Surgical Anatomy Part 1

Surgical Anatomy.

by Joseph Maclise.

PREFACE.

The object of this work is to present to the student of medicine and the pract.i.tioner removed from the schools, a series of dissections demonstrative of the relative anatomy of the princ.i.p.al regions of the human body. Whatever t.i.tle may most fittingly apply to a work with this intent, whether it had better be styled surgical or medical, regional, relative, descriptive, or topographical anatomy, will matter little, provided its more salient or prominent character be manifested in its own form and feature. The work, as I have designed it, will itself show that my intent has been to base the practical upon the anatomical, and to unite these wherever a mutual dependence was apparent.

That department of anatomical research to which the name topographical strictly applies, as confining itself to the mere account of the form and relative location of the several organs comprising the animal body, is almost wholly isolated from the main questions of physiological and transcendental interest, and cannot, therefore, be supposed to speak in those comprehensive views which anatomy, taken in its widest signification as a science, necessarily includes. While the anatomist contents himself with describing the form and position of organs as they appear exposed, layer after layer, by his dissecting instruments, he does not pretend to soar any higher in the region of science than the humble level of other mechanical arts, which merely appreciate the fitting arrangement of things relative to one another, and combinative to the whole design of the form or machine of whatever species this may be, whether organic or inorganic. The descriptive anatomist of the human body aims at no higher walk in science than this, and hence his nomenclature is, as it is, a barbarous jargon of words, barren of all truthful signification, inconsonant with nature, and blindly irrespective of the cognitio certa ex principiis certis exorta.

Still, however, this anatomy of form, although so much requiring purification of its nomenclature, in order to clothe it in the high reaching dignity of a science, does not disturb the medical or surgical pract.i.tioner, so far as their wants are concerned. Although it may, and actually does, trammel the votary who aspires to the higher generalizations and the development of a law of formation, yet, as this is not the object of the surgical anatomist, the nomenclature, such as it is, will answer conveniently enough the present purpose.

The anatomy of the human form, contemplated in reference to that of all other species of animals to which it bears comparison, const.i.tutes the study of the comparative anatomist, and, as such, establishes the science in its full intent. But the anatomy of the human figure, considered as a species, per se, is confessedly the humblest walk of the understanding in a subject which, as anatomy, is relationary, and branches far and wide through all the domain of an animal kingdom. While restricted to the study of the isolated human species, the cramped judgment wastes in such narrow confine; whereas, in the expansive gaze over all allying and allied species, the intellect bodies forth to its vision the full appointed form of natural majesty; and after having experienced the manifold a.n.a.logies and differentials of the many, is thereby enabled, when it returns to the study of the one, to view this one of human type under manifold points of interest, to the appreciation of which the understanding never wakens otherwise. If it did not happen that the study of the human form (confined to itself) had some practical bearing, such study could not deserve the name of anatomical, while anatomical means comparative, and whilst comparison implies inductive reasoning.

However, practical anatomy, such as it is, is concerned with an exact knowledge of the relations.h.i.+p of organs as they stand in reference to each other, and to the whole design of which these organs are the integral parts. The figure, the capacity, and the contents of the thoracic and abdominal cavities, become a study of not more urgent concernment to the physician, than are the regions named cervical, axillary, inguinal, &c., to the surgeon. He who would combine both modes of a relationary practice, such as that of medicine and surgery, should be well acquainted with the form and structures characteristic of all regions of the human body; and it may be doubted whether he who pursues either mode of practice, wholly exclusive of the other, can do so with honest purpose and large range of understanding, if he be not equally well acquainted with the subject matter of both. It is, in fact, more triflingly fas.h.i.+onable than soundly reasonable, to seek to define the line of demarcation between the special callings of medicine and surgery, for it will ever be as vain an endeavour to separate the one from the other without extinguis.h.i.+ng the vitality of both, as it would be to sunder the trunk from the head, and give to each a separate living existence. The necessary division of labour is the only reason that can be advanced in excuse of specialisms; but it will be readily agreed to, that that pract.i.tioner who has first laid within himself the foundation of a general knowledge of matters relationary to his subject, will always be found to pursue the speciality according to the light of reason and science.

Anatomy--the [Greek words], the knowledge based on principle--is the foundation of the curative art, cultivated as a science in all its branchings; and comparison is the nurse of reason, which we are fain to make our guide in bringing the practical to bear productively. The human body, in a state of health, is the standard whereunto we compare the same body in a state of disease. The knowledge of the latter can only exist by the knowledge of the former, and by the comparison of both.

Comparison may be fairly termed the pioneer to all certain knowledge. It is a potent instrument--the only one, in the hands of the pathologist, as well as in those of the philosophic generalizer of anatomical facts, gathered through the extended survey of an animal kingdom. We best recognise the condition of a dislocated joint after we have become well acquainted with the contour of its normal state; all abnormal conditions are best understood by a knowledge of what we know to be normal character. Every anatomist is a comparer, in a greater or lesser degree; and he is the greatest anatomist who compares the most generally.

