Physical diagnosis, including diseases of the thoracic and abdominal organs : a manual for students and physicians ...

Front matter

Class _JR£jlz

Book s

Copyright}! .

Preface To The Second Edition

In revising this work for its second edition the author has preserved its general plan, inasmuch as it represents the methods developed in his experience as a teacher. Especial emphasis is laid on the altered anatomy of the organs under examination, and its relation to the physical signs. The respiratory and cardiac sounds, their production and modifications, both normal and pathological, have been discussed more fully than in most books of moderate scope, since, unless the student clearly understands how these sounds are produced, the tendency is to regard each variation from normal as pathognomonic of special disease rather than as dependent on changes in structure or function which may be present in conditions not necessarily pathological. In this way only can diagnostic values be estimated and the range and limitations of Physical Diagnosis be understood. The subject is now taught at an early period in the curricula of the medical schools, a circumstance which has made it necessary to give a brief account of the morbid changes in different organs, and of their secondary effects, both immediate and remote.

This new edition has been thoroughly revised, some of the sections have been entirely rewritten, the series of illustrations has been enriched, and attention has been called to recent modifications in methods of examivi PREFACE.

nation. The scope of the work has been kept to its title, including the subjects of Inspection, Palpation, Percussion and Auscultation.

Thanks are due to Dr. Charles B. Slade for the revision of the chapter on Topographical and Relational Anatomy, and for the preparation of new illustrations for that portion of the book ; to Mr. L. B. Goldhorn for photographs of the X-Ray outlines of the heart, and to Dr. S. D. Curran for assistance in obtaining illustrative

cases of cardiac disease.

E. LeP.

New York City.

Chapter I. Topographical And Relational Anatomy

Foe convenience in study and reference the entire area of the trunk has been divided into surges and these surfaces subdivided into regwns ^™TO lines and surface prominences The fol owing 18 the most uniformly accepted method of demarcation .

THE CHEST.

In general terms it may be said Wtto^ tow and lateral surfaces of the ^, ar "^S those portions of the ehest surf ace which » P ^ seen when looking at the chest from in front,

hehind or from either side. aimnle

The anterior surface is bounded above by aMge curved line connecting the point of junction '^

and middle thirds of one e avick w ft he «^ respo^ ing point on the opposite side, laterally »yj dropped from the ends of fee curved l"*»j£ OTe tio, ed, and below by the inferior costal margin.

JcS

ANATOMICAL.

REGIONS OF THE ANTERIOR SURFACE.

The supraclavicular and the suprasternal regions, limited above by the superior boundary of the anterior surface, are defined by their names, as are the clavicular

Fig. 1.

Supra- Sternal

Regions of the anterior surface of the chest.

and the sternal regions, the latter being subdivided into upper sternal and lower sternal regions by a line drawn horizontally through the upper border of the third costal cartilage.

The infraclavicular region, limited above by the lower border of the clavicle, internally by the edge of the sternum, and externally by the lateral boundary of the anterior surface, is bounded below by a line drawn horizontally through the upper border of the third costal

cartilage.

The mammary region extends from the lower limit of the infraclavicular region to the upper border of the sixth rib. (The lower border of the sixth rib is given by some writers as its inferior boundary.) Internally and laterally it is bounded by continuation downward of the lines that form the internal and lateral boundaries of the infraclavicular region.

The inframammarjj region is that portion of the anterior surface which lies immediately below the mammary region. (Fig. 1.)

The posterior surface is bounded above by a horizontal line through the spine of the seventh cervical vertebra, laterally by vertical lines passing through the point of insertion of the posterior axillary fold and below by the twelfth ribs.

REGIONS OF THE POSTERIOR SURFACE.

The scapular region, including the supraspinous and infraspinous fossae, is limited above by the superior boundary of the posterior surface, below by a horizontal line passing through the angle of the scapula, internally by a vertical line corresponding approximately with the internal border of the scapula and externally by the lateral boundary of the posterior surface.

The interscapular region is that part of the posterior surface above the horizontal line through the angle of the scapula and between the scapular regions.

The infrascapular or subscapular region is the remainder of the posterior surface.

The right and left interscapular and subscapular regions are separated by the vertebral spines. (Fig. 2.)

The lateral surface is bounded above by the line of

ANATOMICAL.

-junction of the nnder-surface of the arm with the trunk, anteriorly by the lateral boundary of the anterior surface, posteriorly by the lateral boundary of the posterior surface and below by the inferior costal margin.

Fig. 2.

