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FIG. 1103.-ANTERIOR ASPECT OF TRUNK, SHOWING SURFACE TOPOGRAPHY OF VISCERA.
R.L. Right lung.
L.L. Left Lung.
External iliac artery.
I.V.C. Inferior vena cava.
the abdomen along the lumbar regions into the iliac regions, and thence into the pelvis; and, on the other hand, the pus may ascend from the pelvis along the same channels, especially when the patient is in the recumbent posture.
The highest (subphrenic) region of the supracolic compartment is further subdivided into a right and left portion by the falciform ligament.
The omental bursa may be looked upon as a diverticulum of the first-mentioned subdivision.
The subphrenic lymph plexus communicates, by means of lymph vessels which pierce the diaphragm, with the subpleural plexus on its superior surface: hence pus confined under tension in either of these spaces is liable to give rise to secondary infection of the corresponding pleural cavity. By adhesions of the transverse colon and greater omentum to the anterior abdominal wall, the supracolic subdivision of the peritoneal cavity may become more or less completely shut Liv off from the rest of the abdomen. Suppuration in the right half of the phrenicocolic subdivision is generally secondary to leakage from an ulcer of the first part of the duodenum or to disease of the gall-bladder and bile-ducts; while the left half of the space is more usually infected from the stomach. The best method of draining the supracolic subdivision of the peritoneal cavity is to pass a tube through the hepato-renal pouch of Morrison. The entrance to this pouch lies lateral to the gall-bladder between the inferior margin of the liver above and the right flexure of the colon below. The bottom of the pouch is formed by the reflection of the peritoneum from the superior part of the kidney on to the fascia transversalis covering the aponeurosis of origin of the transversus abdominis muscle below the tip of the twelfth rib. To drain it, a tube is introduced into it either from the wound in the anterior abdominal wall, or, still better, through a puncture opening made through the loin lateral to the kidney, in the angle between the twelfth rib and the lateral border of the sacro-spinalis muscle. Another drainage route is by a tube passed from the wound in the anterior abdominal wall into the omental bursa, through either the gastro-hepatic ligament or the great omentum.
The right infra-colic subdivision lies above and to the right of the mesentery the small intestine. It is bounded, above, by the right and middle two-thirds of the transverse colon and the corresponding part of its mesentery, while laterally it is limited by the cæcum and ascending colon. At its right inferior angle are the ileo-cæcal junction and the vermiform process; at its right upper angle is the right flexure of the colon, while at its left upper angle is the inferior part of the duodenum, crossed by the superior mesenteric vessels.
The organs related to this subdivision are, in addition to the parts of the large intestine already mentioned, coils of small intestine, the inferior third of the right kidney, the right ureter, the inferior half of the descending and the horizontal part of the inferior portions of the duodenum.
Suppuration in connexion with the organs in this area involves more especially the right lumbar region, and may extend upwards along the colon into the subdiaphragmatic region, or downwards into the pelvis minor. To drain this region a tube is introduced into the right lumbar region either through the anterior abdominal wall or through a stab-wound in the loin lateral to the ascending colon.
The left infra-colic subdivision, which lies below and to the left of the mesentery, narrows as it passes upwards and reaches to a higher level than the right infra-colic subdivision. Inferiorly, it is directly continuous at the superior aperture of the pelvis with the peritoneal cavity of the pelvis minor. Above, it is bounded by the left third of the transverse colon and its mesentery, and, still more posteriorly, by the inferior surface of the body of the pancreas; laterally it is bounded by the descending and iliac portions of the colon. At its right upper angle is the duodenojejunal flexure, lying immediately to the left of the vertebral column, in the angle between it and the inferior surface of the pancreas. At its left superior angle is the left flexure of the colon, while at its left inferior angle is the junction of iliac with pelvic colon. This subdivision of the peritoneal cavity, in addition to containing the majority of the coils of the small intestine, is related to the inferior third of the left kidney, the left ureter, the lower part of the abdominal aorta and vena cava, and the inferior mesenteric and common iliac vessels. Drainage of this
subdivision may be established through the left loin, or by a tube introduced down to the bottom of the pelvis, namely, into the recto-vesical pouch in the male, and into or through the recto-vaginal pouch (pouch of Douglas) in the female.
On account of the oblique manner in which the mesentery proper is attached to the posterior abdominal wall, it follows that in order to examine the organs related to the right infra-colic subdivision of the abdomen, the coils of small intestine should be displaced downwards and to the left, while to investigate the left infra-colic subdivision they should be carried upwards and to the right.
