK. 59 
 
 The origins of the eight cervical nerves corre- 
 spond to the interval between the occiput and the 
 sixth cervical spine. 
 
 The origins of the first six dorsal nerves corre- 
 spond to the interval between the sixth cervical 
 and the fourth dorsal spines. 
 
 The origins of the six lower dorsal nerves cor- . 
 respond to the interval between the fourth and the 
 eleventh dorsal spines. 
 
 The origins of the five lumbar nerves correspond 
 to the interval between the eleventh and twelfth 
 dorsal spines. 
 
 The origins of the five sacral nerves correspond 
 to the spines of the last dorsal and the first lum- 
 bar vertebrae. 
 
Fig. 2. — Diagram and Table showing the Approximate Relation to the 
 Spinal Nerves of the Various Motor, Sensory, and Reflex Functions op 
 the Spinal Cord. {From anatomical and pathological data.) From Grower. 
 
 ■ Neck and Scalp 
 
 - Neck and Shoulder 
 Shoulder 
 
 Hand 
 
 (ulnar lowest) 
 
 Extensors, knee 
 > Adductors 
 
 t-Abductore 
 
 {■wp 
 
 J Extensors{?) 
 ~| Flexors, knee(?) 
 
 ^Muscles of leg 
 moving foot 
 
 ( Perineal and Anal 
 4 ) muscles 
 
 Arm 
 
 Hand 
 
 Front of Thorax 
 , Ensiform area 
 
 Abdomen 
 (Umbilicus 10th) 
 
 ' Buttock, upper 
 ,' part 
 
 Groin and scrotum 
 (front) 
 
 'outer side 
 
 Scapular 
 
 Thigh 
 
 front 
 
 [inner side 
 Leg, inner side 
 "Buttock, lower 
 
 part 
 
 Back of Thigh 
 
 Leg 
 
 and 
 iFoot 
 Perineum 'and 
 
 Anus 
 
 Except 
 
 inner 
 
 part 
 
 ( Skin from coccyx 
 * to anus 
 
 Epigastric 
 
 Abdominal 
 
 Cremasteric 
 \-Knee-jerTc 
 
 Foot-clonus 
 Plantar] 
 
THE BACK. 
 
 61 
 
 57. Movements of the Spine. — The move- 
 ments of which the spine is capable are threefold : 
 1, flexion and extension ; 2, lateral inclination ; 3, 
 torsion. Flexion and extension are freest between 
 the third and sixth cervical vertebrae, between 
 the eleventh dorsal and the second lumbar, and 
 between the last lumbar and the sacrum. This is 
 well marked in severe cases of opisthotonos, where 
 the body is supported on the back of the head and 
 heels. 1 
 
 [Fig. 3. 
 
 Opisthotonos. After Bell.] 
 
 Still better may it be observed when a mounte- 
 bank bends backwards, and touches the ground 
 with his head. 
 
 i See a beautiful illustration of this in Sir C. Bell's "Anat- 
 omy of Expression," p. 160. 
 6 
 
62 THE BACK. 
 
 The lateral movement is freest in the neck and 
 the loins. 
 
 The movement of torsion or rotation round 
 its own axis may be proved by the following 
 experiment: Seated upright, with the back and 
 shoulders well applied against the back of a chair, 
 we can turn the head and neck as far as 70°. 
 Leaning forwards so as to let the dorsal and 
 lumbar vertebras come into play, we can turn 30° 
 more. 
 
 [The atlo-axoid movement amounts to 25° to 
 each side, the remaining cervical vertebrae give 
 45° more, making 70° in the neck ; the dorso- 
 lumbar movement is about 30° ; to which the hips 
 add from 65° to 80°; or a total rotation of 165° 
 to 180°. For purposes of observation, we gain, in 
 addition to this, about 70° more for the eyeball, so 
 that, posteriorly, the field of vision right and left 
 overlaps very largely.} 
 
 58. Position and Motions of Scapula.— There 
 are a few points worthy of observation about the 
 scapula. It covers the ribs from the second to the 
 seventh inclusive. We can feel its superior angle 
 covered by the trapezius. The inferior angle is 
 covered by the latissimus dorsi, which keeps it 
 well applied against the ribs in the strong and 
 athletic; but in weak and consumptive persons the 
 
THE BACK. 63 
 
 lower angles of the scapulas project like wings — 
 hence the term "scapulae alatae." 
 
 A line drawn horizontally from the spine of the 
 sixth dorsal vertebra over the inferior angle of the 
 scapula gives the upper border of the latissimus 
 dorsi. Another line drawn from the root of the 
 spine of the scapula to the spine of the last dorsal 
 vertebra gives the lower border of the trapezius, 
 which stands a little in relief. 
 
 59. The sliding movement of the scapula on 
 the chest can be properly understood only on the 
 living subject. It can move not only upwards 
 and downwards as in shrugging the shoulders — 
 backwards and forwards as in throwing back the 
 shoulders — biit it has a rotatory movement round 
 a movable centre. This rotation is seen while the 
 arm is being raised from the horizontal to the 
 vertical position, and is effected by the co-opera- 
 tion of the trapezius with the serratus magnus. 
 The glenoid cavity is thus made' to look upwards, 
 the inferior angle slides forwards, and is well held 
 under the latissimus dorsi. 
 
 60. For the medical examination of the back, 
 the patient should sit with the arms hanging 
 between his thighs, to lower the scapulas as much 
 as possible. In this position the spine of the 
 scapula corresponds (nearly) with the fissure be- 
 tween the upper and lower lobes of the lung ; the 
 
64 THE ABDOMEN. 
 
 apex of the lower lobe being about the level of the 
 third rib. 
 
 [Usually I prefer to have the arms folded 
 across the chest — obviously the better position for 
 women; and it uncovers the back rather better. 
 
 The remarkable mobility of the scapula is best 
 seen by contrasting this position with the place of 
 the scapula when the shoulders are thrown well 
 back. In this last position the lower angles of the 
 scapulae will be two or three inches apart, while in 
 the former this interval measures from twelve to 
 sixteen inches. Moreover so soon as the arm is 
 lifted from the trunk at an angle of 30° or 40° 
 and long before it reaches the horizontal line the 
 scapula begins to move. This mobility of the 
 scapula explains readily the great range of move- 
 ment, and therefore the usefulness of the arm, in 
 cases of ankylosis of the shoulder joint.] 
 
 TEE ABDOMEN. 
 
 The student is assumed to be familiar with 
 the conventional lines dividing the abdomen into 
 regions. 
 
 61. Abdominal Lines. — The linea alba, or cen- 
 tral line of the abdomen, marks the union of the 
 aponeuroses of the abdominal muscles. It runs 
 from the apex of the ensiform cartilage to the 
 
THE ABDOMEN. 65 
 
 symphysis pubis. As this line is the thinnest and 
 least vascular part of the abdominal wall, we make 
 our incision along it in ovariotomy [Cesarean sec- 
 tion and most other operations on the abdominal 
 and pelvic viscera] and in the high operation of 
 lithotomy; in it, we tap the abdomen in ascites, 
 and the distended bladder in retention of urine. 
 
 The so-called "linea semilunaris," at the outer 
 border of the sheath of the rectus, corresponds 
 with a line, drawn slightly curved (with the con- 
 cavity towards the linea alba), from the lowest 
 part of the seventh rib to the spine of the pubes. 
 This line would be in an adult about three inches 
 from the umbilicus; but in an abdomen distended 
 by dropsy or other cause, the distance is increased 
 in proportion. [These lines of adhesion in the 
 abdominal wall limit extravasations, emphysema, 
 etc., between their layers.] 
 
 It is important to know the position of the 
 " lineas transversse," or . tendinous intersections 
 across the rectus abdominis. There are rarely any 
 below the umbilicus, and generally three above it. 
 The first is about the level of the umbilicus. The 
 second is about four inches higher — that is, about 
 the level of the lowest part of the tenth rib. These 
 are the principal lines, and they divide the upper 
 part of each rectus into two nearly quadrilateral 
 portions, an upper and a lower; of these, those 
 
 6* 
 
66 THE ABDOMEN. 
 
 on the right side are a trifle larger than on the 
 left. We see these muscular squares pretty plainly 
 in some athletic subjects. Much more frequently 
 we see them, too much exaggerated, on canvas 
 and in marble. Artists are apt to exaggerate 
 them and make the front of the belly too much 
 like a chess-board. It is lucky for them that all 
 the world do not see with anatomical eyes. 
 
 A familiarity with the shape and position of 
 these divisions of the rectus is of importance, lest 
 we should, in ignorance, make a mistake in our 
 diagnosis. A spasmodic contraction of one of these 
 divisions, particularly the upper, or a collection 
 of matter within its sheath, has been frequently 
 mistaken for deep-seated abdominal disease. 
 
 In the erect position, the anterior superior 
 spines of the ilia are a little below the level of the 
 promontory of the sacrum. The bifurcation of 
 the aorta is on about the level of the highest part 
 of the crest of the ilium. 
 
 62. Umbilicus. — The umbilicus is not midway 
 between the ensiform cartilage and the pubes, but 
 rather nearer to the pubes. In all cases it is situ- 
 ated above the centre of a man's height. It is a 
 vulgar error to say that when a man lies with 
 legs and arms outstretched, and a circle is drawn 
 round him, the umbilicus lies in the centre of it. 
 
THE ABDOMEN. 67 
 
 This central point is in most persons just above 
 the pubes. 
 
 [From the vertex to the umbilicus, the whole 
 height being taken as the unit of measurement, is 
 .550 at birth, i. e., the mid-point is above the navel. 
 At two years it is at the navel, and gradually falls 
 as the legs grow longer, until, at thirty, the mid- 
 point is just below the pubes in men (half an inch) 
 and just above it in women. Moreover, while .at 
 three to five years of age the whole height is equal 
 to the distance between the outstretched finger- 
 tips, before that age it is somewhat greater, and in 
 adult life is much less.J 
 
 In very corpulent persons two deep transverse 
 furrows run across the abdomen. One runs across 
 the navel and completely conceals it. The other is 
 lower down, just above the fat of the pubes. In 
 tapping the bladder above the pubes in such a 
 case, the trocar should be introduced where this 
 line intersects the linea alba. 
 
 Although the position of the umbilicus varies 
 a little in different persons, as the abdomen is 
 unusually protuberant or the reverse, still, as a 
 general rule, it is placed about the level of the 
 body of the third lumbar vertebra. Now, since 
 the aorta divides a little below the middle of the 
 fourth lumbar, it follows that the best place to 
 apply pressure on this great vessel is one inch be- 
 
68 THE ABDOMBJST. 
 
 low the umbilicus, and slightly to the left of it (65). 
 That the aorta can, under favorable circumstances, 
 be compressed under chloroform sufficiently to 
 cure an aneurism below it, is proved by recorded 
 cases, and by none more effectually than by a case 
 related in the second volume of the "Eeports of 
 St. Bartholomew's Hospital." 
 
 It may be asked, why not apply pressure on the 
 aorta above the umbilicus? The answer is, that 
 the aorta above the umbilicus is farther from the 
 surface, and is, moreover, covered by important 
 structures upon which pressure would be danger- 
 ous. 
 