Regions of the posterior surface of the chest.

REGIONS OF THE LATERAL SURFACE.

The axillary region is that part of the lateral surface which lies above a line drawn from the inferior boundary of the mammary region to the angle of the scapula.

The- infra-axillary region is the remainder of the lateral surface.

LINES.

The following imaginary vertical lines are used for more definite location of various structures:

The mammillary or nipple line.

The midclavicular line, identical with the mammillary line when the nipple occupies its typical position.

The parasternal line, midway between the edge oi the sternum (sternal line) and the midclavicular line.

The midaxillary line.

The midscapular line.

Table of Contents of the Thoracic Regions.*

RIGHT SUPRACLA- VICULAR.

The apex of the right

lung.

The subclavian vessels.

The termination of the external jugular vein.

The pleura.

Lymph nodes.

RIGHT CLAVICULAR

The lung.

The innominate vein.

The pleura.

Lymph nodes.

RIGHT INFRACLA- VICULAR.

The lung.

The right primary bronchus.

The superior vena cava.

The arch of the aorta.

The pleura.

SUPRASTERNAL.

The trachea.

The (esophagus (very deep.) (The aortic arch may be displaced up into this region by pathological changes.

The common carotid artery and internal jugular vein lie on the bou ndary between this and the supraclavicular region).

The thyroid.

UPPER STERNAL

The trachea and primary bronchi.

The ascending and transverse arch of the aorta.

The innominate artery.

The superior vena cava.

The left innominate vein.

Both lungs.

The pulmonary artery.

The pulmonary valve.

The pleura.

The appendix of the right auricle.

The apex of the pericardium.

(The right innominate vein is on the boundary between this and the right infraclavicular region.)

The thymus.

Lymph nodes.

LEFT SUPRACLA- VICULAR.

The apex of the left

lung.

The subclavian vessels.

The termination of the

external jugular vein.

The pleura.

Lymph nodes.

LEFT CLAVICULAR.

The lung.

The innominate vein.

The common carotid

artery.

The subclavian artery.

The pleura.

Lymph nodes.

LEFT INFRACLA- VICULAR.

The lung.

The primary bronchus.

The left auricle.

The pleura.

ANATOMICAL.

RIGHT MAMMIL- LARY.

The lung.

The right auricle.

The diaphragm.

The right bronchus and

its branches.

The liver.

The pleura.

LOWER STERNAL.

Both lungs.

The pericardium.

The base of the right

ventricle.

The base of the left

ventricle.

The left auricle (deep).

The right auricle.

The mitral, aortic and

tricuspid valves.

The inferior vena cava.

The pleura.

LEFT MAMMIL- LARY.

The lung.

The right and left ventricles.

The left bronchus and its branches.

The diaphragm.

The liver.

The stomach.

The pleura.

RIGHT INFRA. MAMMARY.

The lung.

The diaphragm.

The liver.

The pleura.

LEFT INFRAMAMMARY.

The lung.

The diaphragm.

The liver.

The stomach.

The pleura.

RIGHT AXILLARY.

The lung.

The pleura.

Lymph nodes.

LEFT AXILLARY.

The lung.

The pleura.

Lymph nodes.

RIGHT INFRA-AXILLARY.

The lung The diaphragm.

The liver.

The pleura.

LEFT INFRA- AXILLARY.

The lung.

The diaphragm.

The spleen.

The stomach (this gives a tympanitic quality to the percussion sound in this region; if it contains gas).

The pleura.

RIGHT SCAPULAR.

The lung.

The pleura.

INTERSCAPULAR.

The lungs.

The trachea and bronchi

The aorta.

The oesophagus.

The thoracic duct.

The vena azygous major.

LEFT SCAPULAR.

The lung.

The pleura.

RIGHT.

The lung.

The diaphragm.

The liver.

The kidney.

The pleura.

INFRASCAPULAR.

MEDIAN.

The aorta.

The oesophagus.

The thoracic duct.

The vena azygous major The diaphragm.

LEFT.

The lung.

The diaphragm.

The spleen.

The kidney.

The pleura.

* Organs are mentioned in every region that usually contains any part of them.

THE TRACHEA AND BRONCHI.

The trachea passes almost vertically down through the middle of the suprasternal region, deflected slightly to the right in the upper sternal region by the arch of the aorta, where it is found dividing into right and left primary bronchi opposite the junction of the first and second pieces of the sternum. (Fig. 3.) This level is indicated on the surface by a palpable transverse ridge on the sternum opposite the second costal cartilage.

