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ANATOMY - SUPERFICIAL AND ARTISTIC . The objects of the study of superficial anatomy are to show, first, the form and proportions of the human body and, second, the surface landmarks which correspond to deeper structures hidden from view. This study blends imperceptibly with others, such as physical anthropology, physiognomy, phrenology and palmistry, but whereas these deal chiefly with variations, superficial anatomy is concerned with the type.

With regard to the proportions of the body the artist and anatomist approach the subject from a slightly different point of view. The former, by a process of artistic selection, seeks the ideal and adopts the proportions which give the most pleasing effect, while the latter desires to know only the mean of a large series of measurements.

The scheme which Dr Paul Richer suggests(Anatomie artistique, Paris, 1890) ,and Professor Arthur Thomson approves ( Anatomy for Art Students, 1896), is to divide the whole body into head-lengths, of which seven and a half make up the stature. Four of these are above the fork and three and a half below (see figs. 1 and 2). Of the four above, one forms the head and face, the second reaches from the chin to the level of the nipples, the third from the nipples to the navel, and the fourth from there to the fork. By dividing these into half-heads other points can be determined; for instance the middle of the first head-length corresponds to the eyes, the middle of the second to the shoulder, of the fourth to the top of the hip-joint, and of the fifth to the knee-joint.

The elbow-joint, when the arms are by the side, is a little above the lower limit of the third head-length, whilst the wrist is opposite the very centre of the stature, three head-lengths and three-quarters from the crown or the soles. The tips of the fingers reach a little below the middle of the fifth head-length. (In fig. the fingers are bent.) By making the stature eight head-lengths instead of seven and a half the artistic effect is increased, as it is also by slightly lengthening the legs in proportion to the body. Approximate average breadth measurements are two heads for the greatest width of the shoulders, one and a half for the greatest width of the hips, one for the narrowest part of the waist, and three-quarters for the breadth of the head on a level with the eyes.

The relation of superficial landmarks to deep structures cannot be treated here in full detail, but the chief points may be indicated. Certain parts of the head may easily be felt through the skin. If the finger is run along the upper margin of the orbit, the notch for the supraorbital nerve may usually be felt at the junction of the inner and middle thirds. At the outer end of [[[Superficial And Artistic]] the margin is its junction with the malar bone, and this easily felt point is known as the external angular process. The junction of the frontal and nasal bones at the root of the nose is the nasion, while at the back of the skull the external occipital protuberance or inion is felt and marks the position of the torcular Herophili, where the venous sinuses meet. The zygoma may be felt running back from the malar bone to just in front of the ear, and two fingers' breadth above the middle of it marks the pterion, a very important point in the localization of intracranial structures. It corresponds to the anterior branch of the middle meningeal artery, to the Sylvian point where the three limbs of the fissure of Sylvius diverge, to the middle cerebral artery, the central lobe of the brain or island of Reil, and the anterior part of the corpus striatum. The fissure of Sylvius can be marked out by drawing a line from the external angular process back through the Sylvian point to the lower part of the parietal eminence.

FIG. I.

a, Serratus magnus. /3, Deltoid.

y, Biceps.

Poupart's ligament. e, Patella.

T.P. Transpyloric plane.

S.C. Subcostal plane., Popliteal space.

I.T. Intertubercular plane. n, Gastrocnemius.

The scale between the figures represents head-lengths.

The position of the sulcus of Rolando is important because of the numerous cortical centres which lie close to it. For practical purposes it may be mapped out by taking the superior Rolandic point, z in. behind the bisection of a line drawn from the nasion to the inion over the vault of the skull, and joining that to the inferior Rolandic point, which is just above the line of the fissure of Sylvius and i in. behind the Sylvian point. The external parieto-occipital fissure, which forms the boundary between the parietal and occipital lobes of the brain, is situated practically at the lambda, which is a hand's breadth (2,i in.) above the inion. The lateral sinus can be mapped out by joining the inion to the asterion, a point two-thirds of the distance from the lambda to the tip of the mastoid process; thence the sinus curves downward and forward toward the tip of the mastoid process. A point i in. horizontally backward from the top of the external auditory meatus will always strike it.