 [The umbilicus is a point of fusion of all. the 
 tissues of the abdominal wall. Hence, it becomes 
 a most valuable guide as to our position when 
 attacking tumors, etc., in the abdomen. Attempt 
 to sweep the finger under the umbilicus: if 
 through the abdominal wall and upon the tumor, 
 the finger will meet with no obstacle other than 
 adhesions, which can be destroyed ; if, on the con- 
 trary, still in the thickness of the abdominal wall 
 (and it is not always easy to distinguish this in any 
 other way), the finger will be absolutely arrested 
 at the navel, and no force will carry it further. 
 
 The umbilicus being the remains of an opening 
 into' the belly, when stretched by ascites, as the 
 fluid" can insinuate itself everywhere, it usually 
 
THE ABDOMEN. 69 
 
 bulges out considerably ; but in tumors this cannot 
 be the case. 
 
 Again, it affords passage to the contents of the 
 belly not uncommonly, and so we have umbilical 
 hernise; and sometimes ovarian fluids, pus in peri- 
 tonitis, and entozoa escape here. 
 
 It is also an important point for measurements, 
 sometimes used in fractures and dislocations of the 
 hip and femur, and in fractures of the anterior 
 superior spines, and always in measuring the size 
 of tumors from it to the ensiform, the pubes, and 
 the two iliac spines. 
 
 The umbilicus is always much deeper and wider 
 in women than in men.] 
 
 63. Parts behind Linea Alba. — Let us next 
 consider what viscera lie immediately behind the 
 linea alba. For two or three fingers' breadth 
 below the ensiform cartilage there is the left lobe 
 of the liver, which here crosses the middle line. 
 Below the edge of the liver comes the stomach, 
 more or less in contact with the linea alba, 
 according to its degree of distension. In extreme 
 distension the stomach pushes everything out of 
 the way, and occupies all the room between the 
 liver and the umbilicus. When empty and con- 
 tracted, it retreats behind the liver, and lies flat in 
 front of the pancreas at the back of the abdomen; 
 thus giving rise to the hollow termed the "pit of 
 
70 THE ABDOMEN. 
 
 the stomach." But as the stomach distends, it 
 makes a considerable fulness where there was a 
 pit. The middle of the transverse colon lies above 
 the umbilicus, occupying space (vertically two or 
 three inches) according to its distension. Behind 
 and below the umbilicus, supposing the bladder 
 contracted, are the small intestines, covered by the 
 great omentum. 
 
 64. Peritoneum. — The peritoneum is in con- 
 tact with the linea alba all the way down to the 
 pubes, when the bladder is empty. But when 
 the bladder distends, it raises the peritoneum 
 from the middle line above the pubes; so that 
 with a bladder distended half-way up to the 
 umbilicus, there is a space of nearly two inches 
 above the symphysis where the bladder may be 
 tapped without risk of injury to the peritoneum. 
 For the same reason, we have space sufficient for 
 the successful performance of the high operation 
 for stone. This fact in anatomy must have been 
 well understood by Jean de Dot, the smith at 
 Amsterdam, who, in the seventeenth century, cut 
 himself in the linea alba above the pubes, and 
 took out of his bladder a stone as large as a hen's 
 egg. The stone, the knife, and the portrait of the 
 operator, may be seen to this day in the museum 
 at Leyden. 
 
THE ABDOMEN.' 71 
 
 65. Division of Aorta. — The aorta generally 
 divides at a point one inch and a half below the 
 umbilicus. A more reliable guide to this division 
 than the umbilicus, is a point (a very little to the 
 left) of the middle line about the level of the 
 highest part of the crest of the ilium. A line 
 drawn with a slight curve outwards from this 
 point to the groin, where the pulsation of the 
 common femoral can be distinctly felt (rather 
 nearer to the pubes than the ilium), gives the 
 direction of the common iliac and external iliac 
 arteries. About the first two inches of this line 
 belong to the common iliac, the remainder to the 
 external. Slight pressure readily detects the pulsa- 
 tion of the external iliac above "Poupart's liga- 
 ment." 
 
 As a rule, the length of the common iliac is 
 about two inches, but it should be remembered 
 there are frequent deviations. It may be between 
 three-quarters of an inch and three inches and a 
 half long. These varieties may arise either from 
 a high division of the aorta, or a low division of 
 the common iliac, or both. It is impossible to 
 ascertain during life what is its length in a given 
 instance, for there is no necessary relation between 
 its length and the height of the stature. It is 
 often short in tall men, and vice versa. Anatomists 
 generally describe the right as a trifle longer than 
 
72 THE ABDOMEN. 
 
 the left ; but their average length is pretty nearly 
 the same. 
 
 66. Mr. Abernethy, who in the year 1796 first 
 put a ligature round the external iliac, made his 
 incision in the line of the artery. But the easiest 
 and safest way to reach the vessel is by an inci- 
 sion (recommended in the first instance by Sir 
 Astley- Cooper, and now generally adopted) be- 
 ginning just on the inner side of the artery, a 
 little above Poupart's ligament, and continued 
 upwards and outwards a little beyond the spine 
 of the ilium. The same incision extended farther 
 in the same direction would reach the common 
 iliac. 
 
 67. Bony Prominences. — The anterior supe- 
 rior spine of the ilium, the spine of the pubes, 
 and the line of Poupart's ligament, are landmarks 
 with which every surgeon should be thoroughly 
 familiar. 
 
 68. Spine of Ilium. — The spine of the ilium 
 is the spot from which we measure the length of 
 the lower extremity. It is a valuable landmark 
 in determining the nature of injuries to the pelvis 
 and the hip. The thumb easily feels the spine, 
 even in fat persons. Its position with regard to 
 the trochanter major should be carefully exam- 
 ined. The best way to do this is to place the 
 thumbs firmly on the opposite spines, and to grasp 
 
THE ABDOMEN. 73 
 
 the trochanters with the fingers. Any abnormal 
 position on one side is thus easily ascertained with 
 the sound side as a guide. 
 
 [In all such measurements it is of the utmost 
 importance that a line joining the two spines 
 should be at right angles to the axis of the body, 
 or the measurements cannot fail to be inaccurate. 
 The spines also are so open to error, as points 
 of measurement (for we scarcely ever can get 
 precisely corresponding points on the two sides), 
 that I have long since adopted the following 
 method. See that the body is straight and the 
 pelvis (i. e., the line between the two spines) at 
 right angles to it. Let an assistant hold the head 
 immovably in the middle line. Let the patient 
 seize the tape-line with his teeth. Measure one 
 side, say to the inner malleolus. Then measure 
 the other side, never by keeping the measure of 
 the first side and simply passing across to the 
 other leg, but by an independent measurement. 
 The last precaution eliminates our pre-conceptions. 
 The chief source of error here — which exists in 
 all methods of measurement — is the position of 
 the pelvis. The advantage is in one and the same 
 starting-point, and that in the median line. 
 
 It must not be forgotten, however, that there is 
 not infrequently a normal difference in the length 
 of the two legs.] 
 7 
 
74 THE ABDOMEN. 
 
 69. Spine of Fubes. — The spine of the pubes 
 is the best guide to the external abdominal ring. 
 It cannot easily be felt by placing the finger 
 directly over it, since it is generally covered by 
 fat. To feel it distinctly, we should push up the 
 skin of the scrotum and get beneath the subcu- 
 taneous fat. If there be any difficulty in finding 
 it, abduct the thigh, and the tense tendon of the 
 adductor longus will lead up to it. 
 
 The position of the spine of the pubes is ap- 
 pealed to as a means of diagnosis in doubt between 
 inguinal and femoral hernia. The spine lies on 
 the outer side of the neck of an inguinal hernia, 
 on the inner side of the neck of a femoral. 
 
 The spine of the pubes is nearly on the same 
 horizontal line as the upper part of the trochanter 
 major. In this line, about one full inch external 
 to the spine, is the femoral ring. Here is the seat 
 of stricture in a femoral hernia. 
 
 70. Poupart's Ligament, or Crural Arch. — 
 The line of Poupart's ligament (crural arch) is in 
 most persons indicated by a slight crescent-like 
 furrow along the skin. It corresponds with a 
 line drawn not straight, but with a gentle curve 
 downwards from the spine of the ilium to the 
 spine of the pubes. With the help of the preced- 
 ing landmarks it is easy to find the exact position 
 
THE ABDOMEN. 75 
 
 of the external and internal abdominal rings, and 
 the direction of the inguinal canal. 
 
 [In hernia, it is always treacherous to trust 
 the eye. We must define exactly the iliac and 
 pubic spines by the fingers, and draw the line of 
 Poupart's ligament between them. It lies at the 
 uppermost border of the "groin," or groove be- 
 tween the abdomen and the thigh; and unless we 
 so define its two ends we are very apt to get it, 
 and especially the inner and most important end, 
 too low, and so mistake the variety of hernia we 
 have to deal with. 
 
 Moreover, an examination of the external abdo- 
 minal ring will disclose its condition and show 
 whether the hernia is, or is not, inguinal. Un- 
 fortunately, in women, in whom femoral hernia 
 is most frequent, this examination is least satisfac- 
 tory. The exact location of the line of Poupart's 
 ligament is, therefore, in women doubly important.] 
 
 71. Abdominal Kings. — The external abdomi- 
 nal ring is situated immediately above the spine 
 of the pubes. It is an oval opening with the long 
 axis directed obliquely downwards and inwards. 
 Though its size varies a little in different persons, 
 yet as a rule it will admit the end of the little 
 finger, so that we can tell by examination whether 
 it be free or otherwise. To ascertain this, the best 
 way is to push up the thin skin of the scrotum 
 
76 THE ABDOMEN. 
 
 before the finger ; then, by tracking the spermatic 
 cord, the finger readily glides over the crest of the 
 pubes and feels the sharp margins of the ring. 
 
 The position of the internal ring is about 
 midway between the spine of the ilium and the 
 symphysis of the pubes, and about two-thirds of 
 an inch above Poupart's ligament. 
 
 72. Inguinal Canal. — The position of the exter- 
 nal and internal abdominal rings being ascertained, 
 it is plain that the direction of the inguinal canal 
 must be obliquely downwards and inwards, and 
 that its length in a well-formed adult male is from 
 one and a half to two inches, according as we in- 
 clude the openings or not. In very young children 
 the canal is much shorter and less oblique, the 
 inner ring being behind the outer. With the 
 growth of the pelvis in its transverse direction, the 
 anterior spines of the ilia become farther apart, and 
 thus draw the internal ring more and more away 
 from (i. e., to the outer side of) the external. 
 
 73. Spermatic Cord. — The spermatic cord can 
 be felt as it emerges through the external ring, 
 and its course can be tracked into the scrotum. 
 The vas deferens can be distinctly felt at the back 
 of the cord, and separated from its other compo- 
 nent parts. 
 
 74. Epigastric Artery. — The direction of the 
 deep epigastric artery corresponds with a line 
 
THE ABDOMEN. 77 
 
 drawn from the inner border of the internal ring 
 up the middle of the rectus muscle towards the 
 chest. [It lies to the inside of oblique, and to the 
 outside of direct inguinal hernia.] 
 
 In thin persons the absorbent glands which lie 
 along Poupart's ligament can be distinctly felt. 
 They are usually oval, with their long axes 
 parallel to the line of the ligament. 
 
 75. Abdominal Viscera. — Now let us see how 
 far we can make out externally the position and 
 size of the abdominal viscera. 
 
 To make this examination with anything like 
 success, it is desirable to relax the abdominal 
 muscles. The man should be on his back, the 
 head, shoulders, and thorax being well raised, to 
 relax the recti muscles ; and the thighs bent on 
 the abdomen, to relax the several fascias attached 
 to the crural arch. To induce complete relaxa- 
 tion, where a very careful examination is desired 
 [ether or] chloroform should be given. 
 