Fig. 3.

Diagram showing the relation of the trachea and bronchi to the

anterior chest wall.

From here the right bronchus continues downward and to the right, conforming very nearly to the direction of the trachea just above it, passes behind the extreme inner end of the second intercostal space and the junction of the third costal cartilage with the sternum. Behind the upper border of the third costal cartilage it gives off its first branch, which passes outward and upward to the upper lobe toward the right apex.

ANATOMICAL.

The right primary bronchus is slightly larger in calibre than the left, and its first or hyparterial branch is given off only half an inch from the" tracheal bifurcation and before the bronchus is surrounded by lung tissue. The bronchus continues downward and outward into the lung substance, to break up into its various branches deep in the mammary region. Posterior] v the

Fig

Diagram showing the relation of the trachea and bronchi to the

posterior chest wall.

tracheal bifurcation is opposite the disk between the fourth and fifth dorsal vertebra, or the spinous process of the fourth dorsal vertebra. The right bronchus and its branches, being within the right interscapular region, influences the auscultatory sound in the fourth intercostal space posteriorly.

The right primary bronchus is in relation behind

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TOPOGRAPHICAL AXD RELATIONAL ANATOMY. 25

with the right pneumogastric nerve and 'one or more lymphatic glands. The oesophagus, vena azygons major and bronchial artery also lie jnst posterior to it, but separated from it by the nerve and glands jnst named.

Fig. 5.

Bronchi (child) filled with shot. No. 10. Diameter, .03S inch.

Lateral view.

Above it is the vena azygons major, arching forward to join the superior vena cava, and in front of the bronchus is the right pulmonary artery, with the superior vena cava and the right phrenic nerve. (Fig. 7.)

The left primary bronchus is given off at the bifnrca-

ANATOMICAL.

tion of the trachea (Fig. 3). It immediately passes under the arch of the aorta and goes obliquely downwards and to the left in a direction almost at a right angle to that of the right bronchus, thus being at great

Fig. 6.

Bronchi (adult) filled with shot, No. 4. Diameter, .110 inch.

variance to the direction of the trachea. It passes behind the junction of the third costal cartilage with the sternum, its first branches being given off in the left mammary region twice as far from the tracheal bifurcation as the first branch of the right bronchus, and after the bronchus is well surrounded by lung substance. The calibre of the left bronchus is slightly less than that of the right bronchus. In the back it lies in the left interscapular region a little lower than the right bronchus

The left bronchus is in relation posteriorly with the left pneumogastric nerve and one or more lymph glands, the oesophagus being farther back. Still more posteriorly and to the left of the median line is the descending aorta. The thoracic duct lies against the anterior surfaces of the bodies of the vertebra in this region, crossing obliquely from right to left and upwards. The pulmonary artery lies first in front and then passes upwards and to the left above the bronchus, the left auricle being placed close below and anterior to it. (Fig. 12 and Fig. 7.)

The difference in size, direction and arrangement of the two bronchi have an important influence on the normal variance of certain physical signs found in corresponding regions on the two sides. The relations above mentioned will explain many of the complex physical findings and symptom groups to be met with in certain pathological alterations in these structures.

THE LUNGS.

The lungs occupy all of the thoracic cavity except the mediastinum, and their apices extend above the first ribs from one-half to one and one-half inches, rising with inspiration and receding with expiration. The right lung is larger than the left in the ratio of about 11 to 10. It is wider and shorter than the left, to give place for the liver on the right and the heart on the left side. The lower border of the lungs at the end of expiration is on a level with the sixth rib in the mammillary line, the eighth rib in the midaxillary line and the apex of the spinous process of the tenth dorsal vertebra posteriorly. The anterior borders of both lungs reach the median line above about the middle of the first piece of the sternum and pass down in the median line in apposition with each other to a point opposite the junction of the fourth costal cartilage with the sternum, where the anterior border of the left lung turns obliquely off to the left and downwards parallel with and behind the lower border of the fourth costal cartilage. About three inches from the median line it goes nearly vertically down to a point just behind the upper border of the fifth costal cartilage, about three and one-half inches left of the median line, then turns inwards and downwards to the upper border of the sixth costal cartilage, where it joins the inferior border, thus leaving a small area of the pericardium and the heart uncovered by the lung. The anterior border of the right lung continues vertically down in the median line to the lower end of the sternum, where it joins the inferior border. Posteriorly the lungs extend close up against the vertebral column on both sides.

