THE CONTENTS OF THE ABDOMEN. 



removed from the body is usually flattened, on account of the doughy consistency of the viscus, 

 the study of a liver hardened in situ is most instructive (Fig. 63). Particularly striking is the 

 impressio renalis of the right kidney, and, in front of this, the impressio colica produced by the 

 hepatic flexure of the colon. The duodenum, the pylorus, and the stomach are responsible for 

 the impressiones duodenalis, pylorica, and gastrica, while the tuber omentale lies above the lesser 

 curvature of the stomach opposite the gastro-hepatic omentiun. In addition to these, there are 

 the impressio suprarenalis of the right suprarenal body, the impressio cesophagea, the fossa vena 

 umbilicalis (in adult life containing the ligamentum teres, the remains of the umbilical vein), 

 and the fossa vesica jellece, which lodges the gall-bladder. 



At the porta hepatis the artery lies to the left, the ductus choledochus to the right, and the 

 portal vein behind and between these structures (see page 136 and Fig. 64). The lobus caudatus 

 (Spigelii), which is in relation with the bursa omentalis, together with the inferior vena cava, 

 borders upon the vertebral column and is vertically placed. These parts are in relation with 

 the so-called posterior surface of the liver. The physician directs his examination of the liver 

 chiefly to the anterior (inferior) sharp margin, the position of which is influenced by pathologic 

 enlargements or diminutions in size of the organ. In the axillary line the lower margin is at the 

 level of the eleventh rib ; in the right mammary line the inferior border of the liver leaves the 

 costal margin, passes obliquely upward and to the left, crosses the median line midway between 

 the navel and the base of the xiphoid process, and reaches the left costal margin in the para- 

 sternal line. It will be observed that the portion of the liver below the sternum is in immediate 

 contact with the muscular abdominal wall ("scrobiculus cordis," see page 91). The gall- 

 bladder projects slightly beyond the inferior margin of the liver and is situated in the right para- 

 sternal line, a fingerbreadth to the inner side of the point where the liver extends beyond the 

 costal margin. The normal liver is not palpable at the costal margin in the mammary line. 



If the intestines are distended with an abnormal amount of gas (meteorismus) or if the peri- 

 toneal cavity contains an excessive quantity of fluid (ascites), the liver will be pushed upward 

 and its inferior margin will be correspondingly displaced; the liver will also press upward upon 

 the heart and lungs. 



The gall-bladder is in immediate relation with that portion of the inner surface of the abdom- 

 inal wall which has just been indicated, and is here easily accessible to the surgeon. It may 

 become adherent to the abdominal wall and, after inflammatory processes, gall-stones may pass 

 through the abdominal wall so that a biliary fistula is formed which discharges bile externally. 

 Inspection of the inferior surface of the liver and of the depressions in the vicinity of the gall-blad- 

 der (Fig. 63) shows that gall-stones or pus (empyema of the gall-bladder) may pass through the 

 wall of the gall-bladder into the duodenum, into the colon, into the stomach, and even into the 

 pelvis of the kidney. Such events are always preceded by peritoneal adhesions between the gall- 

 bladder and the affected viscus. 



There are a number of lymphatic glands in the transverse fissure (Fig. 64), enlargements of 

 which may produce disagreeable consequences, since they may press upon the common or hepatic 

 duct, causing biliary stasis (and even death), or compress the vessels and lead to inflammation 

 of the portal vein (pylephlebitis). 



[Several other points with reference to the anatomy of the liver may be recalled with 



