THE ABDOMEN.The student is assumed to be familiar with the conventional lines dividing the abdomen into regions.61.Abdominal lines.—The linea alba, or central line of the abdomen, marks the union of the aponeuroses of the abdominal muscles. It runs from the apex of the ensiform cartilage to the symphysis pubis. As this line is the thinnest and least vascular part of the abdominal wall, we make our incision along it in ovariotomy, and in the high operation of lithotomy; in it, we tap the abdomen in ascites, and the distended bladder in retention of urine.The so-called ‘linea semilunaris,’ at the outer border of the sheath of the rectus, corresponds with a line, drawn slightly curved (with the concavity towards the linea alba), from the lowest part of the seventh rib to the spine of the pubes. This line would be in an adult about three inches from the umbilicus; but in an abdomen distended by dropsy or other cause, the distance is increased in proportion.It is important to know the position of the ‘lineæ transversæ,’ or tendinous intersections across the rectus abdominis. There are rarely any below the umbilicus, and generally three above it. The first is about the level of the umbilicus. The second is about four inches higher—that is, about the level of the lowest part of the tenth rib. These are the principal lines, and they divide the upper part of each rectus into two nearly quadrilateral portions, an upper and a lower: of these, those on the right side are a trifle larger than on the left. Wesee these muscular squares pretty plainly in some athletic subjects. Much more frequently we see them, too much exaggerated, on canvas and in marble. Artists are apt to exaggerate them, and make the front of the belly too much like a chess-board. It is lucky for them that all the world do not see with anatomical eyes.A familiarity with the shape and position of these divisions of the rectus is of importance, lest we should, in ignorance, make a mistake in our diagnosis. A spasmodic contraction of one of these divisions, particularly the upper, or a collection of matter within its sheath, has been frequently mistaken for deep-seated abdominal disease.In the erect position, the anterior superior spines of the ilia are a little below the level of the promontory of the sacrum. The bifurcation of the aorta is on about the level of the highest part of the crest of the ilium.62.Umbilicus.—The umbilicus is not midway between the ensiform cartilage and the pubes, but rather nearer to the pubes. In all cases it is situated above the centre of a man’s height. It is a vulgar error to say that when a man lies with legs and arms outstretched, and a circle is drawn round him, the umbilicus lies in the centre of it. This central point is in most persons just above the pubes.In very corpulent persons two deep transverse furrows run across the abdomen. One runs across the navel and completely conceals it. The other is lower down, just above the fat of the pubes. In tapping the bladder above the pubes in such a case, the trochar should be introduced where this line intersects the linea alba.Although the position of the umbilicus varies a little in different persons, as the abdomen is unusually protuberant or the reverse, still, as a general rule, it is placed about the level of the body of the third lumbar vertebra. Now, since the aorta divides a little below the middle of the fourth lumbar, it follows that the best place to apply pressure on this great vessel is one inch below the umbilicus, and slightly to the left of it (65). That the aorta can, under favourable circumstances, be compressed under chloroform sufficiently to curean aneurysm below it, is proved by recorded cases, and by none more effectually than by a case related in the second volume of the ‘Reports of St. Bartholomew’s Hospital.’It may be asked, why not apply pressure on the aorta above the umbilicus? The answer is, that the aorta above the umbilicus is farther from the surface, and is, moreover, covered by important structures upon which pressure would be dangerous.63.Parts behind linea alba.—Let us next consider what viscera lie immediately behind the linea alba. For two or three fingers’ breadth below the ensiform cartilage there is the left lobe of the liver, which here crosses the middle line. Below the edge of the liver comes the stomach, more or less in contact with the linea alba, according to its degree of distension. In extreme distension the stomach pushes everything out of the way, and occupies all the room between the liver and the umbilicus. When empty and contracted, it retreats behind the liver, and lies flat in front of the pancreas at the back of the abdomen; thus giving rise to the hollow termed the ‘pit of the stomach.’ But as the stomach distends, it makes a considerable fulness where there was a pit. The middle of the transverse colon lies above the umbilicus, occupying space (vertically two or three inches) according to its distension. Behind and below the umbilicus, supposing the bladder contracted, are the small intestines, covered by the great omentum.64.Peritoneum.—The peritoneum is in contact with the linea alba all the way down to the pubes, when the bladder is empty. But when the bladder distends, it raises the peritoneum from the middle line above the pubes; so that with a bladder distended half-way up to the umbilicus, there is a space of nearly two inches above the symphysis where the bladder may be tapped without risk of injury to the peritoneum. For the same reason, we have space sufficient for the successful performance of the high operation for stone. This fact in anatomy must have been well understood by Jean de Dot, the smith at Amsterdam, who, in the seventeenth century, cut himself in the linea alba above the pubes, and took out of hisbladder a stone as large as a hen’s egg. The stone, the knife, and the portrait of the operator, may be seen to this day in the museum at Leyden.65.Division of Aorta.