The main fissure of the lung, which lies above the lower lobe on either side, reaches the surface of the lung posteriorly opposite the interval between the apices of the spinous processes of the second and third dorsal vertebrae, and passes more or less obliquely downwards and forwards to join the inferior border of the lung a short distance from the sternum, a little further outward on the right than on the left side. On the right side the short fissure (usually present) which lies above the middle lobe appears on the anterior surface of the lung in its anterior border on a level with the fourth costal cartilage and passes almost horizontally outwards to the main fissure. It will be seen that the extreme apex of the lower lobe lies in the third intercostal space close to the vertebral column on either side. The highest or central portion of the diaphragmatic or inferior surface of the right lung at the end of expiration is on a level with the fourth intercostal space, while that of the left lung is level with the lower border of the fifth rib. These surfaces are in contact with the superior surface of the diaphragm, which reaches to the elevations stated.

TOPOGRAPHICAL AND RELATIONAL ANATOMY.

The close proximity of the under-surf ace of the right lung to the liver, which lies against the under-surf ace of the diaphragm, is of special importance in connection with abscess of the liver, a condition which not uncommonly gives rise to secondary involvement of the right lung or pleura, and sometimes physical signs which may be confusing, unless the relations just mentioned are kept in mind.

Fig. 7.

Left Pleural Sac

Left Phrenic Ncr»c Left Pulmonary Artery

Left Bronchus

Lymph Glands

Left Vagus

Descending Aorta

> Left Eleurdl Sac

Right Pleural Sac

Ascending Aorta Sight Phrenic .Verve Suj>criur Vena Cava -Right Pulmonary Artery

Right Bronchus Lymph Glands i> Right Vagus Bronchial Artery (Jctstqihayus Vena Aiygus Major

Right Pleural Sac

Mediastinum

Thoracic Duct

Diagram showing the anteroposterior relation of the important structures in the thorax on a level with the lung roots. The heart is placed below and anterior to this region.

THE PLEURA.

The pleural sac covers the lung at all points. On the left side it comes forward, covering most of that part of the pericardium which is not covered by the lung, reaching very near to the left edge of the sternum Its lower limit reaches further down than the inferior border of the lung. This complemental space begins id front near the median line, increasing gradually from

ANAT03IICAL.

before backward to the lateral surface of the chest, where it is of greatest depth, diminishing more gradually as it passes on the posterior surface of the chest, the pleura reaching clown to the body of the twelfth dorsal vertebra in the median line posteriorly one and one-half vertebral bodies lower than the lung at the

Fig. 8.

Relation of lungs, pleura, heart and liver to bony thorax.

end of expiration. Most of the complement al space is occupied by the lung in extreme inspiration.

The mediastinum is that part of the thoracic cavity which lies between the two pleural sacs. It contains all of the intrathoracic structures except the lungs and pleura. (Fig. 7.)

THE PERICARDIUM.

The pericardial sac, attached by its broad base to the diaphragm, is invaginated by the heart, and its apex, which is directed' upwards, extends by diverticulaupon the great vessels about two inches from their

Fig. 9.

Relation of lungs, pleura, spleen and kidneys to bony thorax.

origin. Its most important relations to the lung and pleura, with which it is in contact through most of its extent, have been mentioned. Its relation to the anterior thoracic wall is practically the same as that of the heart, with some additional extension upwards, where it is reflected upon the great blood-vessels.

The serous surfaces of the pericardium and of the pleura are bathed in sufficient fluid to render their motions normally noiseless and free from friction.

ANATOMICAL.

THE HEART.

Besides a knowledge of the shape, arrangement and structure of the several cavities and valves of the heart, as well as the general position of the organ, the following points are of special significance in diagnosis :

Fig. 10.

A nterior

Left

■Right

Posterior

Diagram showing the horizontal relations of the orifices at the base

of the heart.

The right ventricle forms the greater part of the anterior aspect of the heart and also its inferior border.

The right auricle forms most of its visible base from this position (the front), while the left ventricle can be seen to a very slight extent all along the extreme left border, forming the true apex. The small appendix of the left auricle appears above, just to the left of the origin of the pulmonary artery, thus completing the anterior aspect of the heart. The left ventricle and left auricle are chiefly posterior.

The pulmonic orifice lies in front of the aortic orifice, its center being a little to the left of the center of the a«»rtic orifice. "The tricuspid orifice is behind and to the right of the aortic orifice, so that the aortic orifice is directly between the tricuspid and pulmonic. The mitral orifice is placed behind and to the left of the

aortic. (Fig. 10.)

