Surface anatomy

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A Moment in History

William S. Halsted, MD
(1852 – 1922)

American anatomist, teacher, and surgeon, William Stewart Halsted was born in New York City, USA to a wealthy family of English origin. His father was involved in charitable work and Governor and trustee to a city hospital. Not a brilliant student initially, Halsted took an undergraduate in Liberal Arts in Yale, CT., after which he entered the Medical College of Physicians at the Columbia College, where he excelled.

As a second-year medical student Halsted applied and obtained a position in surgery at a local hospital. In here he learned about Lister’s antiseptic technique and became an adamant proponent of it to reduce infection. In 1877 Halsted obtained his MD. After a short time as House Physician at the New York Hospital, Halsted traveled to Europe to further his education studying for two years at the Universities of Vienna, Leipzig, and W?rzburg.

Besides being at the forefront of surgical and antiseptic techniques (introducing the use of rubber gloves in surgery), Halsted was extremely concerned with the way medical students were taught in the US. He pioneered bedside clinical round discussions with the medical students after two years of basic sciences studies. Halsted developed the idea of a patient chart; he also developed the residency program for medical students in use today.

Halsted is probably the most influential researcher and surgeon at the turn of the century. He dedicated time to the study of intestinal anastomoses and the use of silk as a suture material. His experimental work in 1887 proved that the inclusion of the submucosa layer in an anastomosis was mandatory, as well that a single layered anastomosis was enough to attain closure. Perhaps Halsted’s most important contribution was the application and use of the scientific method to surgical questions. Halsted’s principles, also known as "Halsted's Rules of Surgery", set the standards used today in surgical suturing and surgical stapling.

He also pioneered the development and surgical techniques for radical mastectomy as a treatment for breast cancer.

As a side effect of this studied in anesthesia and the use of cocaine for anesthesia, Halsted became addicted to this substance, a problem that followed him through the years. Without impairing his capacity as a researcher and a surgeon, Halsted eventually recovered. He died in Baltimore in 1922 as a complication to surgery.

Sources:
1. Dubay, A. D., & Franz, G. M. (2003). Acute Wound Healing: The Biology of Acute Wound Failure. Surg Clin NA, 83, 463-481.
2. Halsted, W. S. (1887). Circular Suture of the Intestine - An Experimental Study. Am J Med Sci, 436-461.
3. “William Stewart Halsted: his life and contributions to surgery” Osborne, P. Lancet Oncol 2007; 8: 256–65
4. “William Stewart Halsted: Surgical pioneer” Burress, P Endoc Today (2010), 8: (2) 22
5. “William Stewart Halsted (1852–1922) Neurological stamp” Haas, LF J Neurol Neurosurg Psych 2000;69:641
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Details: Published: August 21, 2018

Surface anatomy art by Danny Quirk - with permission

UPDATED: Surface anatomy is a subset of human anatomy that studies the relationship of external anatomical landmarks and deeply situated structures. These landmarks are created by cartilage, bones, tendons and muscles. In some cases they may be caused by a hypertrophic or diseased organ. Palpation is and art and my favorite book on the subject is the "Trail Guide to the Body" series by Andrew Biel

Surface anatomy is a core clinical skill for physicians, physical therapists and other health care professionals (HCP), as palpation in specific locations can lead to rapid diagnosis in certain cases. It is also used in surgery to determine the appropriate place for incisions or insertion of a trocar in the case of minimally invasive surgery.

It is true that individual habitus and anatomical variations must make the HCP wary of potential mistakes, but in the majority of cases these anatomical landmarks and diagnoses are correct.

Many book chapters have been written on the topic, but unfortunately, the need to dedicate time to modern discoveries have reduced the time spent on this wonderful learning tool to the point that modern books of anatomy barely touch upon the subject. Many feel today that the need for this tool has been made irrelevant by the bed-side availability of ultrasound imaging. I have to agree with Standring (2012) when she states “I am not convinced that surface anatomy is under growing threat from modern imaging technology…” There is and always will be the need for applied surface anatomy, although maybe not in the way and depth it was used in the past when imaging technology was scarce and expensive.

In order to make the importance of surface anatomy relevant in medical schools, some have added body painting as a tool in their anatomical curriculum with great results. Will it be used everywhere? I doubt it, but here again is a link between human anatomy and art, which our contributor Pascale Pollier presents through her art in "Artem Medicalis".

The artwork in this article is by Danny Quirk. Click on the image for a larger depiction. The video links are for the RMIT University Muscle Man and the Skeletal Man body paintings from the class by Dr. Claudia Diaz.

Personal note: One of the best book chapters on Surface Anatomy was written in "The Anatomical Basis of Clinical Practice" by Becker, Wilson and Gehweiler (1971). Unfortunately, although the content is very good, the images used, the tongue-in-cheek humor, and writing style used by the authors, plus the times at which the book was published forced the publisher stop the sales of this book. It was banned from use in medical colleges through the country. Known to many as the "green book" because of its cover, it is today considered a collector's curiosity. In the "sources" section of this article you can find a links to a journal article on the subject as well as images of the book. Dr. Miranda.

Sources:
1. “Evidence-Based Surface Anatomy” Standrig, S J Clin Anat (2012) 25:813–815
2. “Giving Color to a New Curriculum: Body paint as a Tool in Medical Education” Den Akker, JW. Et al J Clin Anat (2002) 15:356–362
3. “Body-Painting: A Tool Which Can Be Used to Teach Surface Anatomy” Nanjundaiah, K. J Clin Diag Res (2012) October, Vol-6(8): 1405-1408 Copy of the article here
4. “RMIT students paint anatomical man into human textbook” RMIT Dr. Diaz, C. Copy of the article here
5. “Should We Use Body Painting to Teach Anatomy?” Gambino, M article at Smithsonian.com
6. “The role of Fresh Tissue Dissection and Anatomic Body Painting in Anatomy Education” Bennet, C. PPT presentation on PDF here
7. " The anatomical Basis of Medical Practice" Becker, RF. Wilson, JW, Gehweiler, JA 1971, Baltimore, Williams & Wilkins
8. "The Pornographic Anatomy Book? The Curious Tale of The Anatomical Basis of Medical Practice" Halperin EC, Acad Med (2009) 84:2; 278-283 Article here
9. "The Objectification of Female Surface Anatomy" Ruiz, V. Internet article. Click here

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