Cranio-cerebral topography has been dealt with by Broca, Bischoff, Turner, Fere, Pozzi, Giacomini, Ecker, Hefftler and Hare. Among the more recent papers are those of R. W. Reid (Lancet, 27th September 1884), W. Anderson and G. Makins ( Lancet, 13th July 1889), Prof. Chiene (detailed in Cunningham's Text-Book of Anatomy ), V. Horsley (Am. Journal Med. Sci., 1887), G. Thane and R. Godlee (Quain's Anatomy - appendix to 10th edition). D. J. Cunningham discusses the whole question in his "Contribution to the Surface Anatomy of the Cerebral Hemispheres" (Cunningham Memoirs, No. vii. R. Irish Academy, Dublin, 1892), and he has prepared a series of casts to illustrate it.

The Face

On the front of the face a line drawn down from the supraorbital notch between the bicuspid teeth to the side of the chin will cut the exit of the second division of the fifth nerve from the infraorbital foramen, a quarter of an inch below the infraorbital margin, and also the exit of the third division of the fifth at the mental foramen, midway between the upper and lower margins of the body of the jaw. In practice it will be found that the angle of the mouth at rest usually corresponds to the interval between the bicuspid teeth. The skin of the eyelids is very thin, and is separated from the subjacent fibrous tarsal plates by the orbicularis palpebrarum muscle. On everting the lids the delicate conjunctival membrane is seen, and between this and the tarsal plates lie the meibomian glands, which can be faintly seen as yellowish streaks. From the free edges of the eyelids come the eyelashes, between which many large sweatglands open, and when one of these is inflamed it causes a "stye." Internally the two eyelids form a little recess called the internal canthus, occupied by a small red eminence, the caruncula lachrymalis, just external to which a small vertical fold of conjunctiva may often be seen, called the plica semilunaris, representing the third eyelid of birds and many mammals. By gently drawing down the lower eyelid the lower punctum may be seen close to the caruncula; it is the pinhole opening into the lower of the two canaliculi which carry away the tears to the lachrymal sac and duct. On the side of the face the facial artery may be felt pulsating about an inch in front of the angle of the jaw; it runs a tortuous course to near the angle of the mouth, the angle of the nose and the inner angle of the eye; in the greater part of its course its vein lies some distance behind it. The parotid gland lies between the ramus of the jaw and the mastoid process; anteriorly it overlaps the masseter to form the socia parotidis, and just below this its duct, the duct of Stensen, runs forward to pierce the buccinator and open into the mouth opposite the second upper molar tooth. The line of this duct may be marked out by joining the lower margin of the tragus to a point midway between the lower limit of the nose and the mouth. The facial or seventh nerve emerges from the skull at the stylomastoid foramen just in front of the root of the mastoid process; in the parotid gland it forms a network called the pes anserinus, after which it divides into six branches which radiate over the face to supply the muscles of expression.

The Neck

In the middle line below the chin can be felt the body of the hyoid bone, just below which is the prominence of the thyroid cartilage called "Adam's apple," better marked in men than in women. Still lower the cricoid cartilage is easily felt, while between this and the suprasternal notch the trachea and isthmus of the thyroid gland may be made out. At the side the outline of the sterno-mastoid muscle is the most striking mark; it divides the anterior triangle of the neck from the posterior. The upper part of the former contains the submaxillary gland, which lies just below the posterior half of the body of the jaw. The line of the common and the external carotid arteries may be marked by joining the sterno-clavicular articulation to the angle of the jaw. The eleventh or spinal accessory nerve corresponds to a line drawn from a point midway between the angle of the jaw and the mastoid process to the middle of the posterior border of the sterno-mastoid muscle and thence across the posterior triangle to the deep surface of the trapezius. The external jugular vein can usually be seen through the skin; it runs in a line drawn from the angle of the jaw to the middle of the clavicle, and close to it are some small lymphatic glands. The anterior jugular vein is smaller, and runs down about half an inch from the middle line of the neck. The clavicle or collar-bone forms the lower limit of the neck, and laterally the outward slope of the neck to the shoulder is caused by the trapezius muscle.

