PRACTICAL CONSIDERATIONS : THE ABDOMEN. 537 



those organs, and often, when they overlap its boundaries, displace the colon in 

 definite directions. 



The course of the colon being made apparent by inflating it with air, it may 

 therefore be said that : 



1. Growth in the ce?iira/ region would include tumors of the omentum, mesen- 

 tery, small intestine, and peritoneum, many retroperitoneal tumors, and such growths 

 affecting the female generative apparatus as rise from the pelvis into the abdomen. 

 In the latter case the caecum and sigmoid would be displaced upward and outward. 



2. Tumors beginning in the superior region would include those of the liver, 

 gall-bladder, stomach, lesser omentum, spleen, and pancreas. Harris calls attention 

 to the fact that pancreatic cysts have usually been mistaken for ovarian cysts, 

 although the former almost always displace the transverse colon downward. They 

 also, being retroperitoneal, carry it forward, while tumors of the spleen, although 

 they cause downward displacement of the colon, especially of the splenic flexure, 

 override it and hug the anterior abdominal wall. Enlargement of the gall-bladder 

 similarly tends to depress and to overlap the right half of the transverse colon. 



3 and 4. In the postero-lateral or external regions the most common tumors are 

 those of the kidneys ; but as they are all retroperitoneal, they tend to carry the 

 ascending or descending colon forward as well as inward. There are, of course, 

 exceptions to these relations, — as, for example, in the case of a movable kidney, 

 which may be displaced so as to carry the inner layer of the mesocolon forward and 

 inward and so have the colon lying to the outer side, — but they are rare, and the 

 anatomical relations described are of distinct diagnostic value. 



Bowlby has formulated the anatomical reasons for first exploring the right lower 

 half of the abdomen in cases of intestinal obstruction of doubtful origin. He says 

 that here are to be found : {a') the appendix ; {b) intestinal diverticula perhaps 

 attached to the umbilicus or to the neighboring mesentery ; (r) a common site for 

 volvulus, — that is, the caecum ; (af ) a usual site for the lodgment of an impacted gall- 

 stone, — that is, the lower part of the ileum ; (^) a common place for adhesions due 

 to caseous mesenteric glands ; (_/) the sites of right-sided inguinal, femoral, and 

 obturator herniae. Further, if the obstruction is in the small intestine, it is in the 

 right iliac fossa that undistended intestine will be found, and if this can be secured 

 and traced upward, it is the surest guide to the seat of obstruction. 



A brief resume of some of those svmptoms of abdominal disease having a definite 

 anatomical basis will serve to complete the consideration of this important region. 

 The patient being supine with the thighs flexed : 



1. Inspection may show : {a) an asymmetrical swelling referable to a particular 

 organ or region {vide sjipra) ; {b^ general distention, which, if due to ascites, will 

 cause bulging of the flanks, the fluid settling in the deep lateral recesses of the middle 

 zone ; if to flatulence or intestinal paresis, a more symmetrical enlargement, usually 

 somewhat emphasized in the central region on account of the presence there of the 

 coils of thin and easily dilatable small intestine ; if to pregnancy, a rounded cen- 

 tral prominence in the lower abdomen ; (r) retraction, which if extreme (scaphoid), 

 might be due to tuberculous meningitis, to lead poisoning, or to other cause of great 

 emaciation ; {d) oedema of the skin, indicating, if local, an abscess underlying 

 and close to or in the abdominal wall ; (<') enlarged veins {vide sripra^ ; (./).a flat- 

 tened umbilicus in ovarian or uterine growth, or a pouting umbilicus in ascites or 

 tuberculous peritonitis. 



2. Palpatioji may disclose : {a) rigidity of the abdominal wall, which, if in the 

 right hypochondriac region, would suggest gall-bladder disease ; if in the epigastric 

 region, stomach ulcer or pancreatitis ; if in the right iliac fossa, disease of the appen- 

 dix or caecum. The entire absence of rigidity in a case of acute abdominal pain, 

 especially if the latter is relieved by pressure, indicates an absence of inflammation 

 and suggests irregular or spasmodic peristalsis (colic) as the cause ; {b) pulsation 

 due to the upheaval of a growth by vessels beneath it, to an aneurismal swelling, or, 

 in the line of the vessel and in thin persons, to the pulse in a normal aorta ; (<:) tender- 

 ness, which is sometimes misleading on account of the association of visceral disease 

 and reflected surface pain {vide snpra). For example, the characteristic tenderness 

 of appendicitis is over McBurney's point, but there may be not only pain but also 



