Chapter III: Part 3

The tubercle on the outer side of the head of the tibia gives attachment to the broad and strong aponeurosis (tendon of the tensor fasciæ), which, acting like a brace for the support of the pelvis, is well seen in emaciated persons down the outer side of the thigh. 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 condyle), and thus protects the joint in kneeling. Its inner border is thicker and more prominent than the outer, which slopes down towards its condyle.

108. =Ligamentum patellæ.=--The line of the ligamentum patellæ is vertical. Hence any deviation 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 bulging on either side of the tendon, almost enough to give the feel of fluctuation.

In a well-formed leg the ligamentum patellæ, the tubercle of the tibia, and the middle of the ankle should be in the same straight line. A useful point in the adjustment of fractures.

Behind the upper half of the ligamentum patellæ 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 patellæ.

109. =Patellar bursa.=--The patellar or housemaids’ 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 synovial membrane is, with rare exceptions, independent of that of the knee.

111. =Popliteal tendons.=--The tendons forming 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 tendinous until it gets below it.

112. =Popliteal bursa.=--The precise position of the 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 versâ_. I examined 150 bodies with a view to ascertain how often this bursa communicates with the synovial membrane of the knee. There was a communication 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.

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 carefully 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 LEG AND ANKLE._

115. =Bony points.=--The tubercle of the tibia (for the attachment of the ligamentum patellæ), 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 reverse of the shaft of the tibia. The fact of the bones not being on the same plane should be remembered 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 surface, 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 attachment 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.

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.

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 round 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 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 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 digitorum. When the ankle is sprained, the pain and swelling arise from a stretching of these pulleys and effusion into their synovial sheaths. A laceration 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 synovial 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.

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 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 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 beating 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.

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 saphena veins. The internal saphena vein can be always plainly seen over the front of the inner ankle. Its further course up the inner side of the leg, knee, and thigh to its termination in the femoral is not in all persons manifest.

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 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.

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 following rules for finding the joints may be of service 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 is worth remembering in performing ‘Syme’s’ amputation.

The tubercle of the 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 scaphoid, 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.

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 metatarsal 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 extensor 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.

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.

_THE ARM._

130. =Clavicle.=--The line of the clavicle and the projection of the joint at either end of it can always 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.

131. =Bony points of the shoulder.=--We can distinctly feel the spine of the scapula and the acromion, more especially at the angle where they join behind the shoulder. This angle is the best place from which to measure in taking the comparative length of the arms.

In some shoulders, though very rarely, there is an abnormal symphysis between the spine of the scapula and the acromion. There may indeed be two symphyses and two acromial bones, the acromion having two centres of ossification. These abnormal symphyses might be mistaken for fractures, until we have examined the opposite shoulder, which is sure to present a similar conformation.[9]

=Tuberosities.=--Projecting beyond the acromion (the arm hanging by the side), we can feel, through the fibres of the deltoid, the upper part of the humerus. It distinctly moves under the hand when the arm is rotated. It is not the head of the bone which is felt, but the tuberosities, the greater externally, the lesser in front. These tuberosities form the convexity of the shoulder. When the arm is raised, this convexity disappears; there is a slight depression in its place. The head of the bone can be felt by pressing the fingers high up in the axilla.

The absence of this prominence formed by the upper part of the humerus under the deltoid, and the presence of a prominence low in the hollow of the axilla, or in front, below the coracoid process, or behind, on the back of the scapula, bespeak dislocation of the head of the bone.

In examining obscure injuries about the shoulder, it is worth remembering that, in the normal relation of the bones, and in every position, the great tuberosity faces in the direction of the external condyle. The head of the bone faces very much in the direction of the internal condyle.

It is worth remembering also that the upper epiphysis of the humerus includes the tuberosities; and that it does not unite by bone to the shaft, till about the 20th year.

By making deep pressure in front of the shoulder, when the arm is pendent and supine, we can feel the bicipital groove. It looks directly forwards, and runs in a line drawn vertically downwards through the middle of the biceps to its tendon at the elbow. We should be aware of this, lest it be mistaken for a fracture.

132. =Coraco-acromial ligament.=--Under the anterior fibres of the deltoid, we can distinctly feel the position and extent of the coraco-acromial ligament. A knife, passed vertically through the middle of it, goes at once into the shoulder joint and strikes the bicipital groove with the tendon, a point to be remembered in excision.

In persons of an athletic build the triangular form and beautiful structure of the deltoid become conspicuous when the muscle is in action. The depression on the outer side of the arm, indicating its insertion, is the place selected for issues or setons.

The arm being held up by an assistant, the anterior and posterior borders of the relaxed deltoid admit of being raised so that in amputation at the shoulder the knife can be introduced beneath the muscle to make the flap.