 In manipulating the abdomen we should not use 
 the tips of the fingers. This is sure to excite the 
 contraction of the muscles. The fiat hand should 
 be gently pressed upon it, and with an undulating 
 movement. 
 
 76. It is well to bear in mind that the central 
 tendon of the diaphragm is about the level of the 
 lower end of the sternum at its junction with the 
 
 7* 
 
78 THE ABDOMEN. 
 
 seventh costal cartilage ; that the right half of the 
 diaphragm rises to about the level of the fifth rib — 
 that is, about an inch below the nipple ; that the 
 left half does not rise quite so high. In tranquil 
 breathing the diaphragm descends about half an 
 inch. 
 
 The position of the abdominal viscera varies, to 
 a certain extent, in different persons. In some of 
 them, especially the stomach, their position varies 
 in the same person at different times. 
 
 Let us take, first, the largest of the abdominal 
 viscera — the liver. 
 
 77. Liver. — The liver lies under the right hypo- 
 chondrium, and passes across the middle line over 
 the «tomach into the left hypochondrium, gene- 
 rally speaking, as far as the left mammary line. 
 The extent to which it can be felt below the 
 edges of the ribs depends upon whether it is 
 enlarged or not, as well as upon its texture, and 
 also upon the amount of flatus in the stomach 
 and intestines. As a rule, in health its lower thin 
 border projects about half an inch below the costal 
 cartilages, and can be felt moving up and down 
 with the action of the diaphragm ; but it requires 
 an educated hand to feel it. An uneducated hand 
 would miss it altogether. That part of it, how- 
 ever, which crosses the middle line below the 
 ensiform cartilage is much more accessible to the 
 
THE ABDOMEN. 79 
 
 feel; here it lies immediately behind- the linea 
 alba, and in front of the stomach, nearly half way 
 down to the umbilicus. Here, therefore, is the 
 best place to feel whether the liver be enlarged or 
 pushed down lower than it ought to be. If it be 
 much enlarged and much lower, even the most 
 untutored hand could detect its edge. 
 
 Even if the edge of the liver be felt very much 
 lower than its normal below the ribs, it does not 
 necessarily follow that the liver is enlarged, since 
 it may be. pressed down by other causes — for 
 instance, the habit of wearing tight stays. 
 
 To what height does the liver ascend? This 
 can only be ascertained by careful percussion of 
 the chest wall. The highest part of its convexity 
 on the right side is about one inch below the 
 nipple, or nearly on a level with the external and 
 inferior angle of the pectoralis major. Posteriorly 
 the liver comes to the surface below the base of 
 the right lung, above the level of the tenth dorsal 
 spine. 
 
 Eoughly speaking, the upper border of the liver 
 corresponds with the level of the tendinous centre 
 of the diaphragm ; that is, the level of the lower 
 end of the sternum. Thus a needle thrust into 
 the right side, between the sixth and seventh ribs, 
 would traverse the lung, and then go through the 
 diaphragm into the liver. 
 
80 THE ABDOMEN. 
 
 78. Gall Bladder. — The gall bladder, or rather 
 the fundus of it, is situated, but cannot be felt, 
 just below the edge of the liver about the ninth 
 costal cartilage, outside the edge of the right 
 rectus muscle. 
 
 79. Stomach. — The stomach varies in size more 
 than any [other] organ in the body. When empty 
 and contracted (63) it lies at the back of the 
 abdomen, overlapped by the left lobe of the liver, 
 and in front of the pancreas. When very full, it 
 turns on its axis and swells up towards the front, 
 coming close behind the wall of the abdomen, 
 occupying most of the left hypochondriutn and epi- 
 gastrium, displacing the other contiguous organs, 
 pushing in every direction, and often interfering 
 with the action of the heart and left lung. Hence 
 the palpitation and distressing heart-symptoms in 
 indigestion and flatulence. 
 
 The cardiac orifice of the stomach lies to the 
 left of the middle line, just below the level of the 
 junction of the seventh costal cartilage with the 
 sternum. 
 
 80. Pylorus. — The pylorus lies under the liver, 
 on the right side, near the end of the cartilage of 
 the eighth rib; but it cannot be felt unless occa^ 
 sionally when enlarged and hardened by disease. 
 
 81. Spleen. — The spleen, if it be healthy, can- 
 not be felt, so completely is it sheltered by the 
 
THE ABDOMEN. 81 
 
 ribs. It lies on the left side, connected to the 
 great end of the stomach, beneath the ninth, tenth, 
 and eleventh ribs, between the axillary lines — lines 
 drawn vertically downwards from the anterior and 
 posterior margins of the axilla. Its upper edge 
 is on a level with the spine of the ninth dorsal 
 vertebra, its lower with the spine of the eleventh. 
 
 Its position and size, therefore, in health can 
 only be ascertained, and not very accurately, by 
 the extent of dulness on percussion. The greatest 
 amount of dulness would be over the tenth and 
 eleventh ribs; above this the thin edge of the 
 lung would intervene between the spleen and the 
 abdominal wall. If, therefore, the spleen can be 
 distinctly felt below the ribs, it must be enlarged. 
 In proportion to its enlargement, so can its lower 
 rounded border be detected below the tenth and 
 eleventh ribs, especially when forced downwards 
 by a deep inspiration. 1 
 
 82. Pancreas. — The pancreas lies transversely 
 behind the stomach, and crosses the aorta and the 
 spine about the junction of the first and second 
 lumbar vertebrae. The proper place to feel for it, 
 therefore, would be in the linea alba about two or 
 three inches above the umbilicus. Is it percepti- 
 
 1 See some good observations on the position of the enlarged 
 spleen, by SirW. Jenner, "Brit. Med. Journ.," Jan. 16, 1869. 
 
82 THE ABDOMEN. 
 
 ble to the touch ? — only under very deep pressure, 
 and very favorable circumstances, such as an 
 emaciated and empty, abdomen. It is worth 
 remembering that it may be felt under such con- 
 ditions. The pancreas of normal size, in thin 
 persons, has been mistaken for disease — disease of 
 the transverse arch of the colon, or aneurism of 
 the abdominal aorta. 
 
 83. Kidney.— The kidney lies at the back of 
 the abdomen, on the quadratus lumborum and 
 psoas muscles, opposite the two lower dorsal and 
 two upper lumbar spines. The right, owing to 
 the size of the liver, is a trifle — say, three-quarters 
 of an inch — lower than the left. The pelvis of the 
 kidney is on about the level of the spine of the 
 first lumbar vertebra: the upper border is on 
 about the level of the space between the eleventh 
 and twelfth dorsal spines ; the lower border comes 
 as low as the third lumbar spine. During a deep 
 inspiration both kidneys are depressed by the 
 diaphragm nearly half an inch. 
 
 Can we feel the normal kidney? The only 
 place where it is accessible to pressure is just 
 below the last rib, on the outer edge of the 
 "erector spinae." I say accessible to pressure, for 
 I have never succeeded in satisfying myself that 
 I have distinctly felt its rounded lower border 
 in the living subject, nor even in the dead, with 
 
THE ABDOMEN. 83 
 
 the advantage of flaccid abdominal walls and the 
 opportunity of making hard pressure with both 
 hands, placed simultaneously, one in front of the 
 abdomen, the other on the back. For these reasons, 
 although we can easily ascertain its degree of 
 tenderness, we cannot actually feel it unless it be 
 considerably enlarged. 
 
 We must be on our guard not to mistake for 
 the kidney an enlarged liver or spleen, or an 
 accumulation of feces in the lumbar part of the 
 colon. [As Sir William Jenner has pointed out, 
 the anterior border of the spleen is sharp, and 
 may be notched, in both of which respects it differs 
 from the kidney, even when enlarged.] 
 
 84. Large Intestine. — Let us now trace the 
 large intestine and see where it is accessible to 
 pressure. The "cascum," or "caput coli," and the 
 ileo-csecal valve lie in the right iliac fossa. The 
 ascending colon runs up the right lumbar region 
 over the right kidney. [For its line, see § 51. J 
 The transverse colon crosses the abdomen two or 
 three inches above the umbilicus. The descending 
 colon lies in the left lumbar region in front of the 
 left kidney. The sigmoid flexure occupies the left 
 iliac fossa. 
 
 Throughout this tortuous course, except at the 
 hepatic and splenic flexures, the colon is accessible 
 to pressure, and we could, under favorable circum- 
 
84 THE ABDOMEN. 
 
 stances, detect hardened feces in it. In a case 
 which occurred in St. Bartholomew's Hospital, a 
 collection of feces in the transverse colon formed a 
 distinct tumor in the abdomen. All the symptoms 
 yielded to large and repeated injections of olive 
 oil. In another case an accumulation of fecal 
 matter in the sigmoid flexure during life was 
 mistaken for a malignant disease. 
 
 85. Colotomy. — The operation of opening the 
 colon (colotomy) may be done in the right or left 
 loin, below the kidney, in that part of the colon 
 not covered by peritoneum. 
 
 The landmarks of the operation are: — (1) The 
 last rib, of which feel the sloping edge; (2) the 
 crest of the ilium ; (3) the outer border of the 
 "erector spinas." The incision should be about 
 three inches long, midway between the rib and 
 the ilium. It should begin at the outer border of 
 the "erector spinse," and should slope downwards 
 and outwards in the direction of the rib. The 
 edge of the "quadratus lumborum," which is the 
 guide to the colon, is about one inch external to 
 the edge of the "erector spinse," or three full 
 inches from the lumbar spines. The line of the 
 gut is vertical, and runs for a good two inches 
 between the lower border of the kidney and the 
 iliac crest .on the left side; rather less on the 
 right. 
 
THE ABDOMEN. 85 
 
 Small Intestines.— All the room below the 
 umbilicus is occupied by the small intestines. 
 The coils of the jejunum lie nearer to the umbili- 
 cus (one reason of the great fatality of umbilical 
 hernise). Those of the ilium are lower down. [As 
 the patches of Peyer involved in typhoid fever lie 
 chiefly near the lower end of the ilium, which 
 terminates at the ilio-cascal valve, this will account 
 for the tenderness found here. 
 
 It must be remembered that in ascites, while 
 the fluid will gravitate to the lowest point in the 
 abdominal cavity, the intestines, being filled with 
 air and tethered to the spine by the mesentery, 
 will float on top. Hence the value of "postural 
 diagnosis," i. e., percussion in different postures, on 
 the right side, the left side, the back, etc. In any 
 solid or encysted tumor this cannot hold good.] 
 
 On the right side, a little below the ninth rib, 
 the colon lies close to the gall bladder, and is, 
 after death, sometimes tinged with bile. Pos- 
 teriorly, this part of the colon is in contact with 
 the kidney and duodenum. 
 
 86. Bladder. — When the bladder distends, it 
 gradually rises out of the pelvis into the abdomen, 
 pushes the small intestines out of the way [lifts 
 the peritoneum off from its anterior wall], and 
 forms a swelling above the pubes, reaching in 
 some instances up to the navel. The outline of 
 8 
 
86 THE PERINEUM. 
 
 this swelling is perceptible to the hand as well as 
 to percussion. More than this, fluctuation can be 
 felt through the distended bladder by tapping on 
 it in front with the fingers of one hand, while the 
 forefinger of the other passed up the rectum feels 
 the bottom of the "trigone." 
 
