1066 THE ORGANS OF DIGESTION. 



two inches to the left of the sternum on a level with the sixth left costal cartilage. The lower 

 limit of the liver may be indicated by a line drawn half an inch below the lower border of the 

 thorax on the right side as far as the ninth right costal cartilage, and thence obliquely upward 

 across the subcostal angle to the eighth left costal cartilage. A slight curved line with its con- 

 vexity to the left from this point i. e. the eighth left costal cartilage to the termination of the 

 line indicating the upper limit will denote the left margin of the liver. The fundus of the gall- 

 bladder approaches the surface behind the anterior extremity of the ninth costal cartilage, close 

 to the outer margin of the Right rectus muscle. 



It must be remembered that the liver is subject to considerable alterations in position, and 

 the student should make himself acquainted with the different circumstances under which this 

 occurs, as they are of importance in determining the existence of enlargement or other diseases 

 of the organ. 



Its position varies according to the posture of the body. In the erect position in the adult 

 male the edge of the liver projects about half an inch below the lower edge of the right costal 

 cartilages, and its anterior border can be often felt in this situation if the abdominal wall is thin. 

 In the supine position the liver gravitates backward and recedes above the lower margin of the 

 ribs, and cannot then be detected by the finger. In the prone position it falls forward, and can 

 then generally be felt in a patient with loose and lax abdominal walls. Its position varies also 

 with the ascent or descent of the Diaphragm. In a deep inspiration the liver descends below 

 the ribs; in expiration it is raised behind them. Again, in emphysema, where the lungs are 

 distended and the Diaphragm descends very low, the liver is pushed down ; in some other 

 diseases, as phthisis, where the Diaphragm is much arched, the liver rises very high up. Pres- 

 sure from without, as in tight-lacing, by compressing the lower part of the chest, displaces the 

 liver considerably, its anterior edge often extending as low as the crest of the ileum ; and its 

 convex surface is often at the same time deeply indented from the pressure of the ribs. Again, 

 its position varies greatly according to the greater or less distension of the stomach and intestines. 

 When the intestines are empty the liver descends in the abdomen, but when they are distended 

 it is pushed upward. Its relations to surrounding organs may also be changed by the growth of 

 tumors or by collections of fluid in the thoracic or abdominal cavities. 



Surgical Anatomy. On account of its large size, its fixed position, and its friability, the 

 liver is more frequently ruptured than any of the abdominal viscera. The rupture may vary 

 considerably in extent, from a slight scratch to an extensive laceration completely through its 

 substance, dividing it into two parts. Sometimes an internal rupture without laceration of the 

 peritoneal covering takes place, and such injuries are most susceptible of repair ; but small tears 

 of the surface may also heal ; when, however, the laceration is extensive, death usually takes 

 place from haemorrhage, on account of the fact that the hepatic veins are contained in rigid 

 canals in the liver-substance and are unable to contract, and are moreover unprovided with 

 valves. The liver may also be torn by the end of a broken rib perforating the Diaphragm. 

 The liver may be injured by stabs or other punctured wounds, and when these are inflicted 

 through the chest-wall both pleural and peritoneal cavities may be opened up and both lung and 

 liver be wounded. In cases of wound of the liver from the front, hernia of a part of this viscus 

 may take place, but can generally easily be replaced. Abscess of the liver is of not unfrequent 

 occurrence, and may open in many different ways on account of the relations of this viscus to 

 other organs. Thus, it has been known to burst into the lungs, and the pus been coughed up, 

 or into the stomach and the pus vomited ; it may burst into the colon or into the duodenum ; 

 or, by perforating the Diaphragm, it may empty itself into the pleural cavity. Frequently it 

 makes its way forward and points on the anterior abdominal wall, and finally it may burst into 

 the peritoneal or pericardiac cavities. Abscesses of the liver frequently require opening, and 

 this should be done preferably by an incision in the right semilunar line, in two stages : the 

 peritoneal ctivity being opened and the liver over the summit of the abscess being stitched to the 

 parietal peritoneum on the first occasion, and three or four days subsequently the abscess being 

 evacuated. Hydatid cysts are more often found in the liver than in any other of the viscera. 

 The reason of this is not far to seek. The embryo of the egg of the taenia echinococcus, being 

 liberated in the stomach by the disintegration of its shell, bores its way through the gastric 

 walls, and usually enters a blood-vessel and is carried by the blood-stream to the hepatic capil- 

 laries, where its onward course is arrested, and where it undergoes development into the fully- 

 formed hydatid. 



When the gall-bladder is, ruptured, or one of its main ducts, which may occur indepen- 

 dently of laceration of the liver, the injury is necessarily fatal from peritonitis caused by the 

 extravasation of bile into the peritoneal cavity. 



The gall-bladder may become distended with bile in cases of obstruction of its duct or the 

 common bile-duct, or from a collection of gall-stones within its interior, thus forming a large 

 tumor. The swelling is pear-shaped, and projects downward and forward to the umbilicus. It 

 moves with respiration, since it is attached to the liver. To relieve this condition the gall-blad- 

 der must be opened and the gall-stones removed. The operation is performed by an incision 

 two or three inches long in the right semilunar line, commencing an inch below the costal mar- 

 gin. The peritoneal cavity is opened, and, the tumor having been found, sponges are packed 

 round it to protect the peritoneal cavity, and it is aspirated. When the contained fluid has been 

 evacuated the flaccid bladder is drawn out of the abdominal wound and its \yall incised to the 

 extent of an inch ; any gall-stones in the bladder are now removed and the interior of the sac 

 sponged dry. If the case is one of obstruction of the duct, an attempt must be made to dislodge 



