CAVITY. 



503 



after having partly covered the duodenum.* 

 The lesser splanchnic nerve will also be found 

 in this situation lying on the quadratus lum- 

 borum muscle and on the psoas, and descend- 

 ing to throw itself into the renal plexus. On 

 a plane posterior to the lesser omentum the 

 inferior surface of the liver is in contact with 

 the kidney, and with the angle of junction of 

 the ascending and transverse portions of the 

 colon, as is proved by the frequent adhesion of 

 this intestine to the liver. The situation of 

 the gall-bladder in this region demands atten- 

 tion ; its fundus corresponds to the cartilage 

 of the ninth rib, beneath which it sometimes 

 projects to an extent proportionate to the de- 

 gree to which it is distended ; hence it is evi- 

 dent that an unusually distended gall-bladder 

 is not unlikely to form a tumour below the 

 margin of the ribs presenting all the characters 

 of an hepatic abscess.f The gall-bladder is, in 

 this region, in close connexion either by its neck 

 or body, with the duodenum or tranverse colon, 

 a fact which explains the evacuation of gall- 

 stones into either of those intestines. The left 

 lobe of the liver projects more or less into the 

 central portion of the epigastric region, or that 

 which is called the proper epigastrium. Here 

 it is in contact by its concave surface with the 

 anterior superior surface of the pyloric half or 

 third of the stomach. This latter viscus when 

 contracted lies very far back in the epigastric 

 excavation, and extends towards the left side, 

 so as to occupy the left hypochondrium to a 

 great extent. Its pyloric third or half is in 

 contact with the liver, the remaining or cardiac 

 portion is in contact with the diaphragm ; 

 hence it is always the displaced organ in dia- 

 phragmatic hernia. This close connexion of 

 the stomach and diaphragm likewise explains 

 the peculiar sonorousness which percussion 

 frequently elicits over the left hypochondrium 

 and even for some distance up the anterior 

 surface of the thorax, so that when the sto- 

 mach is large and flatulent, it is often very 

 difficult to ascertain whether the sound pro- 

 duced and heard in this region results from an 

 effusion of air and liquid into the thorax, or 

 from such a stomach rilled partly with liquid 

 and partly with air. When the stomach is 

 full, the aspect of its superior surface is more 

 directly upwards and less forwards than in the 

 empty state ; but a considerable portion of the 

 anterior part of this surface, as well as of the 

 greater curvature, is in contact with the abdo- 

 minal parietes. The great curvature of the 

 stomach for three-fifths of its extent towards 

 the pylorus is closely connected with the upper 



* Blandin records a remarkable case of internal 

 stiangulation which took place by the introduction 

 of a considerable portion of the small intestine 

 through the foramen of Winslow into the cavity of 

 the omentum, from which it escaped through a 

 lacerated opening in the transverse mesocolon 

 which firmly constricted a knuckle of the intestine 

 and occasioned mortification of it. Anat, Topoq. 

 p. 442. 



t See cases recorded by Andral, Clin. Med. t. iv. 

 and Graves, Dublin Hosp. Rep. vol. iv. 



surface of the transverse arch of the colon, 

 and with the two anterior laminae of the great 

 omentum which come in contact along the line 

 of that curvature, enclosing between them the 

 anastomosis of the gastro-epiploic arteries. 

 Hence we sometimes find that, in cases of per- 

 foration of the stomach, the opening is filled up 

 by the adhesion of the wall of the colon to the 

 serous coat of the former viscus, and the effusion 

 of its contents is thereby prevented ; and it has 

 been said that fluids may pass through an 

 ulcer of the great curvature and be effused 

 between the laminae of the omentum, so as to 

 point externally as an abscess.* The extent of 

 the relation of the stomach to the liver varies ; 

 in some instances it extends as far outwards as 

 the gall-bladder ; and Cruveilhier mentions a 

 case in which gall-stones were discharged into 

 the stomach in consequence of an adhesion 

 formed by its' anterior surface with the gall- 

 bladder. The stomach rests by its posterior 

 and inferior surface on the superior lamina of 

 the transverse mesocolon, which forms a natural 

 floor to the epigastric region, and separating it 

 from the umbilical region. Posteriorly the 

 same lamina of the transverse mesocolon sepa- 

 rates it from the inferior transverse portion of 

 the duodenum and from the head of the pan- 

 creas, which again are separated from the spine 

 by the aorta and crura of the diaphragm. 

 The lobulus Spigelii of the liver is seen behind, 

 arid to the left of the lesser curvature of the 

 stomach, and when the latter is drawn down- 

 wards and the liver forwards, this lobe projects, 

 pushing the gastro-hepatic omentum before it ; 

 the lesser curvature has likewise among its 

 connections posteriorly the coeliac axis and 

 solar plexus, and like the great curvature has 

 an arterial anastomosis running along it formed 

 by the superior pyloric and gastric arteries. 

 The spleen is very intimately connected by the 

 gastro-splenic omentum to the left extremity or 

 great cul-de-sac of the stomach, and seems, 

 as it were, moulded upon it, following it in its 

 movements, and each accompanying the other 

 in its displacements : behind this portion of 

 the stomach are the tail of the pancreas, the 

 left kidney, and supra-renal capsule. The 

 point of entrance of the oesophagus into the 

 cardiac extremity of the stomach is overlapped 

 by the left lobe of the liver and its left lateral 

 ligament, and it rests upon the decussating 

 muscular bundles of the diaphragm .f 



In the epigastric region we likewise find the 

 first portion of the duodenum passing from 

 left to right slightly upwards and backwards, 

 terminating at the neck of the gall-bladder, 

 with which it often contracts preternatural 

 adhesions. Behind this superior portion of 

 the duodenum, a little to the left of its ter- 

 mination, the ductus communis choledochus 



* Ledran, quoted by Velpeau, Anat. Chir. t. ii. 

 p. 165. 



t From the relations of the stomach to the abdo- 

 minal parietes we are not surprised to read of fistu- 

 Ions communications being formed between that 

 viscus and various regions of the abdominal surface. 