—The aorta generally divides at a point one inch and a half below the umbilicus. A more reliable guide to this division than the umbilicus, is a point (a very little to the left) of the middle line about the level of the highest part of the crest of the ilium. A line drawn with a slight curve outwards from this point to the groin, where the pulsation of the common femoral can be distinctly felt (rather nearer to the pubes than the ilium), gives the direction of the common iliac and external iliac arteries. About the first two inches of this line belong to the common iliac, the remainder to the external. Slight pressure readily detects the pulsation of the external iliac above ‘Poupart’s ligament.’As a rule, the length of the common iliac is about two inches, but it should be remembered there are frequent deviations. It may be between three-quarters of an inch and three inches and a half long. These varieties may arise either from a high division of the aorta, or a low division of the common iliac, or both. It is impossible to ascertain during life what is its length in a given instance, for there is no necessary relation between its length and the height of the stature. It is often short in tall men, andvice versâ. Anatomists generally describe the right as a trifle longer than the left; but their average length is pretty nearly the same.66.Mr.Abernethy, who in the year 1796 first put a ligature round the external iliac, made his incision in the line of the artery. But the easiest and safest way to reach the vessel is by an incision (recommended in the first instance by Sir Astley Cooper, and now generally adopted), beginning just on the inner side of the artery, a little above Poupart’s ligament, and continued upwards and outwards a little beyond the spine of the ilium. The same incision extended farther in the same direction would reach the common iliac.67.Bony prominences.—The anterior superior spine of the ilium, the spine of the pubes, and the line of Poupart’s ligament, are landmarks with which every surgeon should be thoroughly familiar.68.Spine of ilium.—The spine of the ilium is the spot from which we measure the length of the lower extremity. It is a valuable landmark in determining the nature of injuries to the pelvis and the hip. The thumb easily feels the spine, even in fat persons. Its position with regard to the trochanter major should be carefully examined. The best way to do this is to place the thumbs firmly on the opposite spines, and to grasp the trochanters with the fingers. Any abnormal position on one side is thus easily ascertained with the sound side as a guide.69.Spine of pubes.—The spine of the pubes is the best guide to the external abdominal ring. It cannot easily be felt by placing the finger directly over it, since it is generally covered by fat. To feel it distinctly, we should push up the skin of the scrotum and get beneath the subcutaneous fat. If there be any difficulty in finding it, abduct the thigh, and the tense tendon of the adductor longus will lead up to it.The position of the spine of the pubes is appealed to as a means of diagnosis in doubt between inguinal and femoral hernia. The spine lies on the outer side of the neck of an inguinal hernia, on the inner side of the neck of a femoral.The spine of the pubes is nearly on the same horizontal line as the upper part of the trochanter major. In this line, about one full inch external to the spine, is the femoral ring. Here is the seat of stricture in a femoral hernia.70.Poupart’s ligament, or crural arch.—The line of Poupart’s ligament (crural arch) is in most persons indicated by a slight crescent-like furrow along the skin. It corresponds with a line drawn not straight, but with a gentle curve downwards from the spine of the ilium to the spine of the pubes. With the help of the preceding landmarks it is easy to find the exact position of the external and internal abdominal rings, and the direction of the inguinal canal.71.Abdominal rings.—The external abdominal ring issituated immediately above the spine of the pubes. It is an oval opening with the long axis directed obliquely downwards and inwards. Though its size varies a little in different persons, yet as a rule it will admit the end of the little finger, so that we can tell by examination whether it be free or otherwise. To ascertain this, the best way is to push up the thin skin of the scrotum before the finger; then, by tracking the spermatic cord, the finger readily glides over the crest of the pubes and feels the sharp margins of the ring.The position of the internal ring is about midway between the spine of the ilium and the symphysis of the pubes, and about two-thirds of an inch above Poupart’s ligament.72.Inguinal canal.—The position of the external and internal abdominal rings being ascertained, it is plain that the direction of the inguinal canal must be obliquely downwards and inwards, and that its length in a well-formed adult male is from one and a half to two inches, according as we include the openings or not. In very young children the canal is much shorter and less oblique, the inner ring being behind the outer. With the growth of the pelvis in its transverse direction, the anterior spines of the ilia become farther apart, and thus draw the internal ring more and more away from (i.e.to the outer side of) the external.73.Spermatic cord.