Part 9

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 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.

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.