 THE PERINEUM. 
 
 The body is supposed to be placed in the usual 
 position for lithotomy. 
 
 87. Bony Framework. — We can readily feel 
 the osseous and ligamentous boundaries of the 
 perineum ; namely, the rami of the pubes and 
 ischia, the tuberosities of the ischia, the great 
 sacro-ischiatic ligaments, and the apex of the 
 coccyx. This framework forms a lozenge- shaped 
 space. If we draw an imaginary line across it 
 from the front of one tuber ischii to the other, we 
 divide this space into an anterior and a posterior 
 triangle. The anterior is nearly equilateral, and, 
 in a well-formed pelvis, its sides are from three 
 to three and a half inches long. It is called the 
 urethral triangle. The posterior, containing the 
 greater part of the anus and the ischio-rectal fossa 
 on each side, is called the anal triangle. 
 
 88. Raphe. — A slight central ridge of skin, 
 called the "rapheV runs from the anus up the 
 
THE PERINEUM. 87 
 
 perineum, scrotum, and penis. This "raphe"," or 
 middle line of the perineum, is the "line of safety" 
 in making incisions to let out matter or effused 
 urine, or to divide a stricture. 
 
 89. Central point of Perineum.— It is very 
 important to know that a point of the raphe" 
 about midway between the scrotum (where it 
 joins the perineum) and the centre of the anus, 
 corresponds with the so-called " central tendon" 
 where the perineal muscles meet. The bulb of 
 the urethra lies above this point, and never, at 
 any age, comes lower down. The artery of the 
 bulb, too, never runs below this level. Therefore 
 the incision in lithotomy should never commence 
 above it. A knife introduced at this point, and 
 pushed backwards with a very slight inclination 
 upwards, would enter the membranous part of 
 the urethra just in front of the prostate gland; 
 pushed still farther it would enter the neck of 
 the bladder. This point, then, is a very good 
 landmark to the urethra in lithotomy, or, indeed, 
 in any operations on the perineum. 
 
 The incision in the lateral operation of litho- 
 tomy, beginning below the point indicated, should 
 be carried downwards and outwards between the 
 anus and the tuberosity of the ischium, a little 
 nearer to the tuberosity than the anus [because 
 the rectum is wider than the anus]. The lower 
 
88 THE PERINEUM. 
 
 end of the incision should reach a point just below 
 the [level of the] anus. 
 
 90. Triangular Ligament. — In a thin peri- 
 neum, we can feel the lower border of the deep 
 perineal fascia or the "so-called" triangular liga- 
 ment of the urethra. The urethra passes through 
 it about one inch below the lower part of the sym- 
 physis pubis, and about three-quarters of an inch 
 higher than the central tendon of the perineum. 
 It is important to bear in mind these landmarks 
 in introducing a catheter. If the catheter be 
 depressed too soon, its passage will be resisted by 
 the triangular ligament ; if too late, it will be 
 likely to make a false passage by running through 
 the bulb. 
 
 91. Anus. — One of the most important land- 
 marks which guide a surgeon in his operation 
 about the anus, is a white line 1 at the junction 
 of the skin and mucous membrane. It is easily 
 recognized and is of especial interest, because it 
 marks with great precision the linear interval 
 between the external and internal sphincter mus- 
 cles. From this line the internal sphincter extends 
 upwards, beneath the mucous membrane, for about 
 an inch, becoming gradually more and more at- 
 tenuated. 
 
 • "Lectures on Rest and Pain," by John Hilton, F.R.S. 
 London, 18G3, p. 280. 
 
THE PERINEUM. 89 
 
 The wrinkled appearance of the anus is caused 
 by the contraction of the external sphincter. At 
 the bottom of these cutaneous folds, especially 
 towards the coccyx, we look for "fissure of the 
 anus." 
 
 92. Landmarks in the Rectum. — Many valu- 
 able landmarks may be felt by introducing the 
 finger into the rectum, with a catheter at the 
 same time in the urethra. The principal of these 
 landmarks are the following : — 
 
 a. The finger can feel the extent and powerful 
 grasp of the internal sphincter for about one inch 
 up the bowel. (91) 
 
 b. Urethra. — Through the front wall of the 
 bowel it can most distinctly feel the track of the 
 membranous part of the urethra, exactly in the 
 middle line. This is very important, because you 
 can ascertain with precision whether the catheter 
 has deviated from the proper track. 
 
 c Prostate Gland. — About an inch and a half 
 or two inches from the anus, the finger comes 
 upon the prostate gland. The gland lies in close 
 contact with the bowel, and can be detected by its 
 shape and hard feel. The finger, moved from side 
 to side, can examine the size of its lateral lobes, 
 their consistence and sensibility. 
 
 d. The finger, introduced still farther, can reach 
 beyond the prostate, as far as the apex of the tri- 
 
90 THE PERINEUM. 
 
 gone of the bladder. More than this, it can feel 
 the angle between the "ductus communes ejacu- 
 latorii," which forms the apex of the trigone. 
 This is the precise spot where the distended 
 bladder should be punctured through the rectum. 
 The more distended the bladder, the easier can 
 this spot be felt. Fluctuation is at once detected 
 by a gentle tap on the bladder above the pubes 
 (86). The trocar must be thrust in the direction 
 of the axis of the distended bladder; that is, 
 roughly speaking, in a line drawn from the anus 
 through the pelvis to the umbilicus. 
 
 e. The fold of peritoneum, called the recto- vesi- 
 cal pouch, is about four inches from the anus, 
 therefore it is not within reach of the finger ; and 
 we run no risk of wounding it in tapping the 
 bladder if the trocar be introduced near the 
 angle of the trigone. [Roberts has measured the 
 distance of the recto-vesical (or recto-vaginal) 
 pouch from the anus, both in situ and after 
 removal from the body. The distance was one 
 and a quarter to two inches in situ, and from 
 three and a half to four and a quarter inches after 
 removal.] 
 
 /. The finger can feel one of the ridges or folds 
 of mucous membrane which are situated at the 
 lower part of the rectum. This fold projects from 
 the side, and sometimes from the upper part of the 
 
THE PERINEUM; 91 
 
 rectum, near the prostate. When thickened or 
 ulcerated, this fold occasions great pain in defeca- 
 tion ; and great relief is afforded by its division. 
 
 g. Lastly, the finger can examine the condition 
 of the spaces filled with fat on either side of the 
 rectum, called the ischio-rectal fossae, with a view 
 to ascertain the existence of deep-seated collections 
 of matter, or the internal communications of 
 fistulas. ' 
 
 [It is often important to instruct mothers and 
 nurses as to the difference in the direction of the 
 anus and that of the rectum, in order that they 
 may introduce the nozzle of an enema syringe 
 without pain. The rectum, after following the 
 curve of the sacrum and coccyx, suddenly bends 
 backward and terminates in the anus. The axis 
 of the anal opening is in the direction of the 
 navel for about an inch, and when the finger, the 
 syringe-nozzle, or other instrument, has been intro- 
 duced thus far, it may then be swept around so as 
 to point to the small of the back and be pushed 
 in as far as necessary. 
 
 It is useful to remember that in women the 
 posterior wall of the vagina can be everted from 
 the rectum, and, vice versa, the rectum from the 
 vagina, and so be carefully examined without a 
 speculum.] 
 
92 THE PERINEUM. 
 
 Introduction of Catheters.— In the introduc- 
 tion of catheters the following are good rules. 
 Keep the point of the instrument well applied 
 against the upper surface of the urethra; — depress 
 the handle at the right moment (90); — keep the 
 umbilicus in view ; — in cases of difficulty feel the 
 urethra through the rectum, to ascertain whether 
 the instrument be in the right direction. Atten- 
 tion to these rules diminishes the risk of making 
 a false passage, an injury which under great deli- 
 cacy in manipulation ought never to happen. 
 
 Urethra in the Child. — In children the mem- 
 branous part of the urethra is, relatively speaking, 
 very long, owing to the smallness of the prostate. 
 It is also more sharply curved, because the bladder 
 in children is more in the abdomen than in the 
 pelvis. It is, moreover, composed of thin and 
 delicate walls. The greatest gentleness, therefore, 
 should be used in passing a catheter; else the 
 instrument is likely to pass through the coats 
 and make a false passage. Hence the advantage 
 of being able to ascertain through the rectum 
 whether the instrument be in the right track and 
 moving freely in the bladder, which can also be 
 easily felt in children. 
 
THE THIGH. 93 
 
 THE THIGH. 
 
 93. Poupart's Ligament, or Crural Arch.— 
 
 Mark the anterior superior spine of the ilium, the 
 spine of the pubes, and define the line of "Pou- 
 part's ligament" which extends between them. 
 This line is one of our guides in the diagnosis of 
 inguinal and femoral 'hernias. If the bulk of the 
 tumor be above the line, the hernia is probably- 
 inguinal ; if below it, femoral. The line is not a 
 straight one drawn from the spine of the ilium to 
 the spine of the pubes, but slightly curved, with 
 the convexity downwards, owing to its close con- 
 nection with the fascia lata of the thigh. In many- 
 persons it can be distinctly felt ; in nearly all its 
 precise course is indicated by a slight furrow in 
 the skin. 
 
 For the points about the spine of the pubes, 
 refer to paragraph 69. 
 
 94. Furrow at the Bend of the Thigh.— 
 When the thigh is even slightly bent, there 
 appears a second furrow in the skin below that 
 at the crural arch. This second furrow begins at 
 the angle between the scrotum and the thigh, 
 passes outwards, and is gradually lost between the 
 top of the trochanter and the anterior superior 
 spine of the ilium. It runs right across the. front 
 of the capsule of the hip-joint. For this reason it 
 
94 THE THIGH. 
 
 is a valuable landmark in amputation at the hip- 
 joint. The point of the knife should be introduced 
 externally where the furrow begins, should run 
 precisely along the line of it, and come out where 
 it ends; so that the capsule of the joint may be 
 opened with the first thrust. In suspected disease 
 of the hip, pressure made in this line, just below 
 the spine of the ilium, will tell us if .the joint be 
 tender. Effusion into the joint obliterates all 
 trace of the furrow, and makes a fulness when 
 contrasted with the opposite groin. 
 
 95. Saphenous Opening. — In most persons 
 there is a natural depression over the saphenous 
 opening in the fascia lata, where the saphena vein 
 joins the femoral. The position of this opening is 
 just below the inner third of Poupart's ligament, 
 and about an inch and a half external to the spine 
 of the pubes. This is the place where the swell- 
 ing of a femoral hernia first appears : therefore it 
 ought to be carefully examined in cases of doubt. 
 
 96. Femoral Ring.— The position of the fe- 
 moral ring, through which the hernia escapes 
 from the abdomen, is, on a deeper plane, about 
 half an inch higher than the saphenous opening, 
 and immediately under Poupart's ligament. As 
 the plane of the ring is vertical in the supine 
 position of the body, the way in which we should 
 try to reduce a femoral hernia is by pressure, 
 
THE THIGH. 95 
 
 applied first in a downward direction, afterwards 
 in an upward. The intestine protruded has to 
 pass back under a sharp edge of fascia, namely, 
 the upper horn of the saphenous opening (known 
 as Hey's ligament). At the same time we bend the 
 thigh, to relax the fascia as much as possible. 
 
 A good way to find the seat of the femoral ring 
 with precision is the following : — Feel for the pul- 
 sation of the femoral artery on the pubes; allow 
 half an inch (on the inner side) for the femoral 
 vein ; then comes the femoral ring. 
 