133. =Axilla.=--The anterior border of the axilla, formed by the pectoralis major, follows the line of the fifth rib. In counting the ribs, or in tapping the chest, it is worth remembering that the highest visible digitation of the serratus magnus is attached to the sixth rib. The angle of the digitation is directed forwards, and corresponds to the upper edge of the rib. The second visible digitation corresponds to the seventh rib; the interval between these digitations, therefore, corresponds to the sixth intercostal space--a convenient place for tapping the chest. (38)

In the normal state no glands can be felt in the axilla.

134. =Axillary artery.=--When the arm is raised to a right angle with the body, and the head of the humerus thereby depressed, the axillary artery is plainly felt beating, and can be perfectly compressed on the inner side of the coraco-brachialis. This muscle stands out in relief along the humeral side of the axilla, and is the best guide to the artery. A line drawn along its inner border--that is, down the middle of the axilla--corresponds with the course of the artery.

The depth and form of the axilla alter in different positions of the arm. In the arm raised and abducted the axilla becomes nearly flat; hence this position is always adopted in operations.

In opening abscesses in the axilla, the incision should be made midway between the borders, and the point of the knife introduced from above downwards.

135. =Brachial artery.=--When the arm is extended and supinated, a line drawn from the deepest part of the middle of the axilla down the inner side of the biceps to the middle of the bend of the elbow, corresponds with the course of the brachial artery. The artery can be felt and compressed all the way down; but nowhere so effectually as midway, where it lies on the tendon of the coraco-brachialis close to the inner side of the humerus. The only direction to apply the pressure effectually is outwards and a little backwards, else the artery will slip off the bone.

The musculo-spiral nerve and superior profunda artery wind round the back of the humerus about its middle, and come to the front of the external condyloid ridge. Thus, for full three inches above the condyles, there is nothing to interfere with operations on the back of the bone, which is here broad and flat.

136. =Bend of elbow.=--At the bend of the elbow, the tendon of the biceps can be plainly felt, as well as the pulsation of the brachial artery close to its inner side, before dividing into the radial and ulnar.

=Cutaneous veins.=--The bend of the elbow in young children and in persons with fat and round arms, presents a semicircular fold of which the curve embraces the lower part of the biceps; but in muscular persons we see the distinct boundaries of the triangular space, formed by the pronator teres on the inner side, and the supinator longus on the outer. Here can be traced, standing out in strong relief under the thin white skin, the superficial veins, which, in days gone by, when bloodletting was the fashion, were of such great importance. Their arrangement, although subject to variety, is very much like the branches of the letter M, the middle of the M being at the middle of the elbow. Of these branches the median basilic, which runs over the tendon of the biceps, is the largest and most conspicuous, and is generally selected for venesection; it crosses the course of the brachial artery, nothing intervening but the semilunar aponeurosis from the tendon of the biceps.

137. =Landmarks of elbow.=--It is of great importance to be familiar with the relative positions of the various bony prominences about the elbow. We can always feel the internal and external condyles. The internal is the more prominent of the two, and a trifle higher.

=Olecranon.=--We can always feel the olecranon. This is somewhat nearer to the inner than to the outer condyle. Between the olecranon and the internal condyle is a deep depression in which lies the ulnar nerve (vulgarly called the ‘funny bone’).

On the outer side of the olecranon, just below the external condyle, is a pit in the skin, constant even in fat persons (when the elbow is extended). This pit is considered one of the beauties of the elbow in a graceful arm; it is seen in a child as a pretty little dimple. To the surgeon it is most interesting, as in this valley behind the supinator longus and the radial extensors of the wrist he can distinctly feel the head of the radius rolling in pronation and supination of the forearm. It is, therefore, one of the most important landmarks of the elbow, since it enables us to say whether the head of the radius is in its right place, and whether it rotates with the shaft.

Can the tubercle of the radius be felt? Yes, but only on the back of the forearm in extreme pronation. Its projection is then distinctly perceptible just below the head of the bone.

=Relations of olecranon and condyles.=--To examine the relative positions of the olecranon and condyles in the different motions of the elbow joint, place the thumb on one condyle, the tip of the middle finger on the other, and the tip of the forefinger on the olecranon. In extension, the highest point of the olecranon is never above the line of the condyles; indeed, it is just in this line. With the elbow at right angles the point of the olecranon is vertically below the line of the condyles. In extreme flexion the point of the olecranon lies in front of the line of the condyles.

All these relative positions would be altered in a dislocation of the ulna, but not (necessarily) in a fracture of the lower end of the humerus.

