402 CLINICAL APPLIED ANATOMY. 



Downward displacement, or ptosis of the liver, may occur 

 alone or be associated with general enteroptosis. The liver is 

 supported by the combined action of its ligaments, its attach- 

 ment to the diaphragm by means of the inferior vena cava and 

 extensive posterior non-peritoneal surface, and by the action of 

 the muscular portion of the abdominal wall. The liver, being 

 plastic, undergoes considerable modification of shape when 

 displaced. The displacement may cause obstruction of the 

 structures which enter the portal fissure, and also in rare 

 cases the inferior cava may become distorted. The traction 

 of a displaced liver may induce various nervous symptoms, such 

 as pain in the shoulder, dyspnoea, etc. 



Rupture of the Liver. The liver is bulky and occupies a 

 considerable portion of the upper part of the abdominal cavity ; 

 moreover it is heav}^, friable, and subjacent to yielding ribs. 

 Consequently it is more often ruptured as the result of falls and 

 contusions than any other abdominal organ. The liver substance 

 bleeds freely when torn or penetrated, for the portal and hepatic 

 veins are not provided with valves, and the latter in particular 

 are held open by their intimate relation to the liver substance. If 

 the rupture involves the posterior, non-peritoneal surface, the 

 blood will escape into the retroperitoneal tissues, instead of 

 into the peritoneal cavity. In some cases the liver has been 

 extensively damaged without laceration of Glisson's capsule, 

 the blood then remains confined. Damage to the liver is 

 often associated with fracture of the ribs or costal cartilages 

 which overlie it. Posteriorly, in the scapular line the liver is 

 subjacent to the five right lower ribs, the eighth to the twelfth ; 

 in the axillary region it is also under cover of five right ribs, 

 the seventh to the eleventh ; in front it is under cover of five 

 right costal cartilages, the fifth to the ninth. 



Penetrating wounds of the liver may be in such a position 

 that they also traverse the pleural sac, the lung, the diaphragm, 

 and the peritoneal cavity. Wounds of this nature may be 

 situated in the sixth or seventh intercostal spaces antero- 

 laterally, or in the eighth, ninth, or tenth spaces posteriorly. 