The Chest

It is important to realize that the shape of the FIG. 2.

0, Dimple over posterior superior spine of ilium.

y, Lower angle of scapula.

S, External head of triceps.

e, Depression over great trochanter.

Superficial And Artistic] chest does not correspond to that of the bony thorax which encloses the heart and lungs; all the breadth of the shoulders is due to the shoulder girdle, and contains the axilla and the head of the humerus. In the middle line the suprasternal notch is seen above, while about three fingers' breadth below it a transverse ridge can be felt, which is known as Ludovic's angle and marks the junction between the manubrium and gladiolus of the sternum. Level with this line the second ribs join the sternum, and when these are found the lower ribs may be easily counted in a moderately thin subject. At the lower part of the sternum, where the seventh or last true ribs join it, the ensiform cartilage begins, and over this there is often a depression popularly known as the pit of the stomach. The nipple in the male is situated in front of the fourth rib or a little below; vertically it lies a little external to a line drawn down from the middle of the clavicle; in the female it is not so constant. A little below it the lower limit of the great pectoral muscle is seen running upward and outward to the axilla; in the female this is obscured by the breast, which extends from the second to the sixth rib vertically and from the edge of the sternum to the mid-axillary line laterally. The female nipple is surrounded for half an inch by a more or less pigmented disc, the areola. The apex of a normal heart is in the fifth left intercostal space, three and a half inches from the mid-line.

The Abdomen.

In the mid-line a slight furrow extends from the ensiform cartilage above to the symphysis pubis below; this marks the linea alba in the abdominal wall, and about its middle point is the umbilicus or navel. On each side of it the broad recti muscles can be seen in muscular people. The outline of these muscles is interrupted by three or more transverse depressions indicating the lineae transversae in the recti; there is usually one about the ensiform cartilage, one at the umbilicus, and one between; sometimes a fourth is present below the umbilicus. The upper lateral limit of the abdomen is the subcostal margin formed by the cartilages of the false ribs (8, 9, io) joining one another; the lower lateral limit is the anterior part of the crest of the ilium and Poupart's ligament running from the anterior superior spine of the ilium to the spine of the pubis (see fig. r, 8); these lower limits are marked by definite grooves. Just above the pubic spine is the external abdominal ring, an opening in the muscular wall of the abdomen for the spermatic cord to emerge in the male. The most mddern method of marking out the abdominal contents is to draw three horizontal and two vertical lines; the highest of the former is the transpyloric line of C. Addison (fig. I, T.P.), which is situated half-way between the suprasternal notch and the top of the symphysis pubis; it often cuts the pyloric opening of the stomach an inch to the right of the mid-line. The hilum of each kidney is a little below it, while its left end approximately touches the lower limit of the spleen. It corresponds to the first lumbar vertebra behind. The second line is the subcostal (fig. i, S.C.), drawn from the lowest point of the subcostal arch (tenth rib); it corresponds to the upper part of the third lumbar vertebra, and is an inch or so above the umbilicus; it indicates roughly the transverse colon, the lower ends of the kidneys, and the upper limit of the transverse (3rd) part of the duodenum. The third line is called the intertubercular (fig. i, I.T.), and runs across between the two rough tubercles,which can be felt on the outer lip of the crest of the ilium about two and a half inches from the anterior superior spine. This line corresponds to the body of the fifth lumbar vertebra, and passes through or just above the ileo-caecal valve where the small intestine joins the large. The two vertical or mid-Poupart lines are drawn from the point midway between the anterior superior spine and the pubic symphysis on each side vertically upward to the costal margin. The right one is the most valuable, as the ileo-caecal valve is situated where it cuts the intertubercular line, while the orifice of the vermiform appendix is an inch lower down. At its upper part it meets the transpyloric line at the lower margin of the ribs, usually the ninth, and here the gallbladder is situated. The left mid-Poupart line corresponds in its upper three-quarters to the inner edge of the descending colon. The right subcostal margin corresponds to the lower limit of the liver, while the right nipple is about half an inch above the upper limit of this viscus.

