SUBDIAPHEAGMATIC ABSCESS. 385 



or injury of any of these structures. But the area may also 

 become infected by pus which has travelled up alongside the 

 ascending or descending colon. Conversely, the track of infection 

 may pass from above downwards towards the pelvis. 



A subdiaphragmatic abscess may lie between the liver and the 

 diaphragm in the right cupola, around the spleen in the left 

 cupola, or around the kidney in the right kidney pouch. The 

 falciform ligament sometimes forms the right or left boundary 

 of an abscess beneath the diaphragm. The area of percussion 

 dulness or of tympanitic resonance when gas is present may be 

 sharply limited by the position of the ligament. The latter is a 

 crescentric fold, the remnant of the ventral mesentery of the 

 embryo. Its convex border is attached to the under surface of 

 the diaphragm, near to the right limit of the pericardium, and 

 to the anterior abdominal wall an inch or more to the right of 

 the middle line. Its concave border is attached to the superior 

 and anterior surfaces of the liver. The fold extends downwards 

 to within one or two inches of the umbilicus, and the round 

 ligament lies in its free edge. 



An abscess under the right wing of the diaphragm will tend to 

 raise the diaphragm and depress the liver. Hence on the one 

 hand, respiratory movements are restricted and the right lung 

 becomes partly collapsed, whilst on the other the liver is 

 depressed. Subdiaphragmatic friction, simulating pleural friction 

 may be heard, and pain, tenderness, and even oedema of the 

 right axillary region may be present. 



An abscess under the left iving of the diaphragm lies in the 

 greater sac, occupying part of the stomach chamber, and also 

 the space between the spleen and the chest wall. Such abscesses 

 are sometimes termed perisplenic. The retention of pus in 

 this situation is considerably assisted by the presence of a well 

 marked phrenico-colic fold. This fold is continuous with the 

 left part of the great omentum, from which it is derived, and 

 extends outwards from the splenic flexure of the colon to the 

 diaphragm. Thus, when the patient is supine, there is a natural 

 well in the left subdiaphragmatic region, containing the spleen 



C.A.A. 25 



