THE STOMACH 1373 



Viscera behind the Hnea alba. — From above downward there are the follow- 

 ing:— (1) Above the umbilicus — the left lobe of the liver, the stomach, the 

 transverse colon, part of the great omentum, the pancreas, and cceliac (solar) 

 plexus. (2) Below the umbilicus — the rest of the great omentum, covering in 

 the small intestines and their mesentery. In the child, the bladder occupies a 

 partly abdominal position; and in the adult, the same viscus, if distended, will 

 rise out of the pelvis and displace the above structures, raising the peritoneum 

 until, if distended half way to the umbilicus, there is an area of nearly 5 cm. 

 (2 in.) safe for operations. above the symphysis. The gravid uterus also rises 

 behind the linea alba. 



The liver (figs. 914, 941, and 1125). — In the erect position, the anterior thin 

 margin of the liver projects about 1 cm. (| in.) below the costal cartilages, but 

 can only be made out with difficulty in this position. It may also be displaced 

 downward by pleuritic effusion or tight lacing. The liver is also, proportion- 

 atel}', much larger in small children. 



Of the three more accessible surfaces, the right lateral is opposite the seventh to the eleventh 

 intercostal arches, separated from them by the pleura, the thin base of the lung, and the dia- 

 phragm. The superior sm-face is accurately fitted with its right and left portions into the hol- 

 lows of the diaphragm, a slightly depressed area intervening which corresponds to the central 

 tendon. Its level corresponds to that of the diaphragm given above. On the left side, in the 

 adult, the limit of the left lobe wiU be in the fifth interspace, about 7.5 cm. (3 in.) from the ster- 

 num. The anterior surface is in contact with the diaphragm, costal arches, and, between them, 

 the xiphoid cartilage, and, below, with the abdominal wall. Both the superior and anterior 

 surfaces are subdivided bj^ the falciform ligament, an important point in subphrenic suppura- 

 tion. In the right hypochondrium the anterior margin corresponds to the lower margin of 

 the thorax; but in the epigastric region, running obliquely across from the ninth right to the 

 eighth left costal cartilage, it crosses the middle line about a hand's breadth below the sterno- 

 xiphoid articulation (Godlee), or half-way between the sterno-xiphoid junction and umbihcus, 

 i.e., in the transpyloric line (fig. 914). Behind, the anterior margin, following the right lateral 

 surface within the costal arches, crosses the last rib toward the level of the eleventh thoracic 

 spine. In the anterior border, a little to the right of the median vertical plane, is the umbiUcal 

 notch, where the falciform and round ligaments meet. Still further to the right, and just to the 

 left of the mid-Poupart plane, is the fundus of the gall-bladder. 



Gall-bladder and bile passages. — The fundus of the gall-bladder, situated in a 

 fossa on the under surface of the right lobe of the liver, and having the quadrate 

 lobe to its left, lies opposite to the right nintli costal cartilage, close to the lateral 

 edge of the rectus. This point corresponds to the site of intersection of the lateral 

 vertical and transpyloric lines. It is in contact with the hepatic flexure of the 

 colon and the first piece of the duodenum, into either of which, but particularly 

 the latter, large gall-stones impacted in the neck of the gall-bladder occasionally 

 ulcerate. A distended gall-bladder as it enlarges tends to take a line obliquely 

 from the above point where it emerges from under the costal margin toward the 

 umbilicus. 



The long axis of the gall-bladder is directed from the fundus backward and upward. The 

 cystic duct runs from the neck downward and forward in the gastro-hepatic omentum, and so 

 forms an acute angle with the gall-bladder. A spiral fold of mucous membrane at the junction 

 of the two, which fulfils the function of keeping the lumen open for the flow of bile, adds to the 

 difficulty of passing a bougie from the gall-bladder down into the common duct. 



The hepatic and cystic ducts join in the right free margin of the gastro-hepatic omentum 

 to form the common bile-duct, 7.5 cm. (3 in.) in length, which as it runs down to open into the 

 duodenum presents four distinct stages. (1) It first lies in the free edge of lesser omentum in 

 front of the epiploic foramen, with the hepatic artery to the medial side, and the portal vein 

 behind them both. (2) Behind the first part of the duodenum with the gastro-duodenal artery 

 accompanying it. (.3) In a deep groove in the head of the pancreas, between that gland and 

 the posterior aspect of the second part of the duodenum. The pancreatic tissue surrounds it 

 completely in 75 per cent, of cases, (Bunger) hence the jaundice that occurs in chronic inter- 

 stitial pancreatitis. (4) Piercing the muscular wall of the duodenum obliquely it ends by 

 joining the main duct of the pancreas at the ampulla of Vater and opening into the second part 

 of the duodenum by a common orifice. This orifice, situated on the postero-medial aspect of 

 the gut, rather below the centre of the second portion, is raised on a smaU papilla and is nar- 

 rower than the lumen of the common duct. 



The stomach. — The study of this organ by rendering its contents opaque with 

 bismuth salts and projecting its shadow by X-rays on a fluorescent screen, has 

 greatly modified the conception of its shape and position formed from post- 

 mortem and operative observations. Examined post-mortem, or at operations 

 under general anaesthesia it forms a flaccid sac with its long axis directed from the 

 fundus obliquely downward, forward, and to the right. Seen under X-rays, 



