THE LIVER. 1055 



gall-bladder and undergoes a more or less sharp bend, and passes to the anterior 

 margin of the transverse fissure, following the posterior edge of the quadrate lobe 

 to the left. It now reaches the tuber omentale. ascends on the left side of the 

 fissure for the ductus venosus, and, making nearly a right angle, is prolonged above 

 upon the left lobe. Here it forms the posterior edge of the lateral ligament. All 

 the parts between the lines thus traced are not covered by peritoneum. This all 

 belongs to the peritoneum of the greater sac except that which surrounds the 

 Spigelian lobe ; this belongs to the lesser sac or atrium of the omental bursa. 



Relations of the Liver. 



It lies in both hypochondria and in the epigastrium. It completely fills the 

 right hypochondrium and sometimes enters the right lumbar region. Its entire 

 right lobe lies in the right side of the abdominal cavity ; only the left lobe reaches 

 the left half of the body. The left longitudinal fissure and the attachment of the 

 broad ligament, and the interlobar incisure which mark the limits between the right 

 and left lobes, correspond almost always to the median line of the body (Fig- 626). 

 Its convex upper surface fits itself to the concavity of the diaphragm, in which it 

 glides as if in a joint-socket. The upper limit of the liver corresponds to that of 

 the diaphragm. On the right side in the mammary line it is at the middle of the 

 fourth intercostal space ; on the left in the mammary line it is at the upper bordet 

 of the fifth space. It does not usually go beyond this line. Above the right lobe 

 rests the concave base of the right lung. In percussing the side of the chest down- 

 ward three regions are noted first, one of relative liver dulness, where it is covered 

 by the lung ; second, the region of costo-phrenic sinus, where diaphragm and not 

 lung intervenes ; third, absolute liver dulness below the diaphragm. A stab here 

 could wound at the same time the pleura, right lung, diaphragm, peritoneum, and 

 convex surface of the liver. Above the right and left lobes are the heart and then 

 the left lung. The convex surface of the liver is covered on the right side by the 

 greater part of the lower six or seven ribs, but usually stops at the eleventh. * An- 

 teriorly it is behind the fifth, sixth, seventh, eighth, and ninth costal cartilages 

 and the ensiform cartilage. A part of the liver surface comes into direct contact 

 with the anterior abdominal wall. From between the ninth and tenth rib cartilages 

 the liver passes under the right costal arch into the epigastrium. Close under the 

 ensiform process, at a spot usually called gastric fossa, lies a part of the liver which 

 is turned forward and touches the abdominal wall more closely. In women with a 

 "corset liver" the part in direct contact with the wall is much greater. Here 

 some loops of intestine or transverse colon may intervene and a dulness will be 

 found in percussing the mesogastrium, modified by a tympanitic sound. 



The under surface of the liver is in contact by its* right lobe directly with the 

 upper two-thirds of the right kidney, and internal to that, with the descending 

 duodenum, and above both, near the vena cava, with the suprarenal capsule which 

 also touches the posterior surface (His). Lateral to the gall-bladder is the colon, 

 internal to it the quadrate lobe with the portio pylorica of the stomach in relation. 

 Going to the left and above, we find the tuber omentale. and still more laterally 

 the whole concavity of the left lobe covering the lesser curvature, the cardia, and 

 adjacent part of the anterior surface of the stomach. In an empty contracted 

 stomach it may cover the fundus. 



The posterior edge and surface rest against the tenth and eleventh dorsal ver- 

 tebrae and the posterior ends of those ribs. This part also rests on the crura of the 

 diaphragm, covers the oesophagus, and embraces the vena cava. Against it are 

 the aorta, thoracic duct, nerves, and small vessels which rise from the vertebral 

 column, but are separated from the liver by the diaphragm. 



The anterior edge of the liver follows, in the right hypochondrium, the tenth 

 and eleventh ribs, but normally does not extend over the anterior end of the last. 

 Should one in quiet respiration feel the liver lower than this point, there is enlarge- 

 ment or displacement. Between the ninth and tenth ribs the anterior edge of the 