The Back. - There is a well-marked furrow stretching all the way down the middle line of the back from the external occipital protuberance to the cleft of the buttocks. In this the spinous processes of the vertebrae can be felt, especially if the model bend forward. The cervical spines are difficult to feel, except the seventh and sometimes the second, and although the former is called the vertebra prominens, its spine is less easily felt than is that of the first thoracic. In practice it is not very easy to identify any one spine with certainty: one method is to start from the prominent first thoracic and to count down; another is to join the lower angles of the two scapulae (fig. 2, y) when the arms are hanging down, and to take the spine through which the line passes as the seventh.

The spinal furrow is caused by the prominence of the erector spinae muscles on each side; these become less well marked as they run upward. The outlines of the scapulae can be well seen; they cover the ribs from the second to the seventh inclusive. The scapular spine is quite subcutaneous, and can be followed upward and outward from the level of the third thoracic spine to the acromion, and so to the outer end of the clavicle. On the lower margin of the acromion is a little tubercle known as the metacromial process or acromial angle, which is very useful for taking measurements from. The tip of the twelfth rib may usually be felt about two inches above the middle of the iliac crest, but this rib is very variable in length. The highest point of the iliac crest corresponds to the fourth lumbar spine, while the posterior superior iliac spine is on a level with the second sacral vertebra. This posterior superior spine is not easily felt, owing to the ligaments attached to it, but there is usually a little dimple in the skin over it (fig. 2, /3). By drawing horizontal lines through the ist, 3rd and 5th lumbar spines, the transpyloric, subcostal and intertubercular lines or planes may be reproduced behind and the same viscera localized.

The Arm. - Running downward and outward from the inner half of the clavicle, where that bone is convex forward, is the clavicular part of the pectoralis major, while from the outer third of the bone, where it is concave forward, is the clavicular part of the deltoid; between these two muscles is an elongated triangular gap with its base at the clavicle, and here the skin is somewhat depressed, while the cephalic vein sinks between the two muscles to join the axillary vein. The tip of the coracoid process is situated just under cover of the inner edge of the deltoid, one inch below the junction between the outer and middle thirds of the clavicle. The deltoid muscle (fig. i, /3) forms the prominence of the shoulder, and its convex outline is due to the presence of the head of the humerus deep to it; when this is dislocated the shoulder becomes flattened. The pectoralis major forms the anterior fold of the axilla or armpit, the posterior being formed by the latissimus dorsi and teres major muscles. The skin of the floor of this space is covered with hair in the adult, and contains many large sweat glands. The axillary vessels and brachial plexus of nerves lie in the outer wall, while on the inner wall are the serrations of the serratus magnus muscle, the outlines of some of which are seen on the side of the thorax, through the skin, when the arm is raised (fig. r, a). Below the edge of the pectoralis major, the swelling of the biceps (fig. r, y ) begins to be visible, and this can easily be traced into its tendon of insertion, which reaches below the level of the elbow joint. On each side of the biceps is the external and internal bicipital furrow, in the latter of which the brachial artery may be felt and compressed. The median nerve is here in close relation to the artery. At the bend of the elbow the two condyles of the humerus may be felt; the inner one projects beneath the skin, but the outer one is obscured by the rounded outline of the brachio-radialis muscle. The superficial veins at the bend of the elbow are very conspicuous; they vary a good deal, but the typical arrangement is an M, of which the radial and ulnar veins form the uprights, while the outer oblique bar is the median cephalic and the inner oblique the median basilic vein. At the divergence of these two the median vein comes up from the front of the forearm, while [Superficial And Artistic the two vertical limbs are continued up the arm as the cephalic and basilic, the former on the outer side, the latter on the inner. On the back of the arm the three heads of the triceps are distinguishable, the external forming a marked oblique swelling when the forearm is forcibly extended and internally rotated (fig. 2, 8). In the upper part of the front of the forearm the antecubital fossa or triangle is seen; its outer boundary is the brachio-radialis, its inner the pronator radii teres, and where these two join below is the apex. In this space are three vertical structures - externally the tendon of the biceps, just internal to this the brachial artery, and still more internally the median nerve. Coming from the inner side of the biceps tendon the semi-lunar fascia may be felt; it passes deep to the median basilic vein and superficial to the brachial artery, and in former days was a valuable protection to the artery when unskilful operators were bleeding from the median basilic vein. About the middle of the forearm the fleshy parts of the superficial flexor muscles cease, and only the tendons remain, so that the limb narrows rapidly. In front of the wrist there is a superficial plexus of veins, while deep to this two tendons can usually be made to start up if the wrist be forcibly flexed; the outer of these is the flexor carpi radialis, which is the physician's guide to the radial artery where the pulse is felt. If the finger is slipped to the outer side of this tendon, the artery, which here is very superficial, can be felt beating. The inner of the two tendons is the palmaris longus, though it is not always present. On cutting down between these two the median nerve is reached.