—The spermatic cord can be felt as it emerges through the external ring, and its course can be tracked into the scrotum. The vas deferens can be distinctly felt at the back of the cord, and separated from its other component parts.74.Epigastric artery.—The direction of the deep epigastric artery corresponds with a line drawn from the inner border of the internal ring up the middle of the rectus muscle, towards the chest.In thin persons the absorbent glands which lie along Poupart’s ligament can be distinctly felt. They are usually oval, with their long axes parallel to the line of the ligament.75.Abdominal viscera.—Now let us see how far we can make out externally the position and size of the abdominal viscera.To make this examination with anything like success, it is desirable to relax the abdominal muscles. The man should be on his back, the head, shoulders and thorax being well raised, to relax the recti muscles; and the thighs bent on the abdomen, to relax the several fasciæ attached to the crural arch. To induce complete relaxation, where a very careful examination is desired, chloroform should be given.In manipulating the abdomen we should not use the tips of the fingers. This is sure to excite the contraction of the muscles. The flat hand should be gently pressed upon it, and with an undulating movement.76. It is well to bear in mind that the central tendon of the diaphragm is about the level of the lower end of the sternum at its junction with the seventh costal cartilage; that the right half of the diaphragm rises to about the level of the fifth rib—that is, about an inch below the nipple; that the left half does not rise quite so high. In tranquil breathing the diaphragm descends about half an inch.The position of the abdominal viscera varies, to a certain extent, in different persons. In some of them, especially the stomach, their position varies in the same person at different times.Let us take, first, the largest of the abdominal viscera—the liver.77.Liver.—The liver lies under the right hypochondrium, and passes across the middle line over the stomach into the left hypochondrium, generally speaking, as far as the left mammary line. The extent to which it can be felt below the edges of the ribs depends upon whether it is enlarged or not, as well as upon its texture, and also upon the amount of flatus in the stomach and intestines. As a rule, in health its lower thin border projects about half an inch below the costal cartilages, and can be felt moving up and down with the action of the diaphragm; but it requires an educated hand to feel it. An uneducated hand would miss it altogether. That part of it, however, which crosses the middle line below the ensiform cartilage is much more accessible to the feel; here it lies immediately behind the linea alba, and in front ofthe stomach, nearly half-way down to the umbilicus. Here, therefore, is the best place to feel whether the liver be enlarged or pushed down lower than it ought to be. If it be much enlarged and much lower, even the most untutored hand could detect its edge.Even if the edge of the liver be felt very much lower than is normal below the ribs, it does not necessarily follow that the liver is enlarged, since it may be pressed down by other causes—for instance, the habit of wearing tight stays.To what height does the liver ascend? This can only be ascertained by careful percussion of the chest-wall. The highest part of its convexity on the right side is about one inch below the nipple, or nearly on a level with the external and inferior angle of the pectoralis major. Posteriorly the liver comes to the surface below the base of the right lung, about the level of the tenth dorsal spine.Roughly speaking, the upper border of the liver corresponds with the level of the tendinous centre of the diaphragm; that is, the level of the lower end of the sternum. Thus a needle thrust into the right side, between the sixth and seventh ribs, would traverse the lung, and then go through the diaphragm into the liver.78.Gall bladder.—The gall bladder, or rather the fundus of it, is situated, but cannot be felt, just below the edge of the liver about the ninth costal cartilage, outside the edge of the right rectus muscle.79.Stomach.—The stomach varies in size more than any organ in the body. When empty and contracted (63) it lies at the back of the abdomen, overlapped by the left lobe of the liver, and in front of the pancreas. When very full, it turns on its axis and swells up towards the front, coming close behind the wall of the abdomen, occupying most of the left hypochondrium and epigastrium, displacing the other contiguous organs, pushing in every direction, and often interfering with the action of the heart and left lung. Hence the palpitation and distressing heart-symptoms in indigestion and flatulence.The cardiac orifice of the stomach lies to the left of themiddle line, just below the level of the junction of the seventh costal cartilage with the sternum.80.Pylorus.—The pylorus lies under the liver, on the right side, near the end of the cartilage of the eighth rib; but it cannot be felt unless occasionally when enlarged and hardened by disease.81.Spleen.