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per part of the ureter is exposed by extending the division of the muscles still further downwards and forwards into the iliac region. ping the peritoneum off the quadratus and psoas muscles, the ureter and to cling to the deep surface of the membrane. Care is taken not he internal spermatic or ovarian vessels, which cross the ureter superd from the medial to the lateral side. The ureter is surrounded by a of loose cellular tissue, and, owing to an abundance of elastic fibres in its us coat, is very elastic, so that it can be readily pulled up to the surface. eliver an enlarged kidney out of the loin, it is generally necessary to the incision upwards so as to divide the lateral lumbo-costal arch; and be necessary to divide, fracture, or resect the twelfth rib also. In doing

not always possible to avoid opening into the lowest part of the pleural hich descends in front of the medial half of the rib. operating on the kidney, the last thoracic, and the ilio-hypogastric and uinal nerves, which lie between it and the quadratus lumborum, must not tred; the last thoracic nerve should be retracted upwards and laterally, er two downwards and medially.

needle passed through the medial extremity of the eleventh intercostal will transfix the suprarenal gland. e pus of a perinephric abscess occupies the fatty layer of the tela subserosa nephric fat), and lies, therefore, within the fascial envelope of the abdomen ; pus in a psoas abscess, on the other hand, lies external to the fascia. In ing a psoas abscess from behind, a vertical incision is made in the angle ed by the lateral border of the sacrospinalis and the crest of the ilium; in deeper part of the dissection the surgeon should keep close to the front of transverse process of the fourth lumbar vertebra. Diaphragm, Liver, Stomach, and Large Intestine.—Posteriorly the right h of the diaphragm and the right lobe of the liver extend upwards to the level the angle of the scapula (eighth rib), while the left arch and the fundus of the omach lie one inch lower (eighth interspace); the central tendon reaches up to e eighth thoracic spine. The right lobe of the liver is covered posteriorly by ne eighth to the twelfth ribs, and is overlapped by the base of the right lung as ar as a line drawn horizontally laterally from the tenth thoracic spine; hence, posteriorly, the superior limit of the liver cannot be defined by percussion, and its nferior limit merges into the dulness of the loin muscles and kidney.

The cardiac orifice of the stomach lies one inch to the left of the ninth thoracic spine. The cardiac portion, overlapped by the ninth to the twelfth ribs, extends upwards to the level of the eighth thoracic spine, one inch below the inferior angle of the scapula. The pyloric portion crosses the median plane opposite the first and second lumbar spines, the pylorus itself being situated one inch to the right of the first lumbar spine. The lesser curvature lies to the left of and below the tenth, eleventh, and twelfth thoracic spines.

Viewed from behind, the large intestine, on both sides, overlaps the lateral border of the kidneys and lies parallel to the lateral border of the sacrospinalis muscles. The peritoneum is reflected from the colon on to the posterior abdominal wall along a line drawn vertically upwards from the centre of the iliac crest. The left flexure of the colon, which reaches up to the level of the twelfth thoracic spine and the tenth rib, lies about five inches above the iliac crest. The right flexure lies on a level with the first lumbar spine.

Spleen.—The spleen, situated in the left hypochondrium, behind the cardiac end of the stomach, is overlapped by the ninth, tenth, and eleventh ribs, the long axis of the organ corresponding approximately to that of the tenth rib. Between the superior third of the spleen and the chest wall (pleura and diaphragm intervening) is the base of the left lung, the inferior margin of which crosses the organ horizontally at the level of the tenth thoracic spine. The costo-diaphragmatic reflection of the pleura reaches down as far as the inferior angle of the spleen. The superior limit of the organ cannot therefore be defined by percussion; and unless enlarged, or displaced downwards, the spleen cannot be punctured from behind without traversing the pleural as well as the peritoneal cavity.

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FIG. 1110.–POSTERIOR ASPECT OF TRUNK, SHOWING SURFACE TOPOGRAPHY OF VISCERA.
T. Trachea.
Sp. Spleen.

P. Pancreas.
A. Aorta.
L. Liver.

Pl.

Pleura.
L.L. Left lung

S.R. Suprarenal gland. D.C. Descending colon.
R.L. Right lung.
L.K. Left kidney.

A.C. Ascending colon.
St. Stomach.
R.K. Right kidney.

R. Rectum.
inferior angle lies opposite the eleventh intercostal space on a level with the first
lumbar spine, in a line drawn vertically upwards from a point one inch behind the

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iliac crest. This angle is situated behind the superior part of the olon, immediately lateral to the middle of the lateral border of the e anterior angle is at the level of the ninth interspace in the mid· Having placed a mark on the skin opposite these three angles the pped out on the surface as follows :—The posterior margin is obtained he posterior and inferior angles; this margin, which gives the key to n of the spleen, will be found to follow the tenth intercostal space. inferior margin corresponds to a line joining the anterior and the

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Fig. 1111. ---DISSECTION OF THE LEFT HYPOCHONDRIUM TO SHOW THE RELATIONS OF THE SPLEEN TO THE

SIDE WALL of the Chest, THE DIAPHRAGM, AND THE ADJACENT VISCERA. In addition to the portions of ribs, there has been removed a part of the base of the left lung, and a window has been made in the diaphragm almost down to the level of the costo-diaphragmatic reflection of the pleura.

inferior angles; it is related to the left flexure of the colon. Commencing at the vertebral angle, the anterior margin is at first arched, the summit of the arch reaching to the level of the upper border of the ninth rib in the scapular line; thence it is continued downwards and forwards across the posterior axillary line as the “ anterior crenated border” to the anterior angle. The upper arched portion lies parallel to and about one inch below the highest part of the fundus of the stomach. The only parts of the splenic outline which can be defined by percussion are the lower crenated part of the anterior margin, the anterior angle, and the short postero-inferior or colic border; and it is these parts which may be felt below the costal margin when the organ is considerably enlarged.

