Landmarks Medical and Surgical

by Luther Holden; James Shuter

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.