Part 4

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.[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]