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TABLE INDICATING THE LEVEL

In excising the spleen it is important to remember that the splenic vessels lie between the two layers of the lieno-renal ligament, and not in the gastro-lienal ligament, which contains the short gastric vessels. In a floating spleen these two peritoneal ligaments are elongated to form a distinct pedicle.

Pancreas.—The head of the pancreas lies opposite the last thoracic and first lumbar spines; the tail lies at the same level as the left flexure of the colon, a little above the inferior basal angle of the spleen.

RELATION TO THE SPIN

Spises of Vertebra. Origins of Spina

TABLE INDICATING THE LEVEL OF THE MORE IMPORTANT STRUCTURES IN

RELATION TO THE SPINES OF THE VERTEBRÆ.

I Lumbar..

4 and 5

Spines of Vertebræ.

Origins of Spinal Nerves.

Level of other Structures.

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Soft palate.
Isthmus of fauces.
Upper part of epiglottis.
Vocal folds (O. T. cords).

Conus elasticus.
Arch of thoracic duct.
i Commencement of trachea and esophagus
Inferior end of cervical enlargement of

spinal medulla.
Inferior cervical ganglion of sympathetic.
Apices of lung.
Summit of arch of subclavian artery.
Medial angle of scapula.
Just above level of highest part of arch of

aorta.
(Jugular notch.
Root of spine of scapula.
'Arch of vena azygos.
Highest part of inferior lobes of lungs
Termination of arch of aorta.
Bifurcation of trachea.
Lower limit of superior mediastinum.
Angulus sterni.
Commencement of descending thoracic

aorta.
Bronchi.
Superior limit of heart.

Centre of root of lung.
| Mitral orifice.

Tricuspid orifice.
Inferior angle of scapula.
Orifice of inferior vena cava.
Right arch of diaphragm.
Lowest limit of heart.
Left arch of diaphragm.
Fundus of stomach.
Xiphi-sternal articulation.
Superior limit of spleen.
Cardiac orifice of stomach.
Upper end of lumbar enlargement
Lower border of lung, posteriorly.
Vertebral angle of spleen (apex of spleen
Superior end of left kidney.
Lesser curvature of stomach.
(Lower limit of pleura at vertebral column
Superior end of right kidney.
Suprarenal gland.
Body of pancreas.
Lesser curvature of stomach.
Level at which pleura crosses twelfth rib.
Inferior end of spleen.
Left flexure of colon.
Superior part of head of pancreas.
Pylorus and pyloric portion of stomach.

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INDICATING THE LEVEL OF THE MORE IMPORTANT STRUCTURES IN
RELATION TO THE SPINES OF THE VERTEBRÆ—Continued.

Vertebræ.

Origins of Spinal Nerves.

Level of other Structures.

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Conus medullaris.
Lower limit of pleura (mid-axillary line).
Hila of kidneys.
Head of pancreas.
Right flexure of colon.
Portal vein.
Descending part of duodenum.
Greater curvature of stomach.
Bile-duct.
Commencement of ureters.
Lowest part of head of pancreas.
Inferior limit of spinal medulla in child.
Inferior ends of kidneys.
Horizontal part of duodenum.
Highest part of crest of ilium.
Bifurcation of aorta.
Umbilicus.
Common iliac arteries.

Valve of the colon.
Sacral promontory,

Lower end of sub-dural space.
Superior end of gluteal cleft.
Inferior limit of sub-arachnoid and sub-

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1 Sacral 2

3

dural spaces.

Spinal Medulla.—The spinal medulla ends opposite the inferior border of the irst lumbar spine ; in the infant it reaches to the interval between the second and third lumbar spines. The cervical enlargement, which corresponds to the lower four cervical and the first two thoracic segments, ends opposite the seventh cervical spine. The lumbar enlargement lies opposite the last three thoracic spines. The five lumbar segments are opposite the ninth, tenth, and eleventh thoracic spines, while the five sacral segments extend from the lower border of the eleventh thoracic to the lower border of the first lumbar spine.

The sub-dural space extends down to the level of the second sacral spine. In performing the operation of lumbar puncture (Quincke) a fine trochar and cannula are introduced into the sub-arachnoid space below the level of the spinal medulla, the puncture being made 1 to 1 in. to one side of the interspinous ligament in the interval between the third and fourth or fourth and fifth lumbar spines. The instrument should be directed medially towards the median plane and very slightly upwards. In the adult the distance of the dura mater from the surface is about 2 in., in the infant in.

Fracture-dislocations of the vertebral column are commonest in the lower cervical and thoracico-lumbar regions; that is to say, where the movable cervical and lumbar regions join the more fixed thoracic region. The vertebral column above the injury is generally displaced forwards, so that the spinal medulla is often severely lacerated or completely torn across by the superior end of the portion of the column below the fracture. It is important to remember that in consequence of the shortness of the spinal medulla as compared with the vertebral column, the origins of the spinal nerves are at a higher level than their exits from the vertebral canal. The distance between origins from the spinal medulla and exits through the intervertebral foramina becomes greater the further down the nerves are, the lowest nerve trunks running almost vertically downwards. The cervical nerves leave the vertebral canal above the vertebræ after which they are named (except the eighth, which is above the first thoracic vertebra); the thoracic, lumbar, and sacral nerves, on the other hand, leave the canal below the correspondingly named vertebra.

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