—The spleen, if healthy, cannot be felt, so completely is it sheltered by the ribs. It lies on the left side, connected to the great end of the stomach, beneath the ninth, tenth, and eleventh ribs, between the axillary lines—lines drawn vertically downwards from the anterior and posterior margins of the axilla. Its upper edge is on a level with the spine of the ninth dorsal vertebra, its lower with the spine of the eleventh.Its position and size, therefore, in health can only be ascertained, and not very accurately, by the extent of dulness on percussion. The greatest amount of dulness would be over the tenth and eleventh ribs; above this the thin edge of the lung would intervene between the spleen and the abdominal wall. If, therefore, the spleen can be distinctly felt below the ribs, it must be enlarged. In proportion to its enlargement, so can its lower rounded border be detected below the tenth and eleventh ribs, especially when forced downwards by a deep inspiration.[5]82.Pancreas.—The pancreas lies transversely behind the stomach, and crosses the aorta and the spine about the junction of the first and second lumbar vertebræ. The proper place to feel for it, therefore, would be in the linea alba about two or three inches above the umbilicus. Is it perceptible to the touch?—only under very deep pressure, and very favourable circumstances, such as an emaciated and empty abdomen. It is worth remembering that it may be felt under such conditions. The pancreas of normal size, in thin persons, has been mistaken for disease—disease of the transverse arch of the colon, or aneurysm of the abdominal aorta.83.Kidney.—The kidney lies at the back of the abdomen, on the quadratus lumborum and psoas muscles, opposite the two lower dorsal and two upper lumbar spines. The right,owing to the size of the liver, is a trifle—say, three-quarters of an inch—lower than the left. The pelvis of the kidney is on about the level of the spine of the first lumbar vertebra: the upper border is on about the level of the space between the eleventh and twelfth dorsal spines; the lower border comes as low as the third lumbar spine. During a deep inspiration both kidneys are depressed by the diaphragm nearly half an inch.Can we feel the normal kidney? The only place where it is accessible to pressure is just below the last rib, on the outer edge of the ‘erector spinæ.’ I say accessible to pressure, for I have never succeeded in satisfying myself that I have distinctly felt its rounded lower border in the living subject, nor even in the dead, with the advantage of flaccid abdominal walls and the opportunity of making hard pressure with both hands, placed simultaneously, one in front of the abdomen, the other on the back. For these reasons, although we can easily ascertain its degree of tenderness, we cannot actually feel it unless it be considerably enlarged.We must be on our guard not to mistake for the kidney an enlarged liver or spleen, or an accumulation of fæces in the lumbar part of the colon.84.Large intestine.—Let us now trace the large intestine and see where it is accessible to pressure. The ‘cæcum,’ or ‘caput coli,’ and the ileo-cæcal valve lie in the right iliac fossa. The ascending colon runs up the right lumbar region over the right kidney. The transverse colon crosses the abdomen two or three inches above the umbilicus. The descending colon lies in the left lumbar region in front of the left kidney. The sigmoid flexure occupies the left iliac fossa.Throughout this tortuous course, except at the hepatic and splenic flexures, the colon is accessible to pressure, and we could, under favourable circumstances, detect hardened fæces in it. In a case which occurred in St. Bartholomew’s Hospital, a collection of fæces in the transverse colon formed a distinct tumour in the abdomen. All the symptoms yielded to large and repeated injections of olive oil. Inanother case an accumulation of fæcal matter in the sigmoid flexure during life was mistaken for a malignant disease.85.Colotomy.—The operation of opening the colon (colotomy) may be done in the right or left loin, below the kidney, in that part of the colon not covered by peritoneum.The landmarks of the operation are:—(1) The last rib, of which feel the sloping edge; (2) the crest of the ilium; (3) the outer border of the ‘erector spinæ.’ The incision should be about three inches long, midway between the rib and the ilium. It should begin at the outer border of the ‘erector spinæ,’ and should slope downwards and outwards in the direction of the rib. The edge of the ‘quadratus lumborum,’ which is the guide to the colon, is about one inch external to the edge of the ‘erector spinæ,’ or three full inches from the lumbar spines. The line of the gut is vertical, and runs for a good two inches between the lower border of the kidney and the iliac crest on the left side; rather less on the right.Small intestines.—All the room below the umbilicus is occupied by the small intestines. The coils of the jejunum lie nearer to the umbilicus (one reason of the great fatality of umbilical herniæ). Those of the ilium are lower down.On the right side, a little below the ninth rib, the colon lies close to the gall bladder, and is, after death, sometimes tinged with bile. Posteriorly, this part of the colon is in contact with the kidney and duodenum.86.Bladder.—When the bladder distends, it gradually rises out of the pelvis into the abdomen, pushes the small intestines out of the way, and forms a swelling above the pubes, reaching in some instances up to the navel. The outline of this swelling is perceptible to the hand as well as to percussion. More than this, fluctuation can be felt through the distended bladder by tapping on it in front with the fingers of one hand, while the forefinger of the other passed up the rectum feels the bottom of the ‘trigone.’
The student is assumed to be familiar with the conventional lines dividing the abdomen into regions.
