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ne heart. The greater curvature crosses behind the left costal margin he tip of the ninth costal cartilage, that is to say, where the transpyloric sects the left lateral line. The lowest part of the great curvature, generally in the median plane, extends down to, or a little above, the infraine, about two inches above the umbilicus. The lesser curvature and the

part of the anterior wall of the stomach are overlapped by the anterior of the liver. lography of Stomach.—Radiograms of the stomach, taken after a “bismuth how that the form and position of the stomach in the living subject differ ably from that which it presents in the cadaver. the cadaver, owing to loss of muscular tone, it presents itself as a more empty pear-shaped bag with collapsed and flaccid walls. The same applies cge extent to the stomach as seen in the operating room, its normal tonicity almost entirely held in abeyance by the anæsthetic. the living subject, the form and position of the stomach are found to vary aly according to the amount of food it contains, but also according to er the patient occupies the erect or the recumbent posture. The most reliable ll as the most useful, information regarding the form, the position, and the c activity of the stomach is obtained by “screen” examinations and radiograms 1 with the patient in the erect posture. When examined in this way, after y filling the stomach with a " bismuth meal,” the organ is seen to possess a nctly J-shaped form. The stem of the J, which is represented by the body of stomach, lies immediately and entirely to the left of the vertebral colunin. The lus, which is slightly more expanded than the body, reaches up to the left cupola he diaphragm ; it is represented in the skiagram as a light semilunar shadow,

horizontal inferior margin of which corresponds to the superior limit of the muth. This clear semilunar area is due to the rising up of the gaseous contents the stomach to the highest part of the cavity. The cardiac orifice is seen to lie posite the