 In performing the operation for the relief of the 
 stricture in femoral hernia the incision through 
 the skin should be about an inch and a half ex- 
 ternal to the spine of the pubes. Its direction 
 should be vertical, and its middle should be just 
 over the femoral ring. 
 
 97. Lymphatic Glands in the Groin.— The 
 cluster of inguinal and femoral lymphatic glands 
 can sometimes be felt in thin persons. The ingui- 
 nal lie for the most part along the line of Pou- 
 part's ligament : they receive the absorbents from 
 the wall of the abdomen, the urethra, the penis, 
 the scrotum [perineum, gluteal region], and the 
 anus. The femoral glands lie chiefly over the 
 saphenous opening and along the outer side of 
 the saphena vein : they receive the absorbents 
 of the lower extremity; they receive some also 
 
96 THE THIGH. 
 
 from the scrotum — of which we have practical 
 evidence in cases of chimney-sweepers' cancer. 
 
 98. Trochanter Major. — The trochanter major 
 is a most valuable landmark, to which we are 
 continually appealing in injuries and diseases of 
 the lower extremity. There is a natural depres- 
 sion over the hip (in fat persons) where it lies very 
 near the surface, and can be plainly felt, especially 
 when the thigh is rotated. Nothing intervenes 
 between the bone and the skin except the strong 
 fascia of the gluteus maximus and the great bursa 
 underneath it. 
 
 The top of the trochanter lies pretty nearly on 
 a level with the spine of the pubes, and is about 
 three-fourths of an inch lower than the top of the 
 head of the femur. A careful examination of the 
 bearing of the great trochanter to the other bony 
 prominences of the pelvis, and a comparison of its 
 relative position with that of the opposite side, 
 are the best guides in the diagnosis of injuries 
 about the hip, and the position of the head of the 
 femur. 
 
 99. Nelaton's Line. — "If in the normal state 
 you examine the relations of the great trochanter 
 to the other bony prominences of the pelvis, you 
 will find that the top of the trochanter corresponds 
 to a line drawn from the anterior superior spine 
 of the ilium to the most prominent part of the 
 
THE THIGH. 97 
 
 tuberosity of the ischium. This line also runs 
 through the centre of the acetabulum. The extent 
 of displacement in dislocation or fracture is marked 
 by the projection of the trochanter behind and 
 above this line." 1 
 
 "Nekton's line," as it is termed, theoretically 
 holds good. But in stout persons it is not always 
 easy to feel these bony points so as to draw the 
 line with precision. A surgeon must, after all, in 
 many cases trust to measurement by his eyes and 
 his flat hands — his best guides. Thus, let the 
 thumbs be placed firmly on the spines of the ilia, 
 while the fingers grasp the trochanters on each 
 side. Having the sound side as a standard of 
 comparison, the hand will easily detect any dis- 
 placement on the injured side. Hippocrates bids 
 us compare the sound parts with the parts affected 
 (in fractures) and observe the inequalities. 
 
 The top of the great trochanter is the guide in 
 an operation recently introduced by Mr. Adams, 
 namely, the "subcutaneous section of the neck of 
 the femur." "The puncture should be made one 
 inch above and nearly one inch in front of the top 
 of the trochanter. The neck of the bone is to be 
 sawn through at right angles to its axis, the saw 
 
 1 NSlaton, " Pathologie chirurgicale," t. iv. p. 441. 1848. 
 
 9 
 
98 THE THIGH. 
 
 working parallel to Poupart's ligament, and about 
 one inch below it." 
 
 Spine of the Ilium. — The anterior superior 
 spine of the ilium is the point from which we 
 measure the length of the lower limb. [See § 68.] 
 By looking at the spines of opposite sides we can 
 detect any slant in the pelvis. By pressure on 
 both spines simultaneously we examine if there 
 be a fracture of the pelvis, or disease at the sacro- 
 iliac joint. 
 
 100. "In reducing a dislocation of the hip by 
 manipulation it is important to bear in mind that, 
 in every position, the head of the femur faces 
 nearly in the direction of the inner aspect of its 
 internal condyle." 1 
 
 101. Compression of Femoral Artery. — 
 About a point midway between the spine of the 
 ilium and the symphysis pubis, the femoral artery 
 can be felt beating, and effectually compressed, 
 against the pubes. How should the pressure be 
 applied when the patient lies on the back? In 
 accordance with the slope of the bone — that is, 
 with a slight inclination upwards. A want of 
 attention to this point is the reason why so many 
 fail when they undertake to command the circula- 
 
 1 Bigelow, "Mechanism of Dislocation- and Fracture of the 
 Hip." Philadelphia, 1869. 
 
THE THIGH. 99 
 
 tion through the femoral artery in an amputation, 
 or to cure an aneurism by digital compression. [I 
 think the chief reason of failure in attempting 
 compression of the femoral is that pressure is 
 made two or three inches below Poupart's liga- 
 ment, instead of immediately below it. In the 
 former position, thick muscles form the floor 
 against which it is ineffectually compressed; in 
 the latter, it is directly on the edge of the pelvis 
 or the head of the femur.] 
 
 If the Italian tourniquet be used, we should be 
 careful to adjust the counter-pad well under the 
 tuberosity of the ischium. If digital pressure be 
 used, it is easy to command the femoral by slight 
 pressure of the thumb, provided the fingers have 
 a firm hold on the great trochanter. 
 
 102. Sartorius.— The sartorius is the great 
 fleshy landmark of the thigh, as the biceps is of 
 the arm, and the sterno-cleido-mastoideus of the 
 neck. Its direction and borders may easily be 
 traced by asking the patient to raise his leg, a 
 movement whish puts the muscle in action. The 
 same action defines the boundaries of the triangle 
 (of Scarpa) formed by Poupart's ligament, the 
 adductor longus and sartorius. 
 
 Line of Femoral Artery. — To define the 
 course of the femoral artery, draw a line from 
 midway between the anterior superior spine of 
 
100 THE THIGH. 
 
 the ilium and the symphysis pubis to the (spur- 
 like) tubercle for the adductor magnus on the 
 inner side of the knee. The femoral artery lies 
 under the upper § of this line. 
 
 The sartorius begins to cross the artery, as a 
 rule, from three to four inches below Poupart's 
 ligament. The point at which the profunda artery 
 arises is about one and a half or two inches below 
 the ligament. Therefore the incision for trying 
 the femoral in Scarpa's triangle should commence 
 about a hand's breadth below Poupart's ligament, 
 and be continued for three inches in the line of the 
 artery. 
 
 To command the femoral in Scarpa's triangle, 
 the pad of the tourniquet should be placed at the 
 apex, and the direction of the pressure should be, 
 not backwards, but outwards, so that the artery 
 may be compressed against the femur. 
 
 In the middle third of the thigh the femoral 
 artery lies in Hunter's canal, overlapped by the 
 sartorius. About the commencement of the lower 
 third the artery leaves the canal through the oval 
 opening in the adductor magnus, and, under the 
 name of popliteal, enters the popliteal space. The 
 line for finding the artery in Hunter's canal has 
 been already traced (102). The incision to reach 
 the artery in this part of its course would fall in 
 with the outer border of the sartorius. 
 
THE BUTTOCKS. 101 
 
 To command the femoral artery in Hunter's 
 canal, the pressure should be directed outwardly, 
 so as to press the vessel against, the bone. 
 
 THE BUTTOCKS. 
 
 103. Buttocks. — Bony Landmarks. — The 
 
 bony landmarks of the buttocks which can be 
 distinctly felt are: 1, the posterior superior spine 
 of the ilia ; 2, the spines of the sacral vertebrae ; 
 3, the two tubercles of the last sacral vertebra ; 4, 
 the apex of the coccyx in the deep groove leading 
 to the anus; 5, the tuberosities of the ischia on 
 each side of the anus. 
 
 The posterior spines of the ilia are about the 
 level of the second sacral spine, and corresponds 
 with the middle of the sacro-iliac symphysis. 
 
 The third sacral spine marks the lowest level 
 to which the membranes of the cord and the 
 cerebro-spinal fluid descend in the spinal canal. 
 
 The tuberosities of the ischia, in the erect posi- 
 tion, are covered by the gluteus maximus. In the 
 sitting position they support the weight of the 
 body v a»nd are only covered by a thick pad of 
 coarse* fat.. Between this pad and the bones there 
 is a bursa, which becomes occasionally enlarged 
 and inflamed in eoachmen. 
 
 The prominence of the. nates is one of the 
 9* 
 
102 THE BUTTOCKS. 
 
 characteristics of man in connection with his erect 
 attitude. " Les fesses n'appartiennent qu'a l'espece 
 humaine." They are formed of an accumulation 
 of fat over the great muscle of the buttock (gluteus 
 maximus). From their appearance we may gather 
 some indication of the state of the constitution. 
 They are firm and globose in the vigorous ; loose 
 and flaccid in the infirm. Wasting and flattening 
 of one, compared with the other, is an early symp- 
 tom of disease in the hip. 
 
 104. Fold of the Buttock.— The deep furrow, 
 termed "the fold of the buttock" [or gluteo-femoral 
 fold], which separates the nates- from the back of 
 the thigh, corresponds with the lower border of 
 the gluteus maximus. Its altered direction in dis- 
 ease of the hip is very characteristic. This is the 
 best place to feel for the great ischiatic nerve. We 
 find it by pressing deeply between the trochanter 
 and the tuber ischii, rather nearer to" the latter. 
 When we sit upright, the nerve is not liable to 
 pressure ; but it becomes numbed when we sit 
 long sideways. 
 
 105. Gluteal Artery. — To find at what point 
 the gluteal artery comes out of the pelvis, draw a 
 line from the posterior superior spine of the ilium 
 to the top of the trochanter major, rotated inwards. 
 The junction of the inner with the middle third of 
 this line lies over the artery as it emerges from 
 the upper border of the great ischiatic notch. 
 
THE KNEE. 103 
 
 The point of exit of the ischiatic artery from 
 the pelvis is about half an inch lower than that of 
 the gluteal. 
 
 106. Pudic Artery. — The pudic artery crosses 
 the spine of the ischium. To find it, draw a line 
 from the outer side of the tuber ischii to the 
 posterior superior spine of the ilium. The junc- 
 tion of the lower with the middle third gives the 
 position of the artery. The ischiatic artery lies 
 close to it, but nearer the middle line. 
 
 Looking at the course of these arteries it ap- 
 pears that when we sit on hard seats the pressure 
 is sustained by the bones ; when we recline on soft 
 seats the pressure is sustained more by the. soft 
 parts, and reaches the arteries ; hence the tendency 
 of modern modes of reposing to drive the blood 
 into the interior of the pelvis and favor the pro- 
 duction of piles and uterine disorders. A cele- 
 brated French accoucheur used to say that the 
 fashion of high waists, tight lacing, and easy 
 chairs brought him many thousands a year. 
 
 THE KNEE. 
 
 107. Bony Points. — The patella ; the tuberosi- 
 ties of the two condyles; the tubercle of the tibia 
 for the attachment of the ligamentum patella? ; 
 another (the lateral) tubercle, on the outer side of 
 
104 THE KNEE. 
 
 the head of the tibia ; and the head of the fibula 
 are the chief bony landmarks of the knee. 
 
