THE ORGANS OF DIGESTION 



cystic duct with blood. It passes along the cystic duct, and on reaching the gall-bladder divides 

 into an upper branch and a lower branch. The upper branch lies between the gall-bladder and 

 the liver and sends branches to each. The lower branch is between the peritoneum and the wall 

 of the gall-bladder. The cystic veins empty into the portal vein. The common duct receives 

 branches from the superior pancreaticoduodenal artery. There is a submucous lymphatic 

 network and a muscular lymphatic network. The lymphatics are much less numerous at the 

 fundus of the gall-bladder than at the neck or in the extrahepatic ducts. The collecting trunks 

 end in lymph nodes along the cystic and common ducts, and these glands are in communication 

 with the duodenal lymphatics and the lymphatics from the head of the pancreas. The nerves 

 of the gall-bladder and bile ducts come from the coeliac plexus of the sympathetic. 



The Bile (/<?/). The bile is a reddish-brown or greenish fluid. It contains pigments (bili- 

 rubin and biliverdin), fats and soaps, cholesterin, sodium salts of glycocholic and taurocholic 

 acid, lecithin, and nucleoalbumin furnished by the mucous membrane. There are also present 

 CO 2 ; chlorides, carbonates, phosphates, and sulphates of the alkalies and of calcium, and iron. 

 The amount normally secreted is from one pint to one and one-half pints in the twenty-four hours. 



Surface Relations. The liver is situated in the right hypochondriac and the epigastric 

 regions, and is moulded to the arch of the Diaphragm. In the greater part of its extent it lies 

 under cover of the lower ribs and their cartilages, but in the epigastric region it comes in con 

 tact with the abdominal wall, in the subcostal angle. The upper limit of the right lobe of the 

 liver may be defined in the middle line by the junction of the mesosternum with the ensiform 

 cartilage; on the right side the line must be carried upward as far as the fifth rib cartilage in the 

 midclavicular line and then downward to reach the seventh rib at the side of the thorax. The 

 upper limit of the left lobe may be defined by continuing this line to the left with an inclination 

 downward to a point about 7 cm. to the left of the mesal plane 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 convexity 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 car- 

 tilages, 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 dis- 

 eases, as phthisis, where the Diaphragm is much arched, the liver rises very high up. Pressure 

 from without, as in tight lacing, by compressing the lower part of the thorax, displaces the liver 

 considerably, its anterior edge often extending as low as the crest of the ilium; and its convex 

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

 tion varies greatly according to the greater or less distention 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. 



Applied Anatomy. Movable liver or hepatoptosis is a rare condition, in which the liver 

 moves or can be moved from its normal position. It is due to lessened tone of the abdominal 

 muscles and relaxation of the liver supports. In movable liver the organ may be rotated on its 

 vertical axis or on its transverse axis. Tongue-like lobes have been referred to. 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. Some- 

 times 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, how- 

 ever, the laceration is extensive, death usually takes place from hemorrhage, 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 punc- 

 tured wounds, and when these are inflicted through the chest wall both pleura! and peritoneal 



