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 of the 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 the middle
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. In
another 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 PERINEUM._
The body is supposed to be placed in the usual position for lithotomy.
87. =Bony framework.=--We can readily feel the osseous and ligamentous
boundaries of the perineum; namely, the rami of the pubes and ischia,
the tuberosities of the ischia, the great sacro-ischiatic ligaments,
and the apex of the coccyx. This framework forms a lozenge-shaped
space. If we draw an imaginary line across it from the front of one
tuber ischii to the other, we divide this space into an anterior and
a posterior triangle. The anterior is nearly equilateral, and, in a
well-formed pelvis, its sides are from three to three and a half inches
long. It is called the urethral triangle. The posterior, containing the
greater part of the anus and the ischio-rectal fossa on each side, is
called the anal triangle.
88. =Raphé.=--A slight central ridge of skin, called the ‘raphé,’
runs from the anus up the perineum, scrotum, and penis. This ‘raphé,’
or middle line of the perineum, is the ‘line of safety’ in making
incisions to let out matter or effused urine, or to divide a stricture.
89. =Central point of perineum.=--It is very important to know that
a point of the raphé about midway between the scrotum (where it
joins the perineum) and the centre of the anus, corresponds with the
so-called ‘central tendon’ where the perineal muscles meet. The bulb
of the urethra lies above this point, and never, at any age, comes
lower down. The artery of the bulb, too, never runs below this level.
Therefore the incision in lithotomy should never commence above it.
A knife introduced at this point, and pushed backwards with a very
slight inclination upwards, would enter the membranous part of the
urethra just in front of the prostate gland; pushed still farther it
would enter the neck of the bladder. This point, then, is a very good
landmark to the urethra in lithotomy, or, indeed, in any operations on
the perineum.
The incision in the lateral operation of lithotomy, beginning below
the point indicated, should be carried downwards and outwards between
the anus and the tuberosity of the ischium, a little nearer to the
tuberosity than the anus. The lower end of the incision should reach a
point just below the anus.
90. =Triangular ligament.=--In a thin perineum, we can feel the lower
border of the deep perineal fascia or the ‘so-called’ triangular
ligament of the urethra. The urethra passes through it about one inch
below the lower part of the symphysis pubis, and about three-quarters
of an inch higher than the central tendon of the perineum. It is
important to bear in mind these landmarks in introducing a catheter.
If the catheter be depressed too soon, its passage will be resisted by
the triangular ligament; if too late, it will be likely to make a false
passage by running through the bulb.
91. =Anus.=--One of the most important landmarks which guide a
surgeon in his operations about the anus, is a white line[6] at the
junction of the skin and mucous membrane. It is easily recognised and
is of especial interest, because it marks with great precision the
linear interval between the external and internal sphincter muscles.
From this line the internal sphincter extends upwards, beneath the
mucous membrane, for about an inch, becoming gradually more and more
attenuated.
The wrinkled appearance of the anus is caused by the contraction of the
external sphincter. At the bottom of these cutaneous folds, especially
towards the coccyx, we look for ‘fissure of the anus.’
92. =Landmarks in the rectum.=--Many valuable landmarks may be felt
by introducing the finger into the rectum, with a catheter at the
same time in the urethra. The principal of these landmarks are the
following:--
_a._ The finger can feel the extent and powerful grasp of the internal
sphincter for about one inch up the bowel. (91)
_b._ =Urethra.=--Through the front wall of the bowel it can most
distinctly feel the track of the membranous part of the urethra,
exactly in the middle line. This is very important, because you can
ascertain with precision whether the catheter has deviated from the
proper track.
_c._ =Prostate gland.=--About an inch and a half or two inches from
the anus, the finger comes upon the prostate gland. The gland lies in
close contact with the bowel, and can be detected by its shape and hard
feel. The finger, moved from side to side, can examine the size of its
lateral lobes, their consistence and sensibility.
_d._ The finger, introduced still farther, can reach beyond the
prostate, as far as the apex of the trigone of the bladder. More than
this, it can feel the angle between the ‘ductus communes ejaculatorii,’
which forms the apex of the trigone. This is the precise spot where
the distended bladder should be punctured through the rectum. The more
distended the bladder, the easier can this spot be felt. Fluctuation
is at once detected by a gentle tap on the bladder above the pubes
(86). The trochar must be thrust in the direction of the axis of the
distended bladder; that is, roughly speaking, in a line drawn from the
anus through the pelvis to the umbilicus.
