386 CLINICAL APPLIED ANATOMY. 



and a portion of the stomach, and corresponding to the well 

 around the upper part of the right kidney. This well is ready 

 for the reception of any fluid which may trickle into it. The 

 physical signs produced by a collection of fluid here are similar 

 to those already described as accompanying right-sided collections, 

 with the exception that the left lobe of the liver alone may be 

 depressed and the cardiac impulse may be displaced upwards. 

 The subdiaphragmatic friction sound may have a cardiac or 

 respiratory rhythm. 



A subdiaphragmatic abscess which lies beneath the liver, and 

 is consequently sometimes termed subhepatic, occupies a peri- 

 toneal well, known as the right kidney pouch. This belongs to 

 the greater sac, and its boundaries are as follows. Above and 

 in front, the right lobe of the liver and its ligaments ; below, 

 the hepatic flexure of the colon and its attachment to the 

 posterior abdominal wall; internally, the peritoneum covering 

 the descending duodenum and lumbar spine, and stretching 

 forwards to the foramen of Winslow; externally, the parietal 

 peritoneum of the lumbar region. The peritoneum covering 

 the right kidney forms the floor of the pouch. This well has 

 proved capable of holding nearly a pint of fluid before it over- 

 flows into other parts of the peritoneal cavity. With the patient 

 supine, the right lumbar region slopes from below towards it ; 

 the right half of the transverse mesocolon forms an inclined 

 plane directed to it, and the gall bladder and bile ducts lie in 

 intimate relation with it. Fluid collections in this situation 

 may travel from the appendix along the lumbar region, or from 

 the pylorus and duodenum, being directed by the prominence of 

 the lumbar spine and inclination of the transverse mesocolon, or 

 may be the result of lesions of the gall bladder and its ducts. 

 Abscesses in the liver and right kidney or in connection with 

 malignant growth of the hepatic flexure of the colon may also 

 be found in this part of the peritoneal sac. A large collection 

 of fluid here may so push up the liver and impede the action of 

 the diaphragm as to simulate a collection between the liver and 

 the diaphragm, but the edge of the liver would be raised in 