 Observe that the head of the fibula lies at the 
 outer and back part of the tibia, and that it is 
 pretty nearly on a level with the tubercle for the 
 attachment of the ligamentum patellae. 
 
 We can also feel the adductor tubercle or spur- 
 like projection of bone above the internal condyle 
 ■which gives attachment to the tendon of the ad- 
 ductor magnus. This spur-like projection corre- 
 sponds with the level of the epiphysis of the 
 lower end of the femur, and also with the level 
 of the highest part of the trochlea for the patella: 
 facts worth notice in performing excision of the 
 knee. [The importance of preserving intact this 
 inferior epiphysial cartilage of the femur is best 
 understood when it is remembered that this is the 
 seat of the greatest growth in the entire body. 
 While the whole body from birth to adult life 
 grows (in the male) 3.37 times, and the whole leg 
 4.49 times, the lower femur grows 7.30 times.] 
 
 "In reducing a dislocation of the hip, it is 
 important to bear in mind that the inner aspect of 
 the internal condyle in every position of the limb 
 faces nearly in the direction of the head of the 
 femur." (100) 
 
 The tubercle on the outer side of the head of the 
 tibia gives attachment to the broad and strong 
 
THE KNEE. 105 
 
 aponeurosis (tendon of the tensor fascias), which, 
 acting like a brace for the support of the pelvis, 
 is well seen in emaciated persons down the outer 
 side of the thigh. [In fracture of the neck of the 
 femur, therefore, instead of being tense, the fascia 
 will yield to pressure, especially just above the 
 knee and the great trochanter. The patient should 
 be standing (Allis).] This tubercle indicates the 
 level to which the condyles of the femur descend, 
 and the lower level of the synovial membrane. 
 
 The patella, in extension of the knee, is nearly 
 all above the condyles ; in flexion, it lies in the 
 inter-condyloid fossa (more on the external con- 
 dyle), and thus protects the joint in kneeling. Its 
 inner border is thicker and more prominent than 
 the outer, which slopes down towards its con- 
 dyle. 
 
 108. Ligamentum Patellae. — The line of the 
 ligamentum patellae is vertical. Hence any devia- 
 tion from this line, one way or the other, indicates 
 more or less dislocation of the tibia. There is a 
 pellet of fat under the ligament, which answers a 
 " packing" purpose — sinking in when the knee is 
 bent; rising when the knee is extended, and bulg- 
 ing on either side of the tendon, almost enough 
 to give the feel of fluctuation. 
 
 In a well- formed leg the ligamentum patellae, 
 the tubercle of the tibia, and the middle of the 
 
106 THE KNEE. 
 
 ankle should be in the same straight line. A 
 useful point in the adjustment of fractures. 
 
 Behind the upper half of the ligamentum patellae 
 is the synovial membrane of the knee-joint; behind 
 the lower half is a synovial bursa and a pad of fat. 
 It is well to remember this in cases of injury to 
 the ligamentum patellae. 
 
 109. Patellar Bursa. — The patellar or house- 
 maid's bursa is situated not only over the patella, 
 but over the upper part of the ligament. This is 
 plain enough when the bursa becomes enlarged. 
 There is another subcutaneous bursa over the 
 insertion of the ligament into the tubercle of the 
 tibia. This is quite independent of the deep bursa 
 between the tendon and the bone. 
 
 110. Synovial Membrane of Knee. — The 
 synovial membrane of the knee, when the joint is 
 extended, rises like a cul-de-sac above the upper 
 border of the patella about two inches. It ascends, 
 too, a little higher under the vastus internus than 
 the vastus externus — a fact very manifest when 
 the joint is distended. "When the knee is bent 
 this cul-de-sac is drawn down — hence the rule of 
 bending the knee in operations near the lower end 
 of the femur. 
 
 The lower level of the synovial membrane of 
 the knee is just above the level of the upper part 
 of the head of the fibula. The tibio-fibular syno- 
 
THE KNEE. 107 
 
 vial membrane is, with rare exceptions, indepen- 
 dent of that of the knee. 
 
 [It is surprising to note what a large part of 
 the surface of the joint, and especially on the 
 femur, is exposed to examination by the touch 
 with the knee in flexion. The condition of the 
 synovial membrane and the cartilage, therefore, 
 can be ascertained. The trochlear groove is espe- 
 cially well defined.] 
 
 111. Popliteal Tendons. — The tendons form- 
 ing the boundaries of the popliteal space can be 
 distinctly felt when the muscles which bend the 
 knee are acting. On the outer side, we have the 
 biceps running down to the head of the fibula. 
 On the inner side we feel three tendons, disposed 
 as follows: — nearest to the middle of the popliteal 
 space is the semitendinosus, very salient and 
 traceable high up the thigh ; next comes the 
 thick round tendon of the semimembranosus ; still 
 more internally is the gracilis. The sartorius, 
 which forms a graceful muscular prominence on 
 the inner side of the knee, does not become tendi- 
 nous until it gets below it. 
 
 [A very interesting experiment may be tried 
 on the "ligamentous action" (as Prof. Cleland 
 calls it) of these muscles. Standing with the back 
 fixed against a wall to steady especially the pelvis, 
 the knee can be made almost to touch the belly. 
 
108 THE KNEE. 
 
 But note that the knee is flexed. Eepeat the 
 experiment, the knee being kept rigid, and when 
 the heel has been but slightly raised a sharp pain 
 in the ham follows any effort to carry it higher. 
 Flexion of the rigid leg from the vertical line to a 
 right angle increases the distance from the tuber 
 ischii to the tuberosities of the tibia by some six 
 or eight centimetres, an amount of stretching these 
 muscles cannot undergo. Hence the compulsory 
 flexion of the knee in flexion of the hip. 
 
 The same thing is seen in the wrist. Flex the 
 wrist with the fingers extended, and again with 
 the fingers in a "fist." The first movement can be 
 carried to 90°, the second only to 30°, or in some 
 up to 60°. Making a fist had already stretched 
 the flexors, and they can be stretched but little 
 further. Many surgeons make errors in the leg, 
 but especially in the forearm and hand, and inflict 
 injury as well as needless pain by forgetting these 
 facts while making passive movement. 
 
 It must be noted, however, that in children 
 there is less danger of this over- stretching, for 
 from childhood to old age there is a progressive 
 invasion of the extensible belly by the inextensible 
 tendon in the muscles generally. Hence the ease 
 with which children, even when seated, can lift 
 the heel (without moving the pelvis) and make 
 the hips the point of an acute angle.] 
 
THE KNEE. 109 
 
 112. Popliteal Bursa. — The precise position of 
 this bursa in the popliteal space, which sometimes 
 enlarges to the size of a hen's egg, is between the 
 tendon of the inner head of the gastrocnemius and 
 the tendon of the semimembranosus, just where 
 they rub one against the other. The bursa is 
 from one and a half to two inches long. When 
 enlarged, it makes a swelling on the inner side of 
 the popliteal space, which bulges and becomes 
 tense when the, knee is extended, and vice versa. 
 I examined 150 bodies with a view to ascertain 
 how often this bursa communicates with the syno- 
 vial membrane of the knee. There was a commu- 
 nication about once in five instances. This should 
 make us cautious in interfering too roughly with 
 the bursa when enlarged. 
 
 113. Popliteal Artery. — The popliteal artery 
 can be felt beating and can be compressed against 
 the back of the femur, close to which it lies. But 
 pressure, sufficient to stop the blood, should be 
 firm, and should be made against the bone nearer 
 to the inner than the outer hamstrings. The line 
 of the artery corresponds with the middle of the 
 ham. It lies under cover of the fleshy belly of 
 the semimembranosus, and the outer border of 
 this muscle is the guide to it. An incision down 
 the middle of the ham would fall in with the 
 vessel just above the condyles. 
 
 10 
 
110 THE LEG AND ANKLE. 
 
 114. Peroneal Nerve. — The peroneal nerve 
 runs parallel with and close to the inner border 
 of the tendon of the biceps. It can be felt in 
 thin persons. There is a risk of dividing it in 
 tenotomy of the biceps, unless the knife be care- 
 fully introduced from within outwards. Below 
 the knee the nerve can be felt close to the fibula 
 just below the head, and when pressed upon in 
 this situation causes a sensation to run down its 
 branches to the foot. 
 
 THE LEO AND ANKLE. 
 
 115. Bony Points. — The tubercle of the tibia 
 (for the attachment of the ligamentum patellae), 
 the sharp front edge called the shin, and the 
 broad flat subcutaneous surface of the bone can 
 be felt all the way down. The inner edge can be 
 felt too, but not so plainly. The lower third is 
 the narrowest part of the bone and the most 
 frequent seat of fracture. 
 
 The head of the fibula is a good landmark on 
 the outer side of the leg, about one inch below 
 the top of the tibia and nearly on -a level with the 
 tubercle. Observe that it is placed well back, and 
 that it forms no part of the knee-joint, and takes 
 no share in supporting the weight. 
 
 The shaft of the fibula arches backwards, the 
 
THE LEG AND ANKLE. Ill 
 
 reverse of the shaft of the tibia. The fact of the 
 bones not being on the same plane should be re- 
 membered in flap amputations. The shaft of the 
 fibula is so buried amongst the muscles, that the 
 only part to be distinctly felt is the lower fourth. 
 Here there is a flat triangular subcutaneous sur- 
 face, between the peroneus tertius in front, and 
 the two peronei (longus and brevis) behind. Here 
 is the most frequent seat of fracture. 
 
 116. Malleoli. — The shape and relative position 
 of the malleoli should be carefully studied, as 
 the great landmarks of the ankle. The inner 
 malleolus does not descend so low as the outer, 
 and advances more to the front: at the same time, 
 owing to its greater antero-posterior depth, it is 
 on the same plane as the outer behind. The 
 lower border of the inner malleolus is somewhat 
 rounded, and the slight notch in it for the attach- 
 ment of the lateral ligament can be felt. The 
 outer malleolus descends lower than the inner, 
 thus effectually locking the joint on the outer side. 
 Its shape is not unlike the head of a serpent. 
 Viewed in profile, it lies just in the middle of the 
 joint. 
 
 In Syme's amputation of the foot at the ankle, 
 the line of the incision should run from the apex 
 of the outer malleolus, under the sole to the centre 
 of the inner. 
 
112 THE LEG AND ANKLE. 
 
 In a well-formed leg, the inner edge of the 
 patella, the inner ankle, and the inner side of the 
 great toe, should be in the same vertical plane. 
 Look to these landmarks in adjusting a fracture 
 or dislocation, keeping at the same time an eye 
 upon the conformation of the opposite limb. 
 
 [In consequence of violence, usually a sprain, a 
 sliver of the internal surface of the thick malleoli 
 may be broken off, seriously implicating the joint, 
 but yet not perceptible by mobility, crepitus, or 
 otherwise, from the exterior. Mr. Callender has 
 happily named such, "sprain-fractures." 
 
 Into the inter-malleolar space the astragalus is 
 tightly wedged or mortised, and we have here, as 
 I pointed out some years ago, a valuable means of 
 diagnosis in case of Pott's fracture of the fibula 
 three or four inches above the external malleolus. 
 In such a fracture this inter-malleolar space is 
 widened. If now the leg be seized by one hand 
 above the ankle, and the foot by the other, with 
 the palm under the sole, the thumb and fingers 
 will have the astragalus in their grasp. The 
 astragalus can then be pushed sidewise against 
 the outer malleolus and then shoved suddenly 
 towards the firm inner malleolus, against which 
 it will come with an easily-perceived impact if 
 there be fracture. If none exist, the astragalus 
 will have no lateral play. Motion at the medio- 
 
THE LEG AND ANKLE. 113 
 
 tarsal joints must not be mistaken for this tibio- 
 tarsal movement.] 
 