_e._ The fold of peritoneum, called the recto-vesical pouch, is about
four inches from the anus, therefore it is not within reach of the
finger; and we run no risk of wounding it in tapping the bladder if the
trochar be introduced near the angle of the trigone.
_f._ The finger can feel one of the ridges or folds of mucous membrane
which are situated at the lower part of the rectum. This fold projects
from the side, and sometimes from the upper part of the rectum, near
the prostate. When thickened or ulcerated, this fold occasions great
pain in defæcation; and great relief is afforded by its division.
_g._ Lastly, the finger can examine the condition of the spaces filled
with fat on either side of the rectum, called the ischio-rectal fossæ,
with a view to ascertain the existence of deep-seated collections of
matter, or the internal communications of fistulæ.
=Introduction of catheters.=--In the introduction of catheters the
following are good rules. Keep the point of the instrument well
applied against the upper surface of the urethra;--depress the handle
at the right moment (90);--keep the umbilicus in view;--in cases of
difficulty feel the urethra through the rectum, to ascertain whether
the instrument be in the right direction. Attention to these rules
diminishes the risk of making a false passage, an injury which under
great delicacy in manipulation ought never to happen.
=Urethra in the child.=--In children the membranous part of the
urethra is, relatively speaking, very long, owing to the smallness of
the prostate. It is also more sharply curved, because the bladder in
children is more in the abdomen than in the pelvis. It is, moreover,
composed of thin and delicate walls. The greatest gentleness,
therefore, should be used in passing a catheter; else the instrument
is likely to pass through the coats and make a false passage. Hence
the advantage of being able to ascertain through the rectum whether
the instrument be in the right track and moving freely in the bladder,
which can also be easily felt in children.
_THE THIGH._
93. =Poupart’s ligament, or crural arch.=--Mark the anterior superior
spine of the ilium, the spine of the pubes, and define the line of
‘Poupart’s ligament’ which extends between them. This line is one of
our guides in the diagnosis of inguinal and femoral herniæ. If the bulk
of the tumour be above the line, the hernia is probably inguinal; if
below it, femoral. The line is not a straight one drawn from the spine
of the ilium to the spine of the pubes, but slightly curved, with the
convexity downwards, owing to its close connection with the fascia lata
of the thigh. In many persons it can be distinctly felt; in nearly all
its precise course is indicated by a slight furrow in the skin.
For the points about the spine of the pubes, refer to paragraph 69.
94. =Furrow at the bend of the thigh.=--When the thigh is even slightly
bent, there appears a second furrow in the skin below that at the
crural arch. This second furrow begins at the angle between the
scrotum and the thigh, passes outwards, and is gradually lost between
the top of the trochanter and the anterior superior spine of the ilium.
It runs right across the front of the capsule of the hip-joint. For
this reason it is a valuable landmark in amputation at the hip-joint.
The point of the knife should be introduced externally where the furrow
begins, should run precisely along the line of it, and come out where
it ends; so that the capsule of the joint may be opened with the first
thrust. In suspected disease of the hip pressure made in this line,
just below the spine of the ilium, will tell us if the joint be tender.
Effusion into the joint obliterates all trace of the furrow, and makes
a fulness when contrasted with the opposite groin.
95. =Saphenous opening.=--In most persons there is a natural depression
over the saphenous opening in the fascia lata, where the saphena vein
joins the femoral. The position of this opening is just below the inner
third of Poupart’s ligament, and about an inch and a half external
to the spine of the pubes. This is the place where the swelling of
a femoral hernia first appears: therefore it ought to be carefully
examined in cases of doubt.
96. =Femoral ring.=--The position of the femoral ring, through which
the hernia escapes from the abdomen, is on a deeper plane, about half
an inch higher than the saphenous opening, and immediately under
Poupart’s ligament. As the plane of the ring is vertical in the supine
position of the body, the way in which we should try to reduce a
femoral hernia is by pressure, applied first in a downward direction,
afterwards in an upward. The intestine protruded has to pass back under
a sharp edge of fascia, namely, the upper horn of the saphenous opening
(known as Hey’s ligament). At the same time we bend the thigh, to relax
the fascia as much as possible.
