

SURFACE MARKINGS OF THE ABDOMEN 1315 



recedes above the margin of the ribs and cannot then be detected by the finger; 

 in the prone position it falls forward and is then generally palpable in a patient 

 with loose and lax abdominal walls. Its position varies with the respiratory 

 movements; during a deep inspiration it descends below the ribs; in expiration 

 it is raised. Pressure from without, as in tight lacing, by compressing the lower 

 part of the chest, displaces the liver considerably, its anterior edge frequently 

 extending as low as the crest of the ilium. Again its position varies greatly with 

 the state of the stomach and intestines; w r hen these are empty the liver descends, 

 when they are distended it is pushed upward. 



The pancreas can sometimes be felt, in emaciated subjects, when the stomach 

 > and colon are empty, by making deep pressure in the middle line about 7 or 8 cm. 

 above the umbilicus. 



The kidneys being situated at the back of the abdominal cavity and deeply 

 placed cannot be palpated unless enlarged or misplaced. 





SURFACE MARKINGS OF THE ABDOMEN. 





Bony Landmarks. Above, the chief bony markings are the xiphoid process, 

 the lower six costal cartilages, and the anterior ends of the lower six ribs. The 

 junction between the body of the sternum and the xiphoid process is on the level 

 of the tenth thoracic vertebra. Below, the main landmarks are the symphysis 

 pubis and the pubic crest and tubercle, the anterior superior iliac spine, and the 

 iliac crest. 



Muscles (Fig. 1227). The Rectus lies between the linea alba and the linea semi- 

 lunaris; the former is indicated by the middle line, the latter by a curved line, 

 convex lateral ward, from the tip of the cartilage of the ninth rib to the pubic 

 tubercle; at the level of the umbilicus the linea semilunaris is about 7 cm. from the 

 middle line. The line indicating the junction of the muscular fibers of Obliquus 

 externus with its aponeurosis extends from the tip of the ninth costal cartilage 

 to a point just medial to the anterior superior iliac spine. 



The umbilicus is at the level of the fibrocartilage between the third and fourth 

 lumbar vertebrae. 



The subcutaneous inguinal ring is situated 1 cm. above and lateral to the pubic 

 tubercle; the abdominal inguinal ring lies 1 to 2 cm. above the middle of the inguinal 

 ligament. The position of the inguinal canal is indicated by a line joining these 

 two points. 



Surface Lines. For convenience of description of the viscera and of reference 

 to morbid conditions of the contained parts, the abdomen is divided into nine 

 regions, by imaginary planes, two horizontal and two sagittal, the edges of the planes 

 being indicated by lines drawn on the surface of the body (Fig. 1220). In the older 

 method the upper, or subcostal, horizontal line encircles the body at the level of the 

 lowest points of the tenth costal cartilages; the lower, or intertubercular, is a line 

 carried through the highest points of the iliac crests seen from the front, i. e., 

 through the tubercles on the iliac crests about 5 cm. behind the anterior superior 

 spines. An alternative method is that of Addison, who adopts the following lines: 



(1) An upper transverse, the transpyloric, halfway between the jugular notch 

 and the upper border of the symphysis pubis; this indicates the margin of the 

 transpyloric plane, which in most cases cuts through the pylorus, the tips of the 

 ninth costal cartilages and the lower border of the first lumbar vertebra; (2) a 

 lower transverse line midway between the upper transverse and the upper border 

 of the symphysis pubis; this is termed the transtubercular, since it practically corre- 

 sponds to that passing through the iliac tubercles; behind, its plane cuts the body 

 of the fifth lumbar vertebra. 



