THE LIVER. 



419 



called the left lateral, extends as far to the left of the falciform ligament as the coronary 

 does to the right. It is attached to the diaphragm in front of the oesophagus, while 

 the coronary is attached to the back of the diaphragm. The falciform ligament 

 starts near the umbilicus, passes to the umbilical notch of the liver 2.5 to 4 cm. (i to 

 i YZ in. ) to the right of the median line and thence over the top of the liver to near 

 its posterior edge, where it blends in front of the vena cava on the right side with the 

 coronary ligament and on the left with the triangular ligament. The round ligament 

 is the round cord in the free edge of the falciform ligament which runs from the 

 umbilicus to the umbilical notch and thence to the portal fissure to join the left branch 

 of the portal vein. It is the remains of the fetal umbilical vein. The ligament of the 

 ductus venosus runs from the left branch of the portal vein to the vena cava in the 

 fissure of the ductus venosus. The ductus venosus, like the umbilical vein, becomes 

 obliterated at birth. 



Position of the Liver. The liver rises to the fourth costal interspace on the 

 right side, to or slightly above the xiphosternal junction in the midline, and the lower 

 border of the fifth rib on the left side, to its extremity, just beyond the apex of the 

 heart, at the lower border of the sixth rib. Its lower border passes from this point to 

 the eighth left cartilage, crosses the middle line about midway between the xiphoid 



Suprarenal gland 



Vena cava 



Second portion 

 of duodenum 



Portal vein 

 Hepatic artery 



Common bile-duct 

 Pylorus 



Gastrocolic omentum 



Right gastro-epiploic artery' 

 FIG. 430. The bed of the liver. The liver has been removed to show the surrounding structures. 



articulation and umbilicus to the ninth right costal cartilage, and thence follows the 

 edge of the ribs posteriorly, being about 2.5 cm. (i in.) lower in women. The 

 upper limits of its percussion dulness are the upper border of the sixth rib in the 

 right mammillary line, the eighth in the axillary, and the tenth in the scapular. 



Relations of the Liver. The superior surface lies in contact with the 

 diaphragm, except the portion extending about 7.5 cm. (3 in.) below the xipho- 

 sternal junction in the median line and sometimes the small projecting edge beyond 

 the ribs, which lies in contact with the abdominal wall. The posterior surface lies 

 over the tenth and eleventh thoracic vertebrae, the crura of the diaphragm, the 

 oesophagus, aorta, vena cava, and right suprarenal gland. The inferior surface to 

 the left rests on the cardiac end and upper surface of the stomach and gastrohepatic 

 omentum. Beneath the quadrate lobe is the pylorus and beginning of the duo- 

 denum. Beneath the caudate lobe is the foramen of Winslow, of which it forms 

 the upper boundary. Farther to the right are the depressions for the hepatic flexure 

 of the colon and the right kidney and suprarenal gland (Fig. 430). 



The size of the liver varies, being small in atrophic diseases and much enlarged 

 in others; therefore, alterations in the area of dulness are frequent. It moves with 

 respiration and sometimes hangs lower than normal (ptosis}. 