 There are several strong tendons to be seen and 
 felt about the ankle. 
 
 117. Tendo Achillis. — Behind is the tendo 
 Achillis. It forms a high relief, with a shallow 
 gutter on each side of it. The narrowest part 
 of the tendon, where it should be divided in 
 tenotomy, is about the level of the inner ankle ; 
 below this it expands again to be attached to the 
 lower and back part of the os calcis. Seen in 
 profile, the tendon is not straight, but slightly 
 concave — being drawn in by an aponeurosis which 
 forms a sort of girdle around it. This girdle 
 proceeds from the posterior ligament of the ankle; 
 and, though most of its fibres encircle the tendon, 
 some of them adhere to and draw in its sides. All 
 this disappears when the tendon is laid bare by 
 dissection. 
 
 118. Tendons behind Inner Ankle. — Above 
 and behind the malleolus internus we can feel the 
 broad flat tendon of the tibialis posticus and 
 upon it that of the flexor longus digitorum. The 
 tendon of the tibialis posticus lies nearest to the 
 bone and comes well up in relief in adduction of 
 the foot. It lies close to, and parallel with, the 
 inner edge of the tibia, so that this edge is the 
 best guide to it. Therefore in tenotomy the knife 
 
 10* 
 
114 THE LEG AND ANKLE. 
 
 should be introduced first perpendicularly between 
 the tendon and the bone, and then turned at 
 right angles to cut the tendon. The tendon has a 
 separate sheath and synovial membrane, which 
 commences about one inch and a half above the 
 apex of the malleolus, and is continued to its 
 insertion into the tubercle of the scaphoid bone. 
 The proper place, then, for division of the tendon, 
 is about two inches above the end of the malleolus. 
 
 In a young and fat child, where the inner edge 
 of the tibia cannot be distinctly felt, the best 
 guide to the tendon is a point midway between 
 the front and the back of the ankle. An incision 
 in front of this point might injure the internal 
 saphena vein ; behind this point, the posterior 
 tibial artery. 
 
 119. Tendons behind Outer Ankle.— Behind 
 the malleolus externus we feel the two peroneal 
 (long and short) tendons. They lie close to the 
 edge of the fibula, the short one nearer to the 
 bone. In dividing these tendons, the knife should 
 be introduced perpendicularly to the surface, and 
 about two inches above the apex of the ankle, so 
 as to be above the synovial sheaths of the tendons. 
 
 Tendons in front of Ankle. — Over the front 
 of the ankle, when the muscles are in action, we 
 can see and feel, beginning on the inner side, the 
 tendons of the tibialis anticus, the extensor longus 
 
THE LEG AND ANKLE. 115 
 
 pollicis, the extensor longus digitorum, and the 
 peroneus tertius. They start up like cords when 
 the foot is raised, and are kept in their proper 
 relative position by strong pulleys formed by the 
 anterior annular ligament. Of these pulleys the 
 strongest is that of the extensor communis digi- 
 torum. "When the ankle is sprained, the pain and 
 swelling arise from a stretching of these pulleys 
 and effusion into their synovial sheaths. A lacera- 
 tion of one of the pulleys and escape of the tendon 
 is extremely rare. 
 
 The place for the division of the tendon of the 
 tibialis anticus, so as to divide it below its syno- 
 vial sheath, is about one inch before its insertion 
 into the cuneiform bone. The knife should be 
 introduced on the outer side, so as to avoid the 
 -dorsal artery- of the foot. 
 
 [Most of these tendons can be best seen by 
 standing a model on one foot, i. e., in unstable 
 equilibrium.] 
 
 Now trace the lines of the arteries, and the 
 landmarks near which they divide. 
 
 120. Popliteal Artery. — About one inch and 
 a quarter below the head of the fibula, or say one 
 inch below the tubercle of the tibia, the popliteal 
 artery divides into the anterior and posterior 
 tibial. The peroneal comes off from the posterior 
 
116 THE LEG AND ANKLE. 
 
 tibial about three inches below the head of the 
 fibula. 
 
 Consequently we may lay down, as a general 
 rule, that, in amputations one inch below the head 
 of the fibula, only one main artery, the popliteal, 
 is divided. In amputations two inches below the 
 head of the fibula, two main arteries, the anterior 
 and posterior tibial, are divided. In amputations 
 three inches below the head, three main arteries, 
 the two tibials and the peroneal, are divided. 
 
 121. Anterior Tibial Artery. — The anterior 
 tibial artery comes in front of the interosseous 
 membrane, one inch and a quarter below the head 
 of the fibula, and here lies close to this bone. Its 
 subsequent course is defined by a line drawn from 
 the front of the head of the fibula to the middle 
 of the front of the ankle. This line corresponds 
 pretty nearly with the outer border of the tibialis 
 anticus all the way down. If this muscle be put 
 in action, its outer border (the intermuscular line) 
 is plainly seen, and the incision for the ligature of 
 the artery in any part of its course may be defined 
 with the greatest precision. The artery can be felt 
 beating and can be compressed where it crosses the 
 front of the tibia and ankle. 
 
 122. Posterior Tibial Artery. — The posterior 
 tibial commences about one inch and a quarter 
 below the head of the fibula. Its subsequent 
 
THE LEG AND ANKLE. 117 
 
 course corresponds with a line drawn from the 
 middle of the upper part of the calf to the hollow 
 behind the inner ankle, where it can be felt beat- 
 ing distinctly about half an inch behind the edge 
 of the tibia. A vertical incision down the middle 
 of the calf would reach the artery under cover of 
 the gastrocnemius and soleus. A vertical incision 
 along the middle third of the leg, about half an 
 inch from the inner edge of the tibia, would 
 enable the operator to reach the artery sideways, 
 by detaching from the bone the tibial origin of 
 the soleus. 
 
 [The posterior tibial artery, behind the malle- 
 olus, lies midway between the tendo Achillis, or 
 the heel, and the malleolus. It is the middle of 
 five structures : in front of it are, (1) the tibialis 
 posticus tendon, (2) the flexor longus digitorum 
 tendon ; behind it are (4) the posterior tibial nerve 
 and (5) the flexor longus pollicis tendon. It is 
 important to observe that, as Wyeth has shown, 
 it bifurcates into the two plantar arteries at a line 
 drawn from the point of the malleolus to the 
 middle of the heel.] 
 
 123. Saphena Veins. — The subcutaneous veins 
 on the dorsum of the foot form an arch convex 
 towards the toes (as on the back of the hand), 
 from which issue the two main subcutaneous 
 trunks of the lower limb, the internal and external 
 
118 THE FOOT. 
 
 saphena veins. The internal vein can be always 
 plainly seen over the front of the inner ankle. Its 
 farther course up the inner side of the leg, knee, 
 and thigh to its termination in the femoral is not 
 in all persons manifest. 
 
 [If lies about half an inch behind the internal 
 border of the tibia, skirts the knee postero- 
 internally, and, passing up the inside of the 
 thigh, empties at the saphenous opening into the 
 femoral. A thrombus not uncommonly may form 
 in it, or in the femoral, or may extend from it 
 into the femoral. The careful investigation of 
 both veins then becomes very important, and is 
 not generally difficult, especially if we remember 
 the course of the saphena and the relation of the 
 femoral to its artery.] 
 
 The external saphena vein runs behind the 
 outer ankle and up the middle of the calf to 
 empty itself (generally) into the popliteal vein. 
 
 THE FOOT. 
 
 What are the bony landmarks which guide us 
 in the surgery of the foot ? 
 
 124. Points of Bone. — Along the inner side of 
 the foot, beginning from behind, we can feel — 1, 
 the tuberosity of the os calcis; 2, the projection 
 of the internal malleolus ; 3, the projection of the 
 
THE FOOT. 119 
 
 os calcis, termed "sustentaculum tali," about one 
 full inch below the malleolus; 4, about one inch 
 in front of the malleolus internus, and a little 
 lower, is the tubercle of the' scaphoid bone ; the 
 gap between it and the sustentaculum tali being 
 filled by the calcaneo-scaphoid ligament and the 
 tendon of the tibialis posticus, in which there is 
 often a sesamoid bone ; 5, the internal cuneiform 
 bone ; 6, the projection of the first metatarsal 
 bone; 7, the sesamoid bones of the great toe. 
 [On a line nearly midway from the scaphoid to 
 the inner malleolus the head of the astragalus 
 can be felt. In front, with the foot in extension, 
 we can feel also the upper and lateral articular 
 surfaces of the astragalus, and especially the 
 ridges between them.] 
 
 Along the outer side of the foot we can feel — 1, 
 the external tuberosity of the os calcis; 2, the 
 external malleolus; 3, the peroneal tubercle of the 
 os calcis, one inch below the malleolus, with the 
 long peroneal tendon below it, and the short one 
 above it ; 4, the projection of the base of the fifth 
 metatarsal bone. 
 
 125. Lines of Joints. — In fat persons the fol- 
 lowing' rules for finding the joints may be of ser- 
 vice as regards the surgery of the foot : — 
 
 The level of the ankle joint lies about half an 
 inch above the end of the inner malleolus. This 
 
120 TflE FOOT. 
 
 is worth remembering in performing "Syme's" 
 amputation. 
 
 The tubercle of tbe scaphoid bone is the best 
 guide to the astragalo-scaphoid joint which lies 
 immediately behind it ; and the plane of this joint 
 is in- the same line as that of the calcaneo-cuboid. 
 Thus a line drawn transversely over the dorsum 
 of the foot, behind the tubercle of the scaphoid, 
 would strike both the joints opened in "Chopart's" 
 operation. 
 
 Place your thumb on the tubercle of the sca- 
 phoid, and measure about one inch and a half 
 in front : here you find the joint between the 
 internal cuneiform bone and the metatarsal bone 
 of the great toe. This point is useful in Lisfranc's 
 operation, which consists in the removal of the 
 metatarsal bones. 
 
 The line of the calcaneo-cuboid joint lies midway 
 between the external malleolus and the (tarsal) end 
 of the metatarsal bone of the little toe. 
 
 The projection of the fifth metatarsal bone is 
 the guide to the joint between it and the cuboid. 
 
 Notice that the line of the joints between the 
 metatarsal bones and the first phalanges lies a full 
 inch farther back than the interdigital folds of 
 the skin. This is a point to be remembered in 
 amputating the toes. 
 
THE FOOT. 121 
 
 126. Dorsal Artery.— The line of the dorsal 
 artery of the foot is from the middle of the ankle 
 to the interval between the first and second meta- 
 tarsal bones. The artery can be felt beating over 
 the bones along the outer side of the extensor 
 longus pollicis, which is the best guide to it. 
 
 127. Bursa.— The synovial sheath of the ex- 
 tensor longus pollicis extends from the front of 
 the ankle, over the instep (apex of the internal 
 cuneiform bone) as far as the metatarsal bone of 
 the great toe. There is generally a bursa over the 
 instep, above, or it may be, below, the tendon. 
 
 There is often a large irregular bursa between 
 the tendons of the extensor longus digitorum, and 
 the projecting end of the astragalus, over which 
 the tendons play. There is much friction here. 
 It is well to be aware that this bursa sometimes 
 communicates with the joint of the head of the 
 astragalus. 
 
