332 



Intestinal Obstruction 



passes from the colon to the lateral abdominal wall. Such an injury 

 would be apt to prejudice the result of the operation. But if the 



surgeon, after prolonged search for 

 the bowel, fail to discover it, it is 

 better for him deliberately to incise 

 the peritoneum and to bring up the 

 colon with his hooked finger, rather 

 than to blindly open some neigh- 

 bouring coil of small intestine which 

 he has encountered in the renal 

 region, through a rent in the peri- 

 toneum. I have known this accident 

 happen more than once, and, on the 

 other hand, amongst the most suc- 

 cessful cases of colotomy may be 

 some of those in which the peri- 

 toneum has been accidentally or 

 intentionally opened in the ' extra- 

 peritoneal ' operation. 



If the colon happen to have a 

 short mesentery, or, practically, no 

 mesentery at all, Amussat's operation 

 is simple enough, but when the 

 mesentery is long, as sometimes 

 happens, it is absolutely impossible 

 to perform an extra-peritoneal colotomy. 



Lumbar colotomy; peritoneum necessarily 

 opened. (HERBKRT ALLINGHAM.) 



THE LIVER 



The liver (50 oz.) is situated in the right hypochondriac and epi- 

 gastric regions ; it often extends also into the left hypochondriac region. 

 In the child (and in the adult when it is enlarged) it reaches to the 

 left false ribs, in front of the cardiac end of the stomach and spleen. 



At birth it is very large, reaching across to the spleen, the umbili- 

 cal vein entering the longitudinal fissure in the median line of the body; 

 but with the subsequent growth of the child the proportionate size of 

 the liver diminishes, so that the left lobe lies behind the linea alba, the 

 round ligament and the falciform ligament being dragged towards the 

 right hypochondrium. In the adult, therefore, only the left lobe occu- 

 pies the epigastric region, and its border slopes downwards and to the 

 right, crossing the middle line about three inches below the base of 

 the xiphoid cartilage. (See illustration on p. 163.) 



Normally, the highest level of the liver corresponds with the right 

 sixth or seventh rib ; for draining an empyasma on the right side, 

 therefore, the opening should not be lower than the fifth space. In 

 the case of a large abdominal tumour, and of great inflation of the 