The wrist joint may be marked out by feeling the styloid process of the radius on the outer side, and the styloid process of the ulna on the inner side behind, and joining these two by a line convex upward. The superficial appearance of the palm of the hand is described in the article on Palmistry; with regard to anatomical landmarks the superficial palmar arterial arch is situated in the line of the abducted thumb, while the deep arch is an inch nearer the wrist. The digital nerves correspond to lines drawn from the clefts of the fingers toward the wrist. On the back of the forearm the olecranon process of the ulna is quite subcutaneous, and during extension of the elbow is in a line with the two condyles, while between it and the inner condyle lies the ulnar nerve, here known popularly as the "funny bone." From the olecranon process the finger may be run down the posterior border of the ulna, which is subcutaneous as far as the styloid process at the lower end. On the dorsum of the hand is a plexus of veins, deep to which the extensor tendons are seen on extending the fingers. When the thumb is extended, two tendons stand out very prominently, and enclose a triangular space between them which is sometimes known as the "anatomical snuff box"; the outer of these is the tendon of the extensor brevis, the inner of the extensor longus pollicis. Situated deeply in the space is the radial artery, covered by the radial vein. On the dorsum of the hand there is a plexus of veins, and deep to these the tendons of the extensor longus digitorum stand out when the wrist and fingers are extended.

The Leg

Just below Poupart's ligament (fig. z, 8), a triangular depression with its apex downward may be seen in muscular subjects; it corresponds to Scarpa's triangle, and its inner border is the tendon of the adductor longus, which is easily felt if the model forcibly adducts the thigh. In this triangle the superficial inguinal glands may be made out. The head of the femur lies just below the centre of Poupart's ligament. The sartorius muscle forms the outer boundary of the triangle, and may be traced from the anterior superior spine obliquely downward and inward, across the front of the thigh, to the inner side of the knee. The two vasti muscles are well marked, the internal being the lower and forming with the sartorius the rounded bulging above the inner side of the knee. The internal saphenous vein runs superficially up the inner side of the thigh from behind the internal condyle to the femur to the saphenous opening in the deep fascia, the top of which is an inch horizontally outward from the spine of the pubis. On the other side of the thigh a groove runs down which corresponds to the ilio-tibial band, a thickening of the fascia lata or deep fascia; the lower end of this leads to the head of the fibula. On the front of the thigh, below the sartorius, the rectus muscle makes a prominence which leads down to the patella, the outlines of which bone are very evident (fig. r, e). The only part of the femur besides the great trochanter which is superficial is the lower end, and this forms the two condyles for articulation with the tibia. If the posterior part of the inner condyle be joined to the mid-point between the anterior superior spine and the symphysis pubis, when the thigh is externally rotated, the line will correspond in its upper twothirds to that of the common and superficial femoral arteries, the former occupying the upper inch and a half. The common femoral vein lies just internal to its artery, while the anterior crural nerve is a quarter of an inch external to the latter. The rounded mass of the buttock is formed by the gluteus maximus muscle covered by fat; the lower horizontal boundary is called the fold of the nates, and does not correspond exactly to the lower edge of the muscle. At the side of the buttock is a depression (fig. 2, e) where the great trochanter of the femur can be felt; a line, named after Nelaton, drawn from the anterior superior spine to the tuberosity of the ischium, passes through the top of this. On the back of the thigh the hamstrings form a distinct swelling; below the middle these separate to enclose the diamond-shaped popliteal space (fig. 2, 0, the outer hamstrings or biceps being specially evident, while, on the inner side, the tendons of the semi-tendinosus and semi-membranosus can be distinguished. The external popliteal nerve may be felt just behind the biceps tendon above the head of the fibula.