Impressed with this belief, I have laid particular emphasis on imitating the character of the normal form of the human figure, taken as a whole; that of its several regions as parts of this whole, and that of the various organs (contained within those regions) as its integrals or elements. And in order to present this subject of relative anatomy in more vivid reality to the understanding of the student, I have chosen the medium of ill.u.s.trating by figure rather than by that of written language, which latter, taken alone, is almost impotent in a study of this nature.

It is wholly impossible for anyone to describe form in words without the aid of figures. Even the mathematical strength of Euclid would avail nothing, if shorn of his diagrams. The professorial robe is impotent without its diagrams. Anatomy being a science existing by demonstration, (for as much as form in its actuality is the language of nature,) must be discoursed of by the instrumentality of figure.

An anatomical ill.u.s.tration enters the understanding straight-forward in a direct pa.s.sage, and is almost independent of the aid of written language. A picture of form is a proposition which solves itself. It is an axiom encompa.s.sed in a frame-work of self-evident truth. The best subst.i.tute for Nature herself, upon which to teach the knowledge of her, is an exact representation of her form.

Every surgical anatomist will (if he examine himself) perceive that, previously to undertaking the performance of an operation upon the living body, he stands rea.s.sured and self-reliant in that degree in which he is capable of conjuring up before his mental vision a distinct picture of his subject. Mr. Liston could draw the same anatomical picture mentally which Sir Charles Bell's handicraft could draw in reality of form and figure. Scarpa was his own draughtsman.

If there may be any novelty now-a-days possible to be recognised upon the out-trodden track of human relative anatomy, it can only be in truthful and well-planned ill.u.s.tration. Under this view alone may the anatomist plead an excuse for reiterating a theme which the beautiful works of Cowper, Haller, Hunter, Scarpa, Soemmering, and others, have dealt out so respectably. Except the human anatomist turns now to what he terms the practical ends of his study, and marshals his little knowledge to bear upon those ends, one may proclaim anthropotomy to have worn itself out. Dissection can do no more, except to repeat Cruveilhier. And that which Cruveilhier has done for human anatomy, Muller has completed for the physiological interpretation of human anatomy; Burdach has philosophised, and Magendie has experimented to the full upon this theme, so far as it would permit. All have pushed the subject to its furthest limits, in one aspect of view. The narrow circle is footworn. All the needful facts are long since gathered, sown, and known. We have been seekers after those facts from the days of Aristotle. Are we to put off the day of attempting interpretation for three thousand years more, to allow the human physiologist time to slice the brain into more delicate atoms than he has done hitherto, in order to coin more names, and swell the dictionary? No! The work must now be retrospective, if we would render true knowledge progressive. It is not a list of new and disjointed facts that Science at present thirsts for; but she is impressed with the conviction that her wants can alone be supplied by the creation of a new and truthful theory,--a generalization which the facts already known are sufficient to supply, if they were well ordered according to their natural relations.h.i.+p and mutual dependence. "Le temps viendra peut-etre," says Fontenelle, "que l'on joindra en un corps regulier ces membres epars; et, s'ils sont tels qu'on le souhaite, ils s'a.s.sembleront en quelque sorte d'eux-memes.

Plusieurs verites separees, des qu'elles sont en a.s.sez grand nombre, offrent si vivement a l'esprit leurs rapports et leur mutuelle dependance, qu'il semble qu'apres les avoir detachees par une espece de violence les unes des autres, elles cherchent naturellement a se reunir."--(Preface sur l'utilite des Sciences, &c.)

The comparison of facts already known must henceforward be the scalpel which we are to take in hand. We must return by the same road on which we set out, and reexamine the things and phenomena which, as novices, we pa.s.sed by too lightly. The travelled experience may now sit down and contemplate.

That which I have said and proved elsewhere in respect to the skeleton system may, with equal truth, be remarked of the nervous system--namely, that the question is not in how far does the limit of diversity extend through the condition of an evidently common a.n.a.logy, but by what rule or law the uniform ens is rendered the diverse ent.i.ty? The womb of anatomical science is pregnant of the true interpretation of the law of unity in variety; but the question is of longer duration than was the life of the progenitor. Though Aristotle and Linnaeus, and Buffon and Cuvier, and Geoffroy St. Hilaire and Leibnitz, and Gothe, have lived and spoken, yet the present state of knowledge proclaims the Newton of physiology to be as yet unborn. The iron scalpel has already made acquaintance with not only the greater parts, but even with the infinitesimals of the human body; and reason, confined to this narrow range of a subject, perceives herself to be imprisoned, and quenches her guiding light in despair. Originality has outlived itself; and discovery is a long-forgotten enterprise, except as pursued in the microcosm on the field of the microscope, which, it must be confessed, has drawn forth demonstrations only commensurate in importance with the magnitude of the littleness there seen.