61.Abdominal lines.—The linea alba, or central line of the abdomen, marks the union of the aponeuroses of the abdominal muscles. It runs from the apex of the ensiform cartilage to the symphysis pubis. As this line is the thinnest and least vascular part of the abdominal wall, we make our incision along it in ovariotomy, and in the high operation of lithotomy; in it, we tap the abdomen in ascites, and the distended bladder in retention of urine.
The so-called ‘linea semilunaris,’ at the outer border of the sheath of the rectus, corresponds with a line, drawn slightly curved (with the concavity towards the linea alba), from the lowest part of the seventh rib to the spine of the pubes. This line would be in an adult about three inches from the umbilicus; but in an abdomen distended by dropsy or other cause, the distance is increased in proportion.
It is important to know the position of the ‘lineæ transversæ,’ or tendinous intersections across the rectus abdominis. There are rarely any below the umbilicus, and generally three above it. The first is about the level of the umbilicus. The second is about four inches higher—that is, about the level of the lowest part of the tenth rib. These are the principal lines, and they divide the upper part of each rectus into two nearly quadrilateral portions, an upper and a lower: of these, those on the right side are a trifle larger than on the left. Wesee these muscular squares pretty plainly in some athletic subjects. Much more frequently we see them, too much exaggerated, on canvas and in marble. Artists are apt to exaggerate them, and make the front of the belly too much like a chess-board. It is lucky for them that all the world do not see with anatomical eyes.
A familiarity with the shape and position of these divisions of the rectus is of importance, lest we should, in ignorance, make a mistake in our diagnosis. A spasmodic contraction of one of these divisions, particularly the upper, or a collection of matter within its sheath, has been frequently mistaken for deep-seated abdominal disease.
In the erect position, the anterior superior spines of the ilia are a little below the level of the promontory of the sacrum. The bifurcation of the aorta is on about the level of the highest part of the crest of the ilium.
62.Umbilicus.—The umbilicus is not midway between the ensiform cartilage and the pubes, but rather nearer to the pubes. In all cases it is situated above the centre of a man’s height. It is a vulgar error to say that when a man lies with legs and arms outstretched, and a circle is drawn round him, the umbilicus lies in the centre of it. This central point is in most persons just above the pubes.
In very corpulent persons two deep transverse furrows run across the abdomen. One runs across the navel and completely conceals it. The other is lower down, just above the fat of the pubes. In tapping the bladder above the pubes in such a case, the trochar should be introduced where this line intersects the linea alba.
Although the position of the umbilicus varies a little in different persons, as the abdomen is unusually protuberant or the reverse, still, as a general rule, it is placed about the level of the body of the third lumbar vertebra. Now, since the aorta divides a little below the middle of the fourth lumbar, it follows that the best place to apply pressure on this great vessel is one inch below the umbilicus, and slightly to the left of it (65). That the aorta can, under favourable circumstances, be compressed under chloroform sufficiently to curean aneurysm below it, is proved by recorded cases, and by none more effectually than by a case related in the second volume of the ‘Reports of St. Bartholomew’s Hospital.’
It may be asked, why not apply pressure on the aorta above the umbilicus? The answer is, that the aorta above the umbilicus is farther from the surface, and is, moreover, covered by important structures upon which pressure would be dangerous.
63.Parts behind linea alba.—Let us next consider what viscera lie immediately behind the linea alba. For two or three fingers’ breadth below the ensiform cartilage there is the left lobe of the liver, which here crosses the middle line. Below the edge of the liver comes the stomach, more or less in contact with the linea alba, according to its degree of distension. In extreme distension the stomach pushes everything out of the way, and occupies all the room between the liver and the umbilicus. When empty and contracted, it retreats behind the liver, and lies flat in front of the pancreas at the back of the abdomen; thus giving rise to the hollow termed the ‘pit of the stomach.’ But as the stomach distends, it makes a considerable fulness where there was a pit. The middle of the transverse colon lies above the umbilicus, occupying space (vertically two or three inches) according to its distension. Behind and below the umbilicus, supposing the bladder contracted, are the small intestines, covered by the great omentum.
64.Peritoneum.—The peritoneum is in contact with the linea alba all the way down to the pubes, when the bladder is empty. But when the bladder distends, it raises the peritoneum from the middle line above the pubes; so that with a bladder distended half-way up to the umbilicus, there is a space of nearly two inches above the symphysis where the bladder may be tapped without risk of injury to the peritoneum. For the same reason, we have space sufficient for the successful performance of the high operation for stone. This fact in anatomy must have been well understood by Jean de Dot, the smith at Amsterdam, who, in the seventeenth century, cut himself in the linea alba above the pubes, and took out of hisbladder a stone as large as a hen’s egg. The stone, the knife, and the portrait of the operator, may be seen to this day in the museum at Leyden.
