THE ABDOMINAL VISCERA. 399 



to go to the spleen, forming the anterior layer of the lienorenal ligament. It is then 

 reflected from the spleen to the posterior surface of the stomach, forming the 

 posterior layer of the gastrosplenic omentum. From thence it passes forward on 

 the stomach, past the pylorus to the upper surface of the first portion of the duode- 

 num. Here it winds around the hepatic artery, portal vein, and common bile duct 

 to reach the anterior surface of the stomach. This reflection forms the free anterior 

 edge of the foramen of Winslow. From the fundus of the stomach it passes to the 

 spleen, forming the anterior layer of the gastrosplenic omentum. It winds around 

 the outer or costal surface, and the inner or renal surface of the spleen, and thence 

 passes to the left kidney, forming the posterior layer of the lienorenal ligament. 

 After covering the outer portion of the kidney, it is reflected to the abdominal wall 

 which it follows to the median line. 



The Transversalis Fascia. Superficial to the peritoneum and between it and 

 the structures which it covers is a layer of fibrous tissue which varies in thickness. 

 The part which lines the muscles of the abdomen is called -the transversalis fascia. 

 It is thickest and most marked in the lower portion of the abdomen and accom- 

 panies the femoral vessels down the thigh. 



Subperitoneal Fat. In certain locations there is more or less fatty tissue 

 between the transversalis fascia and the peritoneum, and sometimes it is impossible 

 to differentiate them. They blend in the region of the kidneys, the mesenteries, 

 inguinal regions, etc. In the femoral canal the transversalis fascia is continuous with 

 the sheath of the vessels and the subperitoneal fat with the septum crurale. The 

 protrusion of this subperitoneal fat in the median line usually above the umbilicus 

 forms the fatty hernise alluded to on page 371. 



THE ABDOMINAL VISCERA. 



The abdominal contents should first be studied as to their positions and general 

 relations, so that they can be readily found and identified, and then studied as to 

 their intimate relations to the immediate surrounding structures. 



By knowing the first, an operator is enabled to expose quickly the affected part, 

 and by knowing the second he is enabled to carry out the desired procedures. 

 While it is true that the presence of tumors or enlargement of the various organs 

 may distort and displace them and so render their exposure and recognition difficult, 

 nevertheless a knowledge of the normal relations is essential in order to solve the 

 difficulties which arise in operating for or studying the various abdominal diseases 

 and injuries. 



It must be borne in mind that the extent and position of the various organs is 

 not always the same, even though they are not diseased; it is easier to find a 

 distended than a contracted stomach; in some people the liver though not diseased 

 may be lower than in others, etc. 



When the abdominal cavity is freely opened the general relation of the organs 

 is visible as in Fig. 414. In the upper portion is seen the liver. Its edge usually is 

 inclined upward toward the left, but sometimes it passes almost transversely across. 

 In the male its lower edge should be about even with the lower edge of the thorax 

 (tenth rib) but in females it may be a finger-breadth lower. Its anterior edge is 

 marked by the gall-badder and round ligament. The gall-bladder is liable to be a little 

 to the outside of its normal position at the upper extremity of the right linea semi- 

 lunaris. The round ligament reaches the liver not at the median line but 2.5 to 4 

 cm. ( i to i y-z in. ) to its right. The point at which the liver crosses the median 

 line is approximately 4 cm. ( i ^ in. ) below the tip of the ensiform cartilage. The 

 stomach is seen to the left of the liver, between it and the left costal cartilages. 

 Frequently the stomach is seen to pass a little to the right of the median line, partic- 

 ularly if it is distended. A small portion only, 2.5 to 4 cm. (i to i^ in.), is seen in 

 the median line and its lower border slopes up and to the left to disappear under the 

 edge of the ribs. Immediately below the stomach lies the transverse colon, concealed 

 beneath omentum. The omentum hangs down from the lower edge of the stomach 

 and spreads over almost the whole of the abdomen below. It is almost always 