Liver. The anterior margin of the liver, as it crosses the costal angle, can readily be determined by palpation and light percussion; it passes from the eighth left to the tip of the tenth right costal cartilage, and crosses the median plane at the level of the transpyloric line. In the mid-clavicular line it reaches down to a point a little below the most inferior part of the tenth right costal cartilage. Above the left costal margin the anterior margin passes upwards and to the left to join the left border of the liver at the fifth interspace in the mammary line. The highest part of the liver, which corresponds also to the highest part of the right arch of the diaphragm, reaches, during expiration, to the level of the fourth intercostal space in the mammary line. To the right of the median plane the superior surface of the liver is too far removed from the anterior wall of the chest, and overlapped by too thick a layer of lung substance, to be accurately determined by percussion. Behind the sternum the superior surface reaches to the level of the sixth chondrosternal junctions. To the left of the median plane the superior limit of the liver cannot be determined by percussion since it merges into the cardiac dulness. The base or right lateral surface extends from the level of the seventh to the level of the eleventh rib in the mid-axillary line and is separated by the diaphragm from the lower part of the right lung and pleura.
The falciform ligament of the liver lies, as a rule, a little to the right of the median plane.
The anterior surface of the liver may be reached through a median incision, extending downwards from the xiphoid process, or by an oblique incision, a finger's breadth below and parallel to the right costal margin. To obtain free access to the superior surface the eighth and ninth costal cartilages must be resected; the seventh cartilage should, if possible, be avoided; otherwise the pleural cavity may be opened into. Division of the round and falciform ligaments allows of greater downward displacement of the liver. To reach the upper part of the lateral surface of the right lobe, portions of the seventh and eighth ribs should be resected in the midaxillary line, and both the pleural and peritoneal cavities must be traversed.
Gall-Bladder.-The relation of the fundus of the gall-bladder to the surface of the body is subject to considerable variation. Normally it is situated behind the angle between the ninth costal cartilage and the lateral border of the right rectus; exceptionally, it is pendulous and suspended from the liver by a more or less distinct mesentery; or it may be elongated and drawn downwards by adhesion to the duodenum or colon. When displaced downwards it is liable to be mistaken for a movable kidney, but may be distinguished from that by the fact that although it may be pushed backwards into the lumbar region it returns at once to its habitual position, immediately behind the anterior abdominal wall, as soon as it ceases to be manipulated.
The cystic duct is enclosed in the right extremity of the superior border of the gastro-hepatic ligament. It is about an inch and a half in length, is sharply bent upon itself close to its origin at the neck of the gall-bladder. It joins the hepatic duct at a very acute angle. The passage of a probe along the normal duct is rendered difficult by the marked flexure at its commencement, as well as by the folded condition of its mucous membrane; hence also the frequency with which calculi become impacted at the neck of the gall-bladder. In excising the gall-bladder, it is an advantage to ligature and divide the cystic artery and duct before proceeding to detach the organ from the inferior surface of the liver.
The bile-duct, about three and a half inches in length, lies, in its superiore of third, close to the right free border of the gastro-hepatic ligament. When cutting e into this, the most accessible part of the duct, it should be drawn forwards by the int finger introduced behind it, through the epiploic foramen; the portal vein, which stated must be avoided, lies posterior and a little to the left of the duct. The middl third of the duct lies a little to the right of the commencement of the gastro-th duodenal artery behind the superior part of the duodenum about a finger's breadth M from the pyloro-duodenal junction. The inferior third of the duct, which passe downwards and to the right, is intimately related to the pancreas; in about two out of three instances it is so embedded in the posterior aspect of its head that it cannot be freed by blunt dissection. Close to its termination the duct is joined by the main pancreatic duct of Wirsung, the two opening separately, but close together a the bottom of a diverticulum, which pierces the wall of the duodenum obliquely and opens at the summit of a small papilla situated at the inferior part of the medial wall of the descending part of the duodenum, about four inches from the pylorus. When a calculus becomes impacted in the ampulla there is retention of the pancreatic as well as of the biliary secretion. Frequently, however, the glandh possesses an accessory pancreatic duct (duct of Santorini) which opens into the duodenum at a higher level than the main duct, with which it also communicates A calculus in the ampulla may be reached either by opening the duodenum from the front (trans-duodenal route), or by freeing the duodenum and gaining access to the duodenum from behind (retro-duodenal route). In the latter instance an incision is made, lateral to the right border of the descending part of the duodenum, through that portion of the peritoneum which passes upwards and to the right from the superior layer of the transverse mesocolon, over the superior part of the par descendens of the duodenum on to the anterior surface of the right kidney. By blunt dissection, directed medially, behind the duodenum, that organ, along with the adjacent part of the head of the pancreas, can be separated from the kidney and vena cava, and folded over towards the left like a door on its hinges. In freeing the bile-duct from the posterior aspect of the head of the pancreas a vein of considerable size will be encountered; this vein, which returns the blood from the pancreatic-duodenal system of arteries, lies close to the bile-duct as it ascends behind the head of the pancreas to open into the commencement of the vena porta. Of the lymph glands related to the bile passages it is to be remembered that one lies at the neck of the gall-bladder, another at the junction of the cystic and hepatic ducts, while a third lies close to the termination o the bile-duct. When these glands are enlarged and indurated, care must be taken not to mistake them for impacted gall-stones.