65.Division of Aorta.—The aorta generally divides at a point one inch and a half below the umbilicus. A more reliable guide to this division than the umbilicus, is a point (a very little to the left) of the middle line about the level of the highest part of the crest of the ilium. A line drawn with a slight curve outwards from this point to the groin, where the pulsation of the common femoral can be distinctly felt (rather nearer to the pubes than the ilium), gives the direction of the common iliac and external iliac arteries. About the first two inches of this line belong to the common iliac, the remainder to the external. Slight pressure readily detects the pulsation of the external iliac above ‘Poupart’s ligament.’
As a rule, the length of the common iliac is about two inches, but it should be remembered there are frequent deviations. It may be between three-quarters of an inch and three inches and a half long. These varieties may arise either from a high division of the aorta, or a low division of the common iliac, or both. It is impossible to ascertain during life what is its length in a given instance, for there is no necessary relation between its length and the height of the stature. It is often short in tall men, andvice versâ. Anatomists generally describe the right as a trifle longer than the left; but their average length is pretty nearly the same.
66.Mr.Abernethy, who in the year 1796 first put a ligature round the external iliac, made his incision in the line of the artery. But the easiest and safest way to reach the vessel is by an incision (recommended in the first instance by Sir Astley Cooper, and now generally adopted), beginning just on the inner side of the artery, a little above Poupart’s ligament, and continued upwards and outwards a little beyond the spine of the ilium. The same incision extended farther in the same direction would reach the common iliac.
67.Bony prominences.—The anterior superior spine of the ilium, the spine of the pubes, and the line of Poupart’s ligament, are landmarks with which every surgeon should be thoroughly familiar.
68.Spine of ilium.—The spine of the ilium is the spot from which we measure the length of the lower extremity. It is a valuable landmark in determining the nature of injuries to the pelvis and the hip. The thumb easily feels the spine, even in fat persons. Its position with regard to the trochanter major should be carefully examined. The best way to do this is to place the thumbs firmly on the opposite spines, and to grasp the trochanters with the fingers. Any abnormal position on one side is thus easily ascertained with the sound side as a guide.
69.Spine of pubes.—The spine of the pubes is the best guide to the external abdominal ring. It cannot easily be felt by placing the finger directly over it, since it is generally covered by fat. To feel it distinctly, we should push up the skin of the scrotum and get beneath the subcutaneous fat. If there be any difficulty in finding it, abduct the thigh, and the tense tendon of the adductor longus will lead up to it.
The position of the spine of the pubes is appealed to as a means of diagnosis in doubt between inguinal and femoral hernia. The spine lies on the outer side of the neck of an inguinal hernia, on the inner side of the neck of a femoral.
The spine of the pubes is nearly on the same horizontal line as the upper part of the trochanter major. In this line, about one full inch external to the spine, is the femoral ring. Here is the seat of stricture in a femoral hernia.
70.Poupart’s ligament, or crural arch.—The line of Poupart’s ligament (crural arch) is in most persons indicated by a slight crescent-like furrow along the skin. It corresponds with a line drawn not straight, but with a gentle curve downwards from the spine of the ilium to the spine of the pubes. With the help of the preceding landmarks it is easy to find the exact position of the external and internal abdominal rings, and the direction of the inguinal canal.
71.Abdominal rings.—The external abdominal ring issituated immediately above the spine of the pubes. It is an oval opening with the long axis directed obliquely downwards and inwards. Though its size varies a little in different persons, yet as a rule it will admit the end of the little finger, so that we can tell by examination whether it be free or otherwise. To ascertain this, the best way is to push up the thin skin of the scrotum before the finger; then, by tracking the spermatic cord, the finger readily glides over the crest of the pubes and feels the sharp margins of the ring.
The position of the internal ring is about midway between the spine of the ilium and the symphysis of the pubes, and about two-thirds of an inch above Poupart’s ligament.
72.Inguinal canal.—The position of the external and internal abdominal rings being ascertained, it is plain that the direction of the inguinal canal must be obliquely downwards and inwards, and that its length in a well-formed adult male is from one and a half to two inches, according as we include the openings or not. In very young children the canal is much shorter and less oblique, the inner ring being behind the outer. With the growth of the pelvis in its transverse direction, the anterior spines of the ilia become farther apart, and thus draw the internal ring more and more away from (i.e.to the outer side of) the external.