On the front of the leg, below the knee, the ligamentum patellae is evident, leading down from the patella (fig. i, e) to the tubercle of the tibia. From this point downward the anterior border of the tibia or shin is subcutaneous, as is also the internal surface of the tibia. Internal to the skin is the fleshy mass made by the tibialis anticus and extensor longus digitorum muscles. At the inner side of the ankle the internal malleolus is subcutaneous, while on the outer side the tip of the external malleolus is rather lower and farther back. Both this malleolus and the lower quarter of the shaft of the fibula are subcutaneous, and this area, if traced upward, is continuous with a furrow on the outer side of the leg which separates the anterior tibial from the peroneal groups of muscles, and eventually leads to the subcutaneous head of the fibula. At the back of the leg the two heads of the gastrocnemius form the calf, the inner one (fig. 2, i) being larger than the outer. Between the two, in the mid-line of the calf, the external saphenous vein and nerve lie, while lower down they pass behind the external malleolus to the outer side of the foot. The internal saphenous vein and nerve lie just behind the internal border of the tibia, and below pass in front of the internal malleolus. At the level of the ankle-joint the tibialis posticus and flexor longus digitorum tendons lie just behind the internal malleolus, while the peroneus longus and brevis are behind the external. Running down to the heel is the tendo Achillis with the plantaris on its inner side. On the dorsum of the foot the musculo-cutaneous nerve may be seen through the skin in thin people when the toes are depressed; it runs from the anterior peroneal furrow, already described, to all the toes, except the cleft between the two inner ones. There is also a venous arch to be seen, the two extremities of which pass respectively into the external and internal saphenous veins. The long axis of the great toe, even in races unaccustomed to boots, runs forward and outward, away from the mid-line between the two feet, so that perfectly straight inner sides to boots are not really anatomical. The second toe in classical statues is often longer than the first, but this is seldom seen in Englishmen. On the outer side of the sole the skin is often in contact with the ground all along, but on the inner side the arch is more marked, and, except in flat-footed people, there is an area in which the sole does not touch the ground at all.

For further details of surface anatomy see Anatomy for Art Students, by A. Thomson (Oxford, 1896); Harold Stiles's article in Cunningham's Text-Book of Anatomy (Young J. Pentland, 1902); G. Thane and R. Godlee's Appendix to Quain's Anatomy (Longmans, Green & Co., 1896); Surface Anatomy, by B. Windle and Manners Smith (H. K. Lewis, 1896); Landmarks and Surface Markings of the Human Body, by L. B. Rawling (H. K. Lewis, 1906); Surface Anatomy, by T. G. Moorhead (Bailliere, Tindall & Cox, 1905). No one interested in the subject should omit to read an article on "Art in its relation to Anatomy," by W. Anderson, British Medical Journal, 10th August 1895. (F. G. P.)