THE ABDOMEN. 25 



little internal to the right mamillary line, it generally reaches as high as the fourth 

 intercostal space, or nearly to the level of the nipple. On the left side it does not 

 usually extend more than an inch and a half or two inches (4 5 cm.) beyond the 

 margin of the sternum (see fig. 10). It must be borne in mind, however, that the liver 

 is subject to great variations, not only in size, but also in position, both temporarily 

 and permanently. Thus, it sinks with inspiration, and rises in expiration ; it 

 descends slightly on assuming the upright position ; and it is frequently moved 

 downwards by alterations 1 in the shape of the chest. It is relatively very large in 

 the infant and child, and extends across far into the left hypochondriac region. 

 In adults, the margin of the liver is seldom to be felt below the ribs on the right 

 side during health, unless the abdominal wall be unusually thin. 



The stomach lies in the left hypochondriac and the epigastric regions, in the 

 latter being partly covered by the liver and partly in contact with the abdominal 

 wall. Its cardiac orifice is situated behind the seventh costal cartilage of the left 

 side about an inch (2'5 cm.) from the sternum, and at a depth of about four inches 

 (10 cm.) from the surface. The pyloric orifice is from three to four inches (8 

 10 cm.) below the xiphi-stemal articulation, and, when the stomach is contracted, 

 in or immediately to the right of the median plane ; but when the stomach is 

 distended, the pyloric end moves considerably to the right. The pyloric orifice is 

 much nearer to the surface than the cardiac. The f undus of the stomach is directed 

 upwards into the left portion of the vault of the diaphragm, and reaches, under 

 ordinary circumstances, to the level of, or somewhat higher than, the sixth chondro- 

 sternal articulation, or in the mamillary line to the fifth rib, being a little above 

 (and behind) the apex of the heart. The great curvature of the stomach is directed 

 at first to the left, and afterwards downwards, the latter part reaching, with a 

 moderate degree of distension of the organ, about as far as the infracostal line. 



Large intestine. The transverse colon passes across in the upper part of the 

 umbilical region, following closely the great curvature of the stomach. The csecum 

 is comparatively superficial in the right iliac region ; the ascending colon and the 

 hepatic flexure are deeply placed in the right lumbar and hypochondriac regions. 

 The splenic flexure reaches a higher level than the hepatic, and is situated 

 behind the stomach in the left hypochondriac region, while the descending colon 

 occupies the hinder part of the left hypochondriac and lumbar regions. Deep 

 pressure on the left side detects the sigmoid colon as it passes over the brim of the 

 pelvis, in thin persons even when comparatively empty ; if distended with faeces, it 

 forms a distinct tumour in this situation. 



Small intestine. The intestines below the stomach are all covered more or 

 less completely by the great omentum. The coils of the small intestine occupy the 

 anterior part of the belly below the transverse colon, those of the jejunum being 

 principally found above, those of the ileum below. The upper limit of the attach- 

 ment of the mesentery, corresponding to the duodeno-jejunal flexure, is commonly 

 between three and four inches (8 10 cm.) above the umbilicus and slightly to 

 the left of the median line, while the lower end is, on an average, four inches 

 (10 cm.) from the centre of Poupart's ligament of the right side, along a line 

 directed upwards and somewhat inwards, following the course of the psoas muscle 

 (Lockwood). The termination of the ileum in the large intestine corresponds 

 generally to a spot on the anterior abdominal wall from one to two inches (3 5 cm.) 

 internal to, and slightly above, the anterior superior iliac spine. 



In children under ordinary circumstances, and in adults when it is distended, 

 the bladder rises out of the pelvis into the hypogastric region, being closely applied 

 to the anterior abdominal wall without the intervention of peritoneum for some 

 distance above the pubic bones ; if the distension be excessive, the bladder may 

 reach nearly as far as the umbilicus. 