 128. Plantar Arteries. — The course of the 
 external plantar artery corresponds with a line 
 drawn from the hollow behind the inner ankle 
 obliquely across the sole nearly to the base of the 
 fifth metatarsal bone ; from thence the artery turns 
 transversely across the foot, lying (deeply) near the 
 bases of the metatarsal bones, till it inosculates 
 with the dorsal artery of the foot in the first 
 interosseous space. 
 
 11 
 
122 THE ARM. 
 
 The course of the internal plantar corresponds 
 with a line drawn from the inner side of the os 
 calcis to the middle of the great toe. 
 
 129. Plantar Fascia. — To divide the plantar 
 fascia subcutaneously, the best place is about one 
 inch in front of its attachment to the os calcis. 
 This is the narrowest part of it. The knife should 
 be introduced on the inner side; and the incision 
 will be behind the plantar artery. 
 
 The subcutaneous section of the tendon of the 
 abductor pollicis should be made about one inch 
 before its insertion. 
 
 [It is evidently the opinion of shoemakers that 
 the axis of the sole of the foot ought to be a 
 median straight line, and the two borders sym- 
 metrically curved towards it. If a foot they have 
 not unduly distorted be observed carefully, it will 
 be seen (B. Lee) that the axis is curved ; that on 
 the inner border of the foot, the heel, and the 
 front part of the foot are in nearly a straight line, 
 while the outer border is a curved line. If nature 
 be followed, natural shaped feet will be the result, 
 and the miseries of corns and bunions be unknown.] 
 
 THE ARM. 
 
 130. Clavicle. — The line of the clavicle and 
 the projection of the joint at either end can always 
 
THE ARM. 123 
 
 be felt, even in the fattest persons. Its direction 
 is not perfectly horizontal, but slightly inclined 
 downwards, when the arm hangs quietly by the 
 side. When the body lies flat on the back, the 
 shoulder not only falls back, but rises a little, 
 the weight of the limb being taken off. Hence 
 the modern practice of treating fractures of the 
 clavicle (in the early stage) by the supine position. 
 
 On the front surface of the clavicle, not far 
 from its acromial end, 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. 
 
 [Being subcutaneous throughout, the clavicle 
 can readily be seized and examined for fracture, 
 syphilitic nodes, etc. If before a glass the arm be 
 swung round, raised and lowered, the shoulder be 
 shrugged, etc., we shall appreciate the fact that 
 
124 THE ARM. 
 
 this is the only bony connection the arm has with 
 the body, and to what a very large extent it is 
 movable, the sterno-clavicular joint being the 
 pivot.] 
 
 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 
 normal symphyses might be mistaken for fractures, 
 until we have examined the opposite shoulder, 
 which is sure to present a similar conformation. 1 
 
 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 
 
 1 See Pruge on " Ossa Acromialia" (" Zeitschrift fiir ration- 
 elle Medizin"), 3. Reihe, Bd. vii., 1859. 
 
THE ARM. 125 
 
 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 shoul- 
 der, 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 ex- 
 ternal 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 shoul- 
 der, when the arm is pendent and supine, we can 
 feel the bicipital groove [between the two tuberosi- 
 ties]. 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 
 
 n* 
 
126 THE AEM. 
 
 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 del- 
 toid 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. — [To show its borders best, let the 
 model place his elbow on your shoulder and press 
 down upon it, when the muscles will be brought 
 into strong relief.] 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 
 
THE ARM. 127 
 
 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 in- 
 terval between these digitations, therefore, corre- 
 sponds 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. [But in feeling to see if they are enlarged, 
 remember that they lie next the chest, at the 
 inner, and not the outer, wall of the axilla; a fact 
 which facilitates also their removal.] 
 
 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-brachi- 
 alis. 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 dif- 
 ferent 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 
 
128 THE ARM. 
 
 the point of the- knife introduced from above 
 downwards. 
 
 135. Brachial Artery. — When the arm is ex- 
 tended 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. [A high bifurcation very 
 often occurs, and would probably be perceptible on 
 careful examination. 
 
 The median nerve lies to the outside of the 
 artery above, crosses it, usually in front, at the 
 middle, and lies to the inside below. It can 
 usually be felt and very easily differentiated from 
 the artery .J 
 
 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 [in the groove between the supi- 
 nator longus and the brachialis anticus, where it 
 is accessible to the battery and in operations]. 
 Thus, for full three inches above the condyles, 
 
THE ARM. 129 
 
 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. [If the arm be strongly flexed at a 
 right angle, by attempting to lift a heavy table, 
 for instance, the bicipital fascia can be outlined by 
 the finger, and in many persons by the eye.] 
 
 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 gene- 
 rally selected for venesection; it crosses the course 
 
130 THE ARM. 
 
 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 posi- 
 tions of the various bony prominences about the 
 elbow. We can always feel the internal and ex- 
 ternal condyles. The internal is the more promi- 
 nent 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. [On strong flexion, the groove in 
 the humerus for the olecranon can be readily felt, 
 and even seen.] Between the olecranon and the 
 internal condyle is a deep depression in which lies 
 the ulnar nerve (vulgarly called the "fuuny 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 AEM. 131 
 
 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 per- 
 ceptible 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 con- 
 dyles. In extreme flexion the point of the ole- 
 cranon lies in front of the line of the condyles. 
 
 All these relative positions would be altered in 
 the 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 down- 
 wards, 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 
 
132 THE ARM. 
 
 teres is always attached to it ; this origin covers 
 the brachial artery. 1 
 
 Bursse. — The subcutaneous bursa over the ole- 
 cranon, 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 sub- 
 cutaneous 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 circu- 
 lation 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 lymph- 
 atic 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. 
 
 1 See on this subject a monograph, " Canalis Supra-Con- 
 dyloideus Humeri." By W. Griiber. Petersburg, 1856. • 
 
THE FOREARM AND WRIST. 133 
 
 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 abduc- 
 tion 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. [In supination, it is 
 the styloid process, and not the head of the ulna, 
 which is felt posteriorly.] 
 
 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 
 correspouding process of the ulna. The relative 
 positions of these styloid processes can be best 
 
 12 
 
134 THE FOREARM AND WRIST. 
 
 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 liga- 
 ment and the intercarpal joint. The line of the 
 raido-carpal joint, as already stated, is on a level 
 with the apex of the styloid process of the ulna. 
 
 In forcible [and resisted] 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 
 
THE FOREARM AND WRIST. 135 
 
 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. [The median nerve in the forearm 
 lies under the flexor sublimis digitorum, in a line 
 drawn from the bend of the elbow just inside the 
 artery to a point between the tendons of the 
 palmaris longus and the flexor carpi radialis. It 
 is here not only amenable to operations, but often 
 is cut in accidents.] 
 
 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 superflcialis volse 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 "pul- 
 sus duplex." When in doubt, therefore, it is well 
 to feel the pulse in each wrist. 
 
136 THE FOREARM AND 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. "Tabatiere 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 " tabatiere anato- 
 mique." 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 rela- 
 tive 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 
 
THE FOREARM AND WRIST. 137 
 
 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 crepi- 
 tans" by some writers. It is said to be met with 
 sometimes in pianists. [On the overstretching of 
 these muscles, see § 111. J 
 
 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 over- 
 lapped by the supinator longus. To make allow- 
 ance for this, the incision for the ligature of the 
 artery in this situation should be made, not pre- 
 cisely 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 
 
 12* 
 
138 THE HAND. 
 
 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 ver}' elaborate treatise 
 by Cams, 1 "On the Eeason and Meaning of the 
 Different Forms of the Hand." Still less would I 
 indulge curiosity by inquiring whether the pro- 
 fessors of chiromancy, relying on the text "erit 
 signum in manu tua et quasi monumentum ante 
 oculos tuos,"- can advance any reasonable preten- 
 sions for their assertion that they can read in the 
 furrows of the palm the future destiny of its 
 master. 
 
 148. Furrow in Falm. — The only furrow in 
 the palm useful as a surgical landmark is that 
 which runs transversely across its lower third 
 [from the ulnar border to the interspace between 
 the fore- and middle-fingers], and is well seen when 
 
 1 " Ueber Grund und Bedeutung der verschiedenen Formen 
 der Hand." Stuttgart, 1846. 
 
THE HAND. 139 
 
 the fingers are slightly bent. This transverse fur- 
 row 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 trans- 
 verse 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 cor- 
 responds with the middle of the anterior annular 
 ligament. 
 
140 THE HAND. 
 
 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 inclosed 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 
 
THE HAND. 141 
 
 to the prominence which indicates the joint at 
 the bottom of the "tabatiere anatomique" (140). 
 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 be- 
 tween 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 be- 
 tween 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 arrange- 
 ment 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 out of 
 harm's way. 
 
 156. Interosseous Arteries.— Since the dorsal 
 
142 THE HAND. 
 
 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 Bursae. — Small subcutaneous 
 bursa? 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 thick- 
 ness and breadth of the sentient pulp at their ends, 
 and too great arching of the nails, have been re- 
 garded, ever since the days of Hippocrates, as not 
 unlikely indications of a tendency to pulmonary 
 disease. 
 
 [Staining the nails (e. g., by nitric acid) affords a 
 means of determining the fact and the rate of their 
 growth, and, therefore, of the nutritive processes 
 in the corresponding arm or leg.] 
 
PALPATION BY THE RECTUM. 143 
 
 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 recog- 
 nizes the prostate, which feels like a moderately 
 large chestnut. Immediately behind the prostate, 
 the vesiculse 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 easy recognized, when mode- 
 rately 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 
 
1-44 PALPATION BY THE RECTUM. 
 
 arch of the pubes can be well 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 
 
PALPATION BY THE RECTUM. 145 
 
 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 bifurca- 
 tion 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 dis- 
 tinguished. 
 
 "In the introduction of the hand into the rec- 
 tum, in a patient under chloroform, the dilatation 
 of the sphincter ani should be very gradual : first 
 two fiDgers, then four, and finally the thumb 
 should be passed. It is necessary to use con- 
 siderable force, and unless care be taken, not only 
 the integumentary edge of the anus, but the 
 sphincter itself, may be lacerated. The introduc- 
 tion 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 feces and no 
 •very considerable amount of pain has resulted. 
 
 "We have been informed on reliable authority 
 that permanent incontinence of feces has occasion- 
 ally 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 
 
 13 
 
146 EXAMINATION PER VAGINAM. 
 
 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. 1 
 
 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 carunculae myrtiformes, which are vas- 
 cular membranous processes independent of the 
 hymen, variable in number, size, and form. It 
 also feels the transverse ridges known as "rugae." 
 
 "Along the anterior wall of the vagina the fin- 
 ger 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 dis- 
 tended. With a catheter previously introduced it 
 is much more readily explored. 
 
 1 For further information on this subject, see a paper by Mr. 
 Walsham, in St. Bartholomew's Hospital Reports, vol. xii. 
 
EXAMINATION PER VAGINAM. 147 
 
 "The septum between the vagina and the rectum 
 is so thin that, should the rectum contain fecal 
 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 connec- 
 tion with the vagina. The shape and direction of 
 
148 EXAMINATION PER VAGINAM. 
 
 the cervix uteri are almost as perceptible, and the 
 posterior wall of the uterus can be examined. 
 The peritoneal fold termed recto-vaginal (Doug- 
 las's space) can also be well explored, and any- 
 thing 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 abnor- 
 mal. 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." 
 
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