73.Spermatic cord.—The spermatic cord can be felt as it emerges through the external ring, and its course can be tracked into the scrotum. The vas deferens can be distinctly felt at the back of the cord, and separated from its other component parts.
74.Epigastric artery.—The direction of the deep epigastric artery corresponds with a line drawn from the inner border of the internal ring up the middle of the rectus muscle, towards the chest.
In thin persons the absorbent glands which lie along Poupart’s ligament can be distinctly felt. They are usually oval, with their long axes parallel to the line of the ligament.
75.Abdominal viscera.—Now let us see how far we can make out externally the position and size of the abdominal viscera.
To make this examination with anything like success, it is desirable to relax the abdominal muscles. The man should be on his back, the head, shoulders and thorax being well raised, to relax the recti muscles; and the thighs bent on the abdomen, to relax the several fasciæ attached to the crural arch. To induce complete relaxation, where a very careful examination is desired, chloroform should be given.
In manipulating the abdomen we should not use the tips of the fingers. This is sure to excite the contraction of the muscles. The flat hand should be gently pressed upon it, and with an undulating movement.
76. It is well to bear in mind that the central tendon of the diaphragm is about the level of the lower end of the sternum at its junction with the seventh costal cartilage; that the right half of the diaphragm rises to about the level of the fifth rib—that is, about an inch below the nipple; that the left half does not rise quite so high. In tranquil breathing the diaphragm descends about half an inch.
The position of the abdominal viscera varies, to a certain extent, in different persons. In some of them, especially the stomach, their position varies in the same person at different times.
Let us take, first, the largest of the abdominal viscera—the liver.
77.Liver.—The liver lies under the right hypochondrium, and passes across the middle line over the stomach into the left hypochondrium, generally speaking, as far as the left mammary line. The extent to which it can be felt below the edges of the ribs depends upon whether it is enlarged or not, as well as upon its texture, and also upon the amount of flatus in the stomach and intestines. As a rule, in health its lower thin border projects about half an inch below the costal cartilages, and can be felt moving up and down with the action of the diaphragm; but it requires an educated hand to feel it. An uneducated hand would miss it altogether. That part of it, however, which crosses the middle line below the ensiform cartilage is much more accessible to the feel; here it lies immediately behind the linea alba, and in front ofthe stomach, nearly half-way down to the umbilicus. Here, therefore, is the best place to feel whether the liver be enlarged or pushed down lower than it ought to be. If it be much enlarged and much lower, even the most untutored hand could detect its edge.
Even if the edge of the liver be felt very much lower than is normal below the ribs, it does not necessarily follow that the liver is enlarged, since it may be pressed down by other causes—for instance, the habit of wearing tight stays.
To what height does the liver ascend? This can only be ascertained by careful percussion of the chest-wall. The highest part of its convexity on the right side is about one inch below the nipple, or nearly on a level with the external and inferior angle of the pectoralis major. Posteriorly the liver comes to the surface below the base of the right lung, about the level of the tenth dorsal spine.
Roughly speaking, the upper border of the liver corresponds with the level of the tendinous centre of the diaphragm; that is, the level of the lower end of the sternum. Thus a needle thrust into the right side, between the sixth and seventh ribs, would traverse the lung, and then go through the diaphragm into the liver.
78.Gall bladder.—The gall bladder, or rather the fundus of it, is situated, but cannot be felt, just below the edge of the liver about the ninth costal cartilage, outside the edge of the right rectus muscle.
79.Stomach.—The stomach varies in size more than any organ in the body. When empty and contracted (63) it lies at the back of the abdomen, overlapped by the left lobe of the liver, and in front of the pancreas. When very full, it turns on its axis and swells up towards the front, coming close behind the wall of the abdomen, occupying most of the left hypochondrium and epigastrium, displacing the other contiguous organs, pushing in every direction, and often interfering with the action of the heart and left lung. Hence the palpitation and distressing heart-symptoms in indigestion and flatulence.
The cardiac orifice of the stomach lies to the left of themiddle line, just below the level of the junction of the seventh costal cartilage with the sternum.
80.Pylorus.—The pylorus lies under the liver, on the right side, near the end of the cartilage of the eighth rib; but it cannot be felt unless occasionally when enlarged and hardened by disease.
81.Spleen.—The spleen, if healthy, cannot be felt, so completely is it sheltered by the ribs. It lies on the left side, connected to the great end of the stomach, beneath the ninth, tenth, and eleventh ribs, between the axillary lines—lines drawn vertically downwards from the anterior and posterior margins of the axilla. Its upper edge is on a level with the spine of the ninth dorsal vertebra, its lower with the spine of the eleventh.
