| THE ABDOMINAL CAVITY. 1225 
allows of greater downward displacement of the liver. To reach the centre of the 
lateral surface of the right lobe portions of the seventh and eighth ribs should be 
resected in the mid-axillary line, and both the pleural and peritoneal cavities must 
be traversed. 
The relation of the fundus of the gall-bladder to the surface is subject to 
considerable variation; generally it is situated opposite the angle between the 
ninth costal cartilage and the outer border of the rectus. The eystic duct, which 
passes downwards and forwards, is bent sharply upon itself close to its origin at 
the neck of the gall-bladder. The common bile-duct, about 3 in. in leneth, lies, in 
its upper third, in the right free border of the gastro-hepatic omentum ; its lower 
two-thirds lie at first behind the first part of the duodenum, and then between the 
head of the pancreas and the second part of the duodenum, on the inner wall of 
which it opens a little above its termination. Fenger has shown that the middle 
portion of the common duct is that which is least closely related to the portal vein. 
Stomach.—The stomach hes almost entirely within the left half of the epi- 
gastric and the left hypochondriac regions. The cardiac orifice, which lies 1 in. 
below and to the left of the ce sophageal opening in the diaphragm, is about 4 in. 
from the surface, and corresponds, on the anterior surface of the body, to a 
pot over the sev enth left costal cartilage 1 in. from the sternum. The pylorus, 
which is generally partly overlapped by the lower mar gin of the liver, lies, as a rule, 
about 1 in. to the right of the mesial plane; when the stomach is empty it 
generally lies in the mesial plane, when distended it may reach two, or even three, 
inches to the right of the middle line. The pyloric portion of the stomach is prac- 
tically bisected “by a horizontal plane which passes through the abdomen at the 
level of a pomt midway between the suprasternal notch and pubic symphysis 
(Addison); it hes, therefore, 3 to 4 in. below the infrasternal notch, mid- 
way between it and the umbilicus, opposite the first lumbar vertebra. The 
highest part of the fundus of the stomach corresponds to the left vault of the 
diaphragm, and lies a little above and behind the apex of the heart. The greater 
curvature crosses behind the left costal margin opposite the tip of the ninth costal 
cartilage, that is to say, where the transpyloric line intersects the vertical Poupart 
line. The lowest part of the great curvature, situated generally in the mesial 
plane, extends down to, or a little above, the infracostal plane, about 2 in. above 
the umbilicus. The lesser curvature and the adjacent part of the anterior wall 
of the stomach are overlapped by the lower margin of the liver. 
Overlying the stomach is an important surface area known to clinicians as the 
semilunar space of Traube. This space, which yields a deeply tympanitic note on 
percussion, 1s bounded above by the lower margin of the left lung; below, by the 
left costal margin; to the right, by the lower edge of the left lobe of the liver; 
behind and to the left, by the anterior border and anterior basal angle of the spleen. 
The line of the costo-diaphragmatic pleural reflexion crosses the space about mid- 
way between its upper and lower limits. The tympanitic area of the space is 
diminished superiorly by pleuritic effusion, towards the right by enlargement of 
the liver, and towards the left by enlargement of the spleen. 
Perforation of an ulcer on the anterior wall of the stomach leads to extravasa- 
tion into the greater sac of the peritoneum, while if the perforated ulcer be upon 
the posterior wall, extravasation takes place into the lesser sac. The close relation 
of the splenic artery and its branches to the posterior wall of the stomach explains 
the severe hemorrhage which is sometimes caused by a posterior gastric ulcer. 
The surgeon may see the posterior wall of the stomach through the gastro-colic 
omentum, or, after throwing upwards the great omentum and transverse colon, by 
traversing the transverse mesocolon ; by the former route the posterior wall of the 
stomach is reached through the anterior wall of the lesser sac, in the latter case 
through its posterior wall. 
Duodenum.—The first part of the duodenum, situated in the right half of the 
epigastrium, lies behind the eighth costal cartilage, immediately internal to the 
gall-bladder, and is overlapped by the quadrate lobe of the liver. If the finger 
be passed aboye this part of the duodenum and towards the left, behind the right . 
free border of the lesser omentum, it will occupy the foramen of Winslow, which is 
e 