Sometimes, though rarely, we meet with a hook-like projection of bone above the internal condyle. It is called a ‘supra-condyloid’ process; it can be felt through the skin, with its concavity downwards, and is a rudiment of the bony canal which, in many mammalia, transmits the median nerve and ulnar artery. A third origin of the pronator teres is always attached to it; this origin covers the brachial artery.[10]

=Bursæ.=--The subcutaneous bursa over the olecranon, if distended, would be as large as a walnut. A second bursa sometimes exists a little lower down upon the ulna. There is also a small subcutaneous bursa over each of the condyles.

The vertical extent of the elbow joint is limited, above by a line drawn from one condyle to the other; below, by a line corresponding to the lowest part of the head of the radius.

138. =Interosseous arteries.=--About one inch below the head of the radius, the ulnar artery gives off the common interosseous; and this divides, about half an inch lower, into the anterior and posterior interosseous. Thus, in amputating the forearm, say two inches below the head of the radius, four arteries at least would require ligature.

By flexion of the elbow to the utmost, the circulation through the brachial artery can be arrested; but the position is painful, and can be tolerated only for a short time.

=Lymphatic gland.=--There is a small lymphatic gland just above the inner condyle, in front of the intermuscular septum. It is the first to take alarm in poisoned wounds of the hand.

_THE FOREARM AND WRIST._

139. =Ulna.=--The edge of the ulna can be felt subcutaneous from the olecranon to the styloid process (in supination). Any irregularity could be easily detected. The styloid process of the ulna does not descend so low as the styloid process of the radius, or it would impede the free abduction of the hand. Its apex is on a level with the radio-carpal joint. The head of the ulna is plainly felt and seen projecting at the back of the wrist, especially in pronation of the forearm. It then lies between the tendons of the extensor carpi ulnaris and extensor minimi digiti. There is often a subcutaneous bursa over it.

140. =Radius.=--The upper half of the shaft of the radius is so covered by muscles that we cannot feel it; the lower half is more accessible to the touch, especially just above and just below the part where it is crossed by the extensors of the thumb. Its styloid process is readily felt, and made all the more manifest by being covered by the first two extensor tendons of the thumb. It descends lower, and lies more to the front than the corresponding process of the ulna. The relative positions of these styloid processes can be best examined by placing the thumb on one and the forefinger on the other.

Feel for the little bony pulley on the back of the radius near the wrist, which keeps in place the third extensor tendon of the thumb. This and the bone just above it is the place which we examine for a suspected fracture (termed Colles’s) near the lower end of the radius.

141. =Carpus.=--Below the styloid process of the radius, just on the inner side of the extensors of the thumb, we feel the tubercle of the scaphoid bone. Between the styloid process and the tubercle is the level of the radio-carpal joint. A little lower we feel the trapezium.

Just below the ulna on the palm of the hand we feel the pisiform bone; and on the inner side of this, the cuneiform.

There are several transverse furrows on the palmar aspect of the wrist. The lowest of these, which is slightly convex downwards, corresponds with the upper edge of the anterior annular ligament and the intercarpal joint. The line of the radio-carpal joint, as already stated, is on a level with the apex of the styloid process of the ulna.

In forcible flexion of the wrist, the tendon of the flexor carpi radialis and that of the palmaris longus come up in relief. On the outer side of the first-named tendon we feel the pulse, the radial artery here lying close to the radius.

The tendon of the palmaris longus runs near the middle of the wrist, and close to its inner border runs the median nerve. In letting out deep-seated matter near the wrist, the incision should be made close to and parallel with the inner edge of the radial flexor tendon, so as to avoid injury to the median nerve.

We can feel the tendon of the flexor carpi ulnaris for some distance above the wrist. It overlies the ulnar artery, and somewhat masks its pulsation.

142. =Pulse.=--The ‘pulse at the wrist’ is felt just outside the tendon of the flexor carpi radialis. In feeling the pulse it should be remembered that, in some cases, the superficialis volæ arises higher and is larger than usual. In such cases it runs by the side of the radial artery, and gives additional volume to the pulse. The old writers call it ‘pulsus duplex.’ When in doubt, therefore, it is well to feel the pulse in each wrist.

143. =Great carpal bursa.=--The great synovial sheath under the annular ligament common to the flexor tendons of the fingers and the long flexor of the thumb, extends, upwards, about an inch and a half above the edge of the ligament, and, downwards, as low as the middle of the palm. This general synovial sheath communicates with the special sheaths of the thumb and the little finger; not with that of the index, middle, and ring fingers.

144. ‘=Tabatière anatomique.=’--On the outer side of the wrist we can distinctly see and feel, when in action, the three extensor tendons of the thumb. Between the second and third there is deep depression, at the root of the thumb, which the French humorously call the ‘tabatière anatomique.’ In this depression we can make out--1, the relief of the superficial radial vein; 2, the radial artery, in its passage to the back of the hand; 3, the upper end of the metacarpal bone of the thumb.