These four valves are each on a different plane from above downward in the following order: Pulmonic, aortic, mitral and tricuspid, the interval between the planes of the aortic and mitral orifices being greater than the other two intervals. The plane of the surface of the pulmonic valve faces upward ; that of the aortic orifice, upward to the right and slightly forward; that of the mitral, upward to the right and slightly backward, while that of the tricuspid is directed to the right and slightly upward. The first two are given in the direction of the normal blood current and the last two in the direction of a regurgitating current.

The under-surface of the heart rests on the diaphragm, which separates it from the cardiac end of the stomach and left lobe of the liver. The left ventricle and auricle and the left margin of the right ventricle are covered by lung and pleura, the lung here being quite

thin.

The projection of the outline of the heart upon the anterior surface of the chest is approximately as follows :

A point in the fifth intercostal space three and one-half inches to the left of the median line indicates the site of the apex. Connect this with a point on the lower border of the left second costal cartilage one inch to the

ANATOMICAL.

left of its sternal end by a line gently curved, with its convexity to the left; then connect this last point with a point on the upper border of the right third costal cartilage one-half inch from its sternal end by a straight

Pulmonic Aortic Mitral Tricuspid

Apex

Diagram showing the approximate outline of the heart and the relative location of the orifices.

line, and connect this point and the apex with the right seventh costo-sternal articulation by straight lines.

The pulmonic orifice is directly behind the upper part of the third left costo-sternal articulation.

The aortic orifice is behind the sternum opposite the lower part of the third left costo-sternal articulation to the left of the median line.

The mitral orifice is behind the sternum opposite the fourth costo-sternal articulation, slightly to the left of the median line.

The tricuspid orifice is behind the sternum opposite the fourth intercostal space and in the median line. (Fig. 11.)

THE AORTA.

The aorta, arising at the aortic orifice, first appears between the pulmonary artery and the apex of the right auricle,, coming forward and upward. It soon attains a

Diagram showing relations between great vessels at base of heart and

bronchi.

position anterior to the pulmonary artery, which upwards and then backward, dividing into the righ left pulmonary arteries, the right going behind the ascending aorta, which continues upwards to the right goes ght and

—

ANATOMICAL.

and forward, approaching very close to the posterior surface of the sternum behind its right border at the second intercostal space, where it "usually projects

Regions of the abdomen.

slightly into the right infraclavicular region. From this point it arches backwards to the left of the trachea and over the left primary bronchus, with which struc-

PLATE III.

Situation of the Viscera (Anterior Aspects

Outlines of heart and vessels — broad red lines Margins of lungs and individual lobes— dotted green lines. Limits of pleural saes solid green lines. Liver — red shading. Stomach — green shading.

(In part after His-Spalteholz and Lusehka.l

PLATE IV

U—W-^T^J

Situation of the Viscera (Posterior Aspect).

Outlines of heart and vessels — broad red lines Margins of lungs and individual lobes— dotted green lines. Limits of pleural saes-solid green lines. Liver— red shading. Stomach —green shading.

(In part after H is-Spalteholz and Lusehka.l

PLATE V.

Situation of the Viscera (Right Lateral Aspect).

Margins of lungs and of individual lobes— dotted green lines. Limits of pleural saes — solid green lines. Liver and spleen— solid red lines. Diaphragm — dotted red lines Stomach (portion not covered by lung") — green shading.

(In part after Lusehka.)

PLATE VI

Situation of the Viscera (Left Lateral Aspect).

Margins of lu.ngs and of individual lobes— dotted green lines. Limits of pleural saes solid green lines. Liver and spleen — solid red lines. Diaphragm — dotted red lines. Stomach (portion not covered by lung) — green shading.

(Tn part after Lusehka.)

tures it is in direct contact. (This relation has an important bearing upon the causation of tracheal tugging, which occurs in aneurism of the aortic arch. (Fig. 12.) Going backwards and downward to the left of the oesophagus the descending aorta reaches the left side of the vertebral column at the lower border of the fourth dorsal vertebra. It then goes down on the surface of the vertebral column, gradually approaching the median line, where it is located as it goes between the crura of the diaphragm, becoming the abdominal aorta at the lower border of the twelfth dorsal vertebra.

THE ABDOMEN.