Stomach. The stomach lies almost entirely within the left half of the epigastric region and in the left hypochondriac region. The cardiac orifice, which lies 1 in. below and to the left of the oesophageal opening in the diaphragm, is about 4 in. from the surface, and corresponds, on the anterior surface of the body, to a point over the seventh left costal cartilage 1 in. from the median plane. The pylorus, which is generally partly overlapped by the anterior margin of the liver, lies in, or a little to the right of the median plane; when the stomach. is empty it generally lies in the median plane, when distended it may reach two or even three inches to the right of the median plane. Passing from the superior to the inferior border of the pylorus opposite its junction with the duodenum is the anterior pyloric vein of Mayo. This vein affords a useful visible guide to the position of the pylorus. Another guide is furnished by the ring-like thickening of the pyloric sphincter which projects into the commencement of the duodenum (like the cervix uteri into the vagina), and can be readily palpated through its this wall. The pyloric portion of the stomach is practically bisected by a horizontal plane which passes through the abdomen at the level of a point midway betwee the jugular notch of the sternum and pubic symphysis (Addison); it lies, there fore, three to four inches below the infra-sternal notch, midway between it an the umbilicus, opposite the first lumbar vertebra. The highest part of the fundus of the stomach corresponds to the left vault of the diaphragm, and le at the level of the fifth rib in the mammary line, a little above and behind the
apex of the heart. The greater curvature crosses behind the left costal margin opposite the tip of the ninth costal cartilage, that is to say, where the transpyloric line intersects the left lateral line. The lowest part of the great curvature, situated generally in the median plane, extends down to, or a little above, the infracostal plane, about two inches above the umbilicus. The lesser curvature and the adjacent part of the anterior wall of the stomach are overlapped by the anterior margin of the liver.
Radiography of Stomach.-Radiograms of the stomach, taken after a "bismuth meal," show that the form and position of the stomach in the living subject differ considerably from that which it presents in the cadaver.
In the cadaver, owing to loss of muscular tone, it presents itself as a more or less empty pear-shaped bag with collapsed and flaccid walls. The same applies to a large extent to the stomach as seen in the operating room, its normal tonicity being almost entirely held in abeyance by the anaesthetic.
In the living subject, the form and position of the stomach are found to vary not only according to the amount of food it contains, but also according to whether the patient occupies the erect or the recumbent posture. The most reliable as well as the most useful, information regarding the form, the position, and the motor activity of the stomach is obtained by "screen" examinations and radiograms taken with the patient in the erect posture. When examined in this way, after partly filling the stomach with a "bismuth meal," the organ is seen to possess a distinctly J-shaped form. The stem of the J, which is represented by the body of the stomach, lies immediately and entirely to the left of the vertebral column. The fundus, which is slightly more expanded than the body, reaches up to the left cupola of the diaphragm; it is represented in the skiagram as a light semilunar shadow, the horizontal inferior margin of which corresponds to the superior limit of the bismuth. This clear semilunar area is due to the rising up of the gaseous contents of the stomach to the highest part of the cavity. The cardiac orifice is seen to lie opposite the left side of the fibro-cartilage between the tenth and eleventh thoracic vertebræ. The shadow of the curved pyloric portion of the stomach, after crossing the left side of the vertebral column opposite the third and fourth lumbar vertebræ, ascends as the pyloric canal to join the duodenum at or a little to the right of the median plane, opposite the second (not infrequently the third) lumbar vertebra. The pylorus itself is represented by a light disc due to a break in the continuity of the bismuth, caused by contraction of the pyloric sphincter. The lowest portion of the greater curvature, which generally lies at or a little to the left of the median plane, reaches, in the erect posture, down to the level of the middle or inferior border of the fourth lumbar vertebra, or, in other words, to the umbilicus and the highest part of the iliac crest.
As more food enters the stomach its capacity is increased by lateral expansion rather than by any elevation of its fundus or downward expansion of its greater curvature. The normal tonic action of the gastric muscle is able to hold up the meal against the action of gravity to the level of the cardiac orifice.
When, as not infrequently happens, the normal muscular tonicity of the stomach is lost, the bismuth meal is no longer held up against the action of gravity, but at once sinks to the most dependent part of the stomach where it lies as in a flaccid sac, and gives rise to a crescentic shadow which may reach down almost, or even quite, to the level of the pubes.
In gastroptosis, and in general visceroptosis, the whole stomach may be displaced downwards without any great loss of its tonicity.
During a "screen" examination after a bismuth meal, the peristaltic movements of the stomach can be seen to pass in distinct wave-like indentations from left to right along the greater curvature, and to increase in force as they approach the pylorus.
When the stomach is hypertrophied and dilated, as a result of pyloric obstruction, the peristaltic waves are more pronounced, and the bismuth shadow extends well over to the right of the median plane, owing to the dilated pyloric antrum and pyloric canal being carried over to the right, in front of the superior part of the duodenum. The stomach tends, therefore, to lose its somewhat J-shaped