145. =Tendons on back of wrist.=--The relative positions of the several extensor tendons of the wrist and fingers, as they play in their grooves over the back of the radius and ulna, can all be distinctly traced when the several muscles are put in action. The length of their synovial sheaths should be remembered. They vary from one inch and a half to two inches and a half. The longest of all are those of the extensors of the thumb. When these sheaths are inflamed and swollen, the motion of the tendons becomes painful and gives rise to a feeling of crepitus, called ‘tenalgia crepitans’ by some writers. It is said to be met with sometimes in pianists.

146. =Lines of arteries.=--The course of the radial artery corresponds with a line drawn from the outer border of the tendon of the biceps at the bend of the elbow down the front of the forearm to the front of the styloid process of the radius. In the upper third of its course the artery is overlapped by the supinator longus. To make allowance for this, the incision for the ligature of the artery in this situation should be made, not precisely in the line of its course, but rather nearer the middle of the forearm.

The line of the ulnar artery runs from the middle of the bend of the elbow (slightly curving inwards) to the outer side of the pisiform bone. The radial and ulnar arteries can, in most cases, be effectually commanded by pressure well applied at the wrist, in wounds of the palmar arch.

Before we make incisions along the forearm, it is always desirable to ascertain whether the ulnar artery, which usually runs under the superficial muscles, may not run abnormally over them; in which case its pulsations can be felt all down the forearm.

_THE HAND._

147. It is beside the purpose here to examine the question whether the hand can tell more than the arm, the leg, or any other part of the body, about the physical constitution of its owner, and to what use it has been put. Those who are interested in this subject should read a very elaborate treatise by Carus,[11] ‘On the Reason and Meaning of the Different Forms of the Hand.’ Still less would I indulge curiosity by inquiring whether the professors of chiromancy, relying on the text ‘erit signum in manu tua et quasi monumentum ante oculos tuos,’ can advance any reasonable pretensions for their assertion that they can read in the furrows of the palm the future destiny of its master.

148. =Furrow in palm.=--The only furrow in the palm useful as a surgical landmark is that which runs transversely across its lower third, and is well seen when the fingers are slightly bent. This transverse furrow corresponds pretty nearly with the metacarpal joints of the fingers, with the upper limit of the synovial sheaths of the flexor tendons of the fingers (that of the little finger excepted (143)); also with the splitting of the palmar fascia into its four slips. The transverse metacarpal ligament lies in the same line with it. Again, a little below this furrow, the digital arteries bifurcate to run along the opposite sides of the fingers.

149. =Interdigital folds.=--By pressing upon the interdigital folds of skin, we can feel the transverse ligament of the fingers, which prevents their too wide separation. The skin of these folds is much thinner on the dorsal than the palmar aspect; hence deep-seated abscesses in the palm very frequently burst on the back of the hand.

150. =Digital furrows.=--Concerning the transverse furrows on the palmar surface of the fingers, notice that the first furrows, close to the palm, do not correspond with the metacarpal joints. The second and third furrows do correspond with their respective joints.

The slight depression observable between the ball of the thumb and that of the little finger corresponds with the middle of the anterior annular ligament.

151. =Palmar arterial arches.=--In opening abscesses in the palm, it is important to bear in mind the position of the large arterial arches which lie beneath the palmar fascia. The line of the superficial palmar arch crosses the palm about the junction of the upper with the lower two-thirds--that is, in the line of the thumb separated widely from the fingers. From this, the digital arteries run straight between the shafts of the metacarpal bones towards the clefts of the fingers. Incisions, therefore, to let out pus beneath the palmar fascia may safely be made in the lower two-thirds of the palm, provided they run in the direction of the middle line of the fingers. The deep palmar arch lies half an inch nearer the wrist than the superficial.

152. =Digital arteries.=--As the digital arteries run along the sides of the fingers, the incision to open a thecal abscess should be made strictly in the middle line. It should be made not over but between the joints, since the sheath is strongest and thickest over the shafts of the phalanges, and therefore more likely to produce strangulation of the enclosed tendons.

153. =Metacarpal joint of thumb.=--The joint of the metacarpal bone of the thumb with the trapezium can be distinctly felt by tracing the dorsal surface of the bone upwards till we come to the prominence which indicates the joint at the bottom of the ‘tabatière anatomique’ (144). Supposing, however, there be much swelling, the knife introduced at the angle between the first and second metacarpal bones readily finds the joint if the blade be directed outwards.

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

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

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

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

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

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

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

_PALPATION BY THE RECTUM._

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

_EXAMINATION PER VAGINAM._

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

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

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

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

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

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

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

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

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

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

NOTES.

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

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

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

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

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

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

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

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

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

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

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

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

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

Transcriber’s Notes

A few obvious errors in punctuation have been fixed.

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