THE ABDOMINAL V1SCEKA. 1415 



subdivision may be established through the left loin, or by a tube introduced down 

 to the bottom of the pelvis, namely, into the recto-vesical pouch in the male, and 

 into or through the recto-vaginal pouch (pouch of Douglas) in the female. 



On account of the oblique manner in which the mesentery proper is attached 

 to the posterior abdominal wall, it follows that in order to examine the organs 

 related to the right infra-colic subdivision of the abdomen, the coils of small 

 intestine should be displaced downwards and to the left, while to investigate the 

 left infra-colic subdivision they should be carried upwards and to the right. 



ABDOMINAL VISCERA. 



Liver. The anterior margin of the liver, as it crosses the costal angle, can readily 

 be determined by palpation and light percussion ; it passes from the eighth left to 

 the tip of the tenth right costal cartilage, and crosses the median plane at the level 

 of the transpyloric line. In the mid-clavicular line it reaches down to a point a 

 little below the most inferior part of the tenth right costal cartilage. Above the 

 left costal margin the anterior margin passes upwards and to the left to join the 

 left border of the liver at the fifth interspace in the mammary line. The highest 

 part of the liver, which corresponds also to the highest part of the right arch of the 

 diaphragm, reaches, during expiration, to the level of the fourth intercostal space in 

 the mammary line. To the right of the median plane the superior surface of the 

 liver is too far removed from the anterior wall of the chest, and overlapped by too 

 thick a layer of lung substance, to be accurately determined by percussion. 

 Behind the sternum the superior surface reaches to the level of the sixth chondro- 

 sternal junctions. To the left of the median plane the superior limit of the liver 

 cannot be determined by percussion since it merges into the cardiac dulness. The 

 base or right lateral surface extends from the level of the seventh to the level 

 of the eleventh rib in the mid-axillary line and is separated by the diaphragm 

 from the lower part of the right lung and pleura. 



The falciform ligament of the liver lies, as a rule, a little to the right of the 

 median plane. 



The anterior surface of the liver may be reached through a median incision, 

 extending downwards from the xiphoid process, or by an oblique incision, a finger's 

 breadth below and parallel to the right costal margin. To obtain free access to the 

 superior surface the eighth and ninth costal cartilages must be resected ; the seventh 

 cartilage should, if possible, be avoided ; otherwise the pleural cavity may be opened 

 into. Division of the round and falciform ligaments allows of greater downward 

 displacement of the liver. To reach the upper part of the lateral surface of the 

 right lobe, portions of the seventh and eighth ribs should be resected in the mid- 

 axillary line, and both the pleural and peritoneal cavities must be traversed. 



Gail-Bladder. The relation of the fundus of the gall-bladder to the surface of 

 the body is subject to considerable variation. Normally it is situated behind the 

 angle between the ninth costal cartilage and the lateral border of the right rectus ; 

 exceptionally, it is pendulous and suspended from the liver by a more or less 

 distinct mesentery; or it may be elongated and drawn downwards by adhesion 

 to the duodenum or colon. When displaced downwards it is liable to be mistaken 

 for a movable kidney, but may be distinguished from that by the fact that although 

 it may be pushed backwards into the lumbar region it returns at once to its 

 habitual position, immediately behind the anterior abdominal wall, as soon as it 

 ceases to be manipulated. 



The cystic duct is enclosed in the right extremity of the superior border of the 

 gastro-hepatic ligament. It is about an inch and a half in length, is sharply bent 

 upon itself close to its origin at the neck of the gall-bladder. It joins the hepatic 

 duct at a very acute angle. The passage of a probe along the normal duct is 

 rendered difficult by the marked flexure at its commencement, as well as by the folded 

 condition of its mucous membrane ; hence also the frequency with which calculi 

 become impacted at the neck of the gall-bladder. In excising the gall-bladder, 

 it is an advantage to ligature and divide the cystic artery and duct before pro- 

 ceeding to detach the organ from the inferior surface of the liver. 



90 a 