Regions: Draw two horizontal lines across the surface of the abdomen, one through the lower border of the tenth costal cartilage (i. e., the subcostal line), the other through the highest points of the iliac crests (or through the tubercles felt on the outer lip of the crest of the ilium about two inches posterior to the anterior superior spine, i. e., the intertubercular line). Then erect two vertical lines on either side, from the center of Poupart's ligament (i. e., the right and left Poupart lines), and the abdominal surface is thus divided into nine regions, namely : in the middle, from above downwards, epigastric, umbilical and hypogastric or suprapubic; on either side, hypochondriac, lumbar, and iliac or inguinal. (Fig. 13.) (Plates III., IV., V. and VI.)

ANATOMICAL.

Table of Contents of the Abdominal Regions *

RIGHT HYPOCHON- DRIAC.

The liver.

The gall-bladder.

The hepatic flexure of

the colon.

The right kidney.

EPIGASTRIC.

The stomach.

The liver.

The transverse colon.

The omentum.

The pancreas.

The duodenum

Both kidneys and suprarenal capsules.

The coeliae axis.

The aorta.

The posterior extremity of the spleen.

Lymph nodes.

RIGHT LUMBAR.

The ascending colon.

The right kidney.

The small intestine.

LEFT HYPOCHON- DRIAC.

The spleen.

The stomach.

The pancreas.

The spleenic flexure of

the colon.

The left kidney.

The left extremity of

the liver.

UMBILICAL.

The transverse colon.

The omentum.

The duodenum.

The small intestine.

Right kidney (left kidney occasionally).

The aorta.

Lymph nodes.

LEFT UMBILICAL.

The descending colon.

The omentum.

The left kidney (occasionally).

The small intestine.

RIGHT INGUINAL (OR ILIAC)

The Caecum (the origin of the appendix is behind the right Poupartline).

HYPOGASTRIC.

The small intestine.

The sigmoid flexure (the bladder in children or if greatly distended, and the uterus in pregnancy;.

The caecum.

Lymph nodes.

LEFT INGUINAL (OR ILIAC.)

The sigmoid flexure.

* Organs are mentioned in every region that usually contains any part of them

THE STOMACH.

The general shape of the stomach is characteristic. The cardiac or oesophageal orifice is immediately behind the seventh costo-sternal articulation on the left side. The fundus is in contact with the under-surface of the diaphragm. The great curvature or superior, left and inferior border or margin follows a well-pronounced curve with its convexity to the left, and is in contact with the diaphragm, except in its lower portion it comes from under the left inferior costal margin one and one-quarter inches above the subcostal line, from which point it goes almost horizontally to the right and passes behind the free border of the liver just to the right of the median line. The pylorus is just to the right of the median line one and one-quarter inches above the subcostal line and behind the left lobe of the liver. It is carried to the right behind the quadrate lobe when the stomach is distended.

The stomach lies in front of the abdominal aorta, the pancreas and the left kidney. Its great curvature is in relation with the spleen, to the left, and the transverse colon and its meso-colon lie immediately below it. The lesser curvature, slightly concave to the right, lies to tinleft of the median line. The cardiac orifice, part of the fundus, the lesser curvature and the pylorus are covered anteriorly by the free border of the liver. The long axis of the stomach is about parallel with the inferior border of the liver.

It will be seen that the stomach is in contact with the anterior abdominal wall to a comparatively small extent in the epigastric region, and to a very slight extent in the left hypochondriac region.

THE LIVER.

The liver completely fills the right and middle of the dome of the diaphragm, its left lobe extending in contact with the under-surface of the diaphragm in front of the stomach and oesophagus as far as one-third of an inch to the left of the left Poupart line. Its lower border corresponds approximately with a line drawn from a point immediately below the lower extremity of the right costal margin to a point one inch below the left nipple. Then connect these points with a point one-half of an inch below the right nipple by lines slightly concave toward the liver, and the organ is more or less accurately outlined. Posteriorly and to the right its limits are about those of the diaphragm.

The gall bladder presents its fundus (usually in contact with the anterior abdominal wall) immediately beneath the point where the right Poupart line crosses the inferior costal margin (i. e., in the angle formed by the outer border of the right rectus muscle and the free border of the ribs).

THE SPLEEN.

The spleen is placed well back in the left hypochondriac region against the diaphragm, with the splenic flexure of the colon in front of and below it, the stomach against it internally and the upper part of the left kidney posteriorly and internally. It lies between the ninth and twelfth ribs — its long axis is nearly parallel with the posterior portion of the tenth rib. Its posterior extremity is about one and three-quarter inches from the vertebral column. It is usually about Rve inches long and three inches wide. It glides up and down with respiration, but cannot be palpated when normal.