Its position and size, therefore, in health can only be ascertained, and not very accurately, by the extent of dulness on percussion. The greatest amount of dulness would be over the tenth and eleventh ribs; above this the thin edge of the lung would intervene between the spleen and the abdominal wall. If, therefore, the spleen can be distinctly felt below the ribs, it must be enlarged. In proportion to its enlargement, so can its lower rounded border be detected below the tenth and eleventh ribs, especially when forced downwards by a deep inspiration.[5]
82.Pancreas.—The pancreas lies transversely behind the stomach, and crosses the aorta and the spine about the junction of the first and second lumbar vertebræ. The proper place to feel for it, therefore, would be in the linea alba about two or three inches above the umbilicus. Is it perceptible to the touch?—only under very deep pressure, and very favourable circumstances, such as an emaciated and empty abdomen. It is worth remembering that it may be felt under such conditions. The pancreas of normal size, in thin persons, has been mistaken for disease—disease of the transverse arch of the colon, or aneurysm of the abdominal aorta.
83.Kidney.—The kidney lies at the back of the abdomen, on the quadratus lumborum and psoas muscles, opposite the two lower dorsal and two upper lumbar spines. The right,owing to the size of the liver, is a trifle—say, three-quarters of an inch—lower than the left. The pelvis of the kidney is on about the level of the spine of the first lumbar vertebra: the upper border is on about the level of the space between the eleventh and twelfth dorsal spines; the lower border comes as low as the third lumbar spine. During a deep inspiration both kidneys are depressed by the diaphragm nearly half an inch.
Can we feel the normal kidney? The only place where it is accessible to pressure is just below the last rib, on the outer edge of the ‘erector spinæ.’ I say accessible to pressure, for I have never succeeded in satisfying myself that I have distinctly felt its rounded lower border in the living subject, nor even in the dead, with the advantage of flaccid abdominal walls and the opportunity of making hard pressure with both hands, placed simultaneously, one in front of the abdomen, the other on the back. For these reasons, although we can easily ascertain its degree of tenderness, we cannot actually feel it unless it be considerably enlarged.
We must be on our guard not to mistake for the kidney an enlarged liver or spleen, or an accumulation of fæces in the lumbar part of the colon.
84.Large intestine.—Let us now trace the large intestine and see where it is accessible to pressure. The ‘cæcum,’ or ‘caput coli,’ and the ileo-cæcal valve lie in the right iliac fossa. The ascending colon runs up the right lumbar region over the right kidney. The transverse colon crosses the abdomen two or three inches above the umbilicus. The descending colon lies in the left lumbar region in front of the left kidney. The sigmoid flexure occupies the left iliac fossa.
Throughout this tortuous course, except at the hepatic and splenic flexures, the colon is accessible to pressure, and we could, under favourable circumstances, detect hardened fæces in it. In a case which occurred in St. Bartholomew’s Hospital, a collection of fæces in the transverse colon formed a distinct tumour in the abdomen. All the symptoms yielded to large and repeated injections of olive oil. Inanother case an accumulation of fæcal matter in the sigmoid flexure during life was mistaken for a malignant disease.
85.Colotomy.—The operation of opening the colon (colotomy) may be done in the right or left loin, below the kidney, in that part of the colon not covered by peritoneum.
The landmarks of the operation are:—(1) The last rib, of which feel the sloping edge; (2) the crest of the ilium; (3) the outer border of the ‘erector spinæ.’ The incision should be about three inches long, midway between the rib and the ilium. It should begin at the outer border of the ‘erector spinæ,’ and should slope downwards and outwards in the direction of the rib. The edge of the ‘quadratus lumborum,’ which is the guide to the colon, is about one inch external to the edge of the ‘erector spinæ,’ or three full inches from the lumbar spines. The line of the gut is vertical, and runs for a good two inches between the lower border of the kidney and the iliac crest on the left side; rather less on the right.
Small intestines.—All the room below the umbilicus is occupied by the small intestines. The coils of the jejunum lie nearer to the umbilicus (one reason of the great fatality of umbilical herniæ). Those of the ilium are lower down.
On the right side, a little below the ninth rib, the colon lies close to the gall bladder, and is, after death, sometimes tinged with bile. Posteriorly, this part of the colon is in contact with the kidney and duodenum.
86.Bladder.—When the bladder distends, it gradually rises out of the pelvis into the abdomen, pushes the small intestines out of the way, and forms a swelling above the pubes, reaching in some instances up to the navel. The outline of this swelling is perceptible to the hand as well as to percussion. More than this, fluctuation can be felt through the distended bladder by tapping on it in front with the fingers of one hand, while the forefinger of the other passed up the rectum feels the bottom of the ‘trigone.’