The subject of our study, whichever it happen to be, may appear exhausted of all interest, and the promise of valuable novelty, owing to two reasons:--It may be, like descriptive human anatomy, so cold, poor and sterile in its own nature, and so barren of product, that it will be impossible for even the genius of Promethean fire to warm it; or else, like existing physiology, the very point of view from which the mental eye surveys the theme, will blight the fair prospect of truth, distort induction, and clog up the paces of ratiocination. The physiologist of the present day is too little of a comparative anatomist, and far too closely enveloped in the absurd jargon of the anthropotomist, ever to hope to reveal any great truth for science, and dispel the mists which still hang over the phenomena of the nervous system. He is steeped too deeply in the base nomenclature of the antique school, and too indolent to question the import of Pons, Commissure, Island, Taenia, Nates, Testes, Cornu, Hippocamp, Thalamus, Vermes, Arbor Vitro, Respiratory Tract, Ganglia of Increase, and all such phrase of unmeaning sound, ever to be productive of lucid interpretation of the cerebro-spinal ens.

Custom alone sanctions his use of such names; but

"Custom calls him to it!

What custom wills; should custom always do it, The dust on antique time would lie unswept, And mountainous error be too highly heaped, For truth to overpeer."

Of the ill.u.s.trations of this work I may state, in guarantee of their anatomical accuracy, that they have been made by myself from my own dissections, first planned at the London University College, and afterwards realised at the Ecole Pratique, and School of Anatomy adjoining the Hospital La Pitie, Paris, a few years since. As far as the subject of relative anatomy could admit of novel treatment, rigidly confined to facts unalterable, I have endeavoured to give it.

The unbroken surface of the human figure is as a map to the surgeon, explanatory of the anatomy arranged beneath; and I have therefore left appended to the dissected regions as much of the undissected as was necessary. My object was to indicate the interior through the superficies, and thereby ill.u.s.trate the whole living body which concerns surgery, through its dissected dead counterfeit. We dissect the dead animal body in order to furnish the memory with as clear an account of the structure contained in its living representative, which we are not allowed to a.n.a.lyse, as if this latter were perfectly translucent, and directly demonstrative of its component parts.

J. M

TABLE OF CONTENTS.

PREFACE

INTRODUCTORY TO THE STUDY OF ANATOMY AS A SCIENCE.

COMMENTARY ON PLATES 1 & 2

THE FORM OF THE THORAX, AND THE RELATIVE POSITION OF ITS CONTAINED PARTS--THE LUNGS, HEART, AND LARGER BLOOD VESSELS.

The structure, mechanism, and respiratory motions of the thoracic apparatus. Its varieties in form, according to age and s.e.x. Its deformities. Applications to the study of physical diagnosis.

COMMENTARY ON PLATES 3 & 4

THE SURGICAL FORM OF THE SUPERFICIAL, CERVICAL, AND FACIAL REGIONS, AND THE RELATIVE POSITION OF THE PRINc.i.p.aL BLOOD VESSELS, NERVES, ETC.

The cervical surgical triangles considered in reference to the position of the subclavian and carotid vessels, &c. Venesection in respect to the external jugular vein. Anatomical reasons for avoiding transverse incisions in the neck. The parts endangered in surgical operations on the parotid and submaxillary glands, &c.

COMMENTARY ON PLATES 5 & 6

THE SURGICAL FORM OF THE DEEP CERVICAL AND FACIAL REGIONS, AND THE RELATIVE POSITION OF THE PRINc.i.p.aL BLOOD VESSELS, NERVES, ETC.

The course of the carotid and subclavian vessels in reference to each other, to the surface, and to their respective surgical triangles.

Differences in the form of the neck in individuals of different age and s.e.x. Special relations of the vessels. Physiological remarks on the carotid artery. Peculiarities in the relative position of the subclavian artery.

COMMENTARY ON PLATES 7 & 8

THE SURGICAL DISSECTION OF THE SUBCLAVIAN AND CAROTID REGIONS, AND THE RELATIVE ANATOMY OF THEIR CONTENTS.

General observations. Abnormal complications of the carotid and subclavian arteries. Relative position of the vessels liable to change by the motions of the head and shoulder. Necessity for a fixed surgical position in operations affecting these vessels. The operations for tying the carotid or the subclavian at different situations in cases of aneurism, &c. The operation for tying the innominate artery. Reasons of the unfavourable results of this proceeding.

COMMENTARY ON PLATES 9 & 10

THE SURGICAL DISSECTION OF THE EPISTERNAL OR TRACHEAL REGION, AND THE RELATIVE POSITION OF ITS MAIN BLOOD VESSELS, NERVES, ETC.

Varieties of the primary aortic branches explained by the law of metamorphosis. The structures at the median line of the neck. The operations of tracheotomy and laryngotomy in the child and adult, The right and left brachio-cephalic arteries and their varieties considered surgically.

COMMENTARY ON PLATES 11 & 12

THE SURGICAL DISSECTION OF THE AXILLARY AND BRACHIAL REGIONS, DISPLAYING THE RELATIVE POSITION OF THEIR CONTAINED PARTS.

The operation for tying the axillary artery. Remarks on fractures of the clavicle and dislocation of the humerus in reference to the axillary vessels. The operation for tying the brachial artery near the axilla.

Mode of compressing this vessel against the humerus.