A good way to find the seat of the femoral ring with precision is the
following:--Feel for the pulsation of the femoral artery on the pubes;
allow half an inch (on the inner side) for the femoral vein; then comes
the femoral ring.
In performing the operation for the relief of the stricture in femoral
hernia the incision through the skin should be about an inch and a half
external to the spine of the pubes. Its direction should be vertical,
and its middle should be just over the femoral ring.
97. =Lymphatic glands in the groin.=--The cluster of inguinal and
femoral lymphatic glands can sometimes be felt in thin persons. The
inguinal lie for the most part along the line of Poupart’s ligament:
they receive the absorbents from the wall of the abdomen, the urethra,
the penis, the scrotum, and the anus. The femoral glands lie chiefly
over the saphenous opening and along the outer side of the saphena
vein: they receive the absorbents of the lower extremity; they receive
some also from the scrotum--of which we have practical evidence in
cases of chimney-sweepers’ cancer.
98. =Trochanter major.=--The trochanter major is a most valuable
landmark, to which we are continually appealing in injuries and
diseases of the lower extremity. There is a natural depression over the
hip (in fat persons) where it lies very near the surface, and can be
plainly felt, especially when the thigh is rotated. Nothing intervenes
between the bone and the skin except the strong fascia of the gluteus
maximus and the great bursa underneath it.
The top of the trochanter lies pretty nearly on a level with the spine
of the pubes, and is about three-fourths of an inch lower than the top
of the head of the femur. A careful examination of the bearing of the
great trochanter to the other bony prominences of the pelvis, and a
comparison of its relative position with that of the opposite side, are
the best guides in the diagnosis of injuries about the hip, and the
position of the head of the femur.
99. =Nélaton’s line.=--‘If in the normal state you examine the
relations of the great trochanter to the other bony prominences of the
pelvis, you will find that the top of the trochanter corresponds to a
line drawn from the anterior superior spine of the ilium to the most
prominent part of the tuberosity of the ischium. This line also runs
through the centre of the acetabulum. The extent of displacement in
dislocation or fracture is marked by the projection of the trochanter
behind and above this line.’[7]
‘Nélaton’s line,’ as it is termed, theoretically holds good. But in
stout persons it is not always easy to feel these bony points so as
to draw the line with precision. A surgeon must, after all, in many
cases trust to measurement by his eyes and his flat hands--his best
guides. Thus, let the thumbs be placed firmly on the spines of the
ilia, while the fingers grasp the trochanters on each side. Having the
sound side as a standard of comparison, the hand will easily detect
any displacement on the injured side. Hippocrates bids us compare the
sound parts with the parts affected (in fractures) and observe the
inequalities.
The top of the great trochanter is the guide in an operation recently
introduced by Mr. Adams, namely, the ‘subcutaneous section of the neck
of the femur.’ ‘The puncture should be made one inch above and nearly
one inch in front of the top of the trochanter. The neck of the bone
is to be sawn through at right angles to its axis, the saw working
parallel to Poupart’s ligament, and about one inch below it.’
=Spine of the ilium.=--The anterior superior spine of the ilium is the
point from which we measure the length of the lower limb. By looking
at the spines of opposite sides we can detect any slant in the pelvis.
By pressure on both spines simultaneously we examine if there be a
fracture of the pelvis, or disease at the sacro-iliac joint.
100. ‘In reducing a dislocation of the hip by manipulation it is
important to bear in mind that, in every position, the head of the
femur faces nearly in the direction of the inner aspect of its internal
condyle.’[8]
101. =Compression of femoral artery.=--About a point midway between
the spine of the ilium and the symphysis pubis, the femoral artery
can be felt beating, and effectually compressed, against the pubes.
How should the pressure be applied when the patient lies on the back?
In accordance with the slope of the bone--that is, with a slight
inclination upwards. A want of attention to this point is the reason
why so many fail when they undertake to command the circulation
through the femoral artery in an amputation, or to cure an aneurysm by
digital compression.
If the Italian tourniquet be used, we should be careful to adjust
the counter-pad well under the tuberosity of the ischium. If digital
pressure be used, it is easy to command the femoral by slight pressure
of the thumb, provided the fingers have a firm hold on the great
trochanter.