RELATION OF KIDNEYS TO ABDOMINAL WALLS 1119 



of the spine. This portion of the intestine being firmly secured in place by fibres 

 from the left cms of the diaphragm and the connriencement of the mesentery, 

 accounts for rupture of the intestine usually occurring near this spot. 



Of the jejunum and ileum it may be .said that, if undistended, the coils of the 

 jejunmn (about eight feet} occui)y rather the left side, and that of the ileum 

 (twelve feet), the right side, in addition to the central regions, where the jejuiuim 

 would be chieHy above, and the ileum below. According to Mr. Treves, the coils 

 most usually found in the pelvis belong to the terminal jiart of the ileum, and that 

 ])art of the intestine which has the longest mesentery, viz. : that extending between 

 two jioints respectively six and eleven feet fnjm the end of the duodenum. But as 

 there is no definite limit between the jejunum and ileum, so is there no regular 

 arrangement of their coils. If i>resent, a Meckel's diverticulum would arise from 

 one to three feet from the termination of the ileum. 



The upper limit of the mesentery would be marked by a spot about three 

 inches above the umbilicus and a little to the left of the centre of the body of the 

 second lumbar vertebra. From this point it extends obliquely to the right iliac 

 fossa, where it ends in the ileo-ctecal junction, about four inches above the centre 

 of Poupart's ligament. Its average length is about eight inches. 



(B) Large intestine. — The caecum measuring about two and a half inches 

 both in its vertical and transverse diameters, lies in front of the ilio-psoas, and 

 should be so mapped out behind the anterior abdominal wall as to lie above the 

 outer half of Poupart's ligament, and with its apex or lowest point projecting 

 just beyond the inner border of the psoas, and thus corresponding to a point a 

 little to the inner side of the centre of Poupart's ligament. Not unfrequently it 

 lies more external, still in the right iliac region, but entirely on the iliacus. The 

 ileo-caecal valve, or junction of the small and large intestines, corresponds to a 

 point about two inchc^s internal to and a little above the anterior superior spine. 

 The l)ase of the vermiform appendix, which usually comes off close to the valve on 

 the posterior Avail of the caecum, would be represented by the above point with 

 sutlicient accuracy. The appendix itself, averaging four inches in length, of the 

 size of a goose-quill, and usually twisted on itself owing to the shortness of its 

 mesentery, generally projects behind the caecum, ileum, and mesentery, in the 

 direction of the spleen (Treves), or downwards to the left, so as to approach the 

 l)rim of the pelvis. The ascending colon, covered by small intestine, lies deei)ly 

 as it passes up over the kidney through the right luml)ar region. The hepatic and 

 splenic flexures lie deeply also in the hypochondriac regions, the splenic being 

 higher than the hepatic, and behind the stomach, while the former is in contact 

 with the under surface of the liver. Between the two courses the transverse 

 colon, in close contact with the great curvature of the stomach, and varying in 

 position from one, two, or thnc inches above the umbilicns, to one nearer or even 

 below this point. The descending colon follows a similar course to the ascend- 

 ing; and the sigmoid flexure occupies the left iliac fossa, and from this point 

 passes over the brim of the i)elvis. Except at its hepatic and s])lenic flexures, the 

 colon can be examined through the parietes, aided by an anaesthetic. The ca?cum 

 is the most superficial of all. 



Landmarks for lumbar colotomy. — (A ) The lower border and Uy of the last 

 rib, which varies in length; (2) a point half an inch bchintl the centre of the iliac 

 crest, this point being found by accurate measurement along the crest between the 

 anterior and po.'^terior spines (Allingham); (o) a line drawn vertically ujnvards 

 from the last-mentioned point to the last rib. This gives with sufficient correct- 

 ness the line of the outer edge of the quadratus, and the position of a normal 

 colon. 



Iliac or anterior colotomy. — The incision here, whether for opening the 

 sigmoitl flexure or the ciecum, is one, two and a half, or three inches long, made 

 parallel with the outer part of Poupart's ligament, and one and a half inches 

 above it. 



The kidneys. — Tiie.se lie at the back of the abdominal cavity so deeply in the 

 hypochondriac and epigastric region as to be beyond palpation. unle.>;s enlarged or 

 unduly mobile. The lower end of the right being slightly li»wer than its fellow, 

 encr<.>aclies in health upon the lumbar and epigastric region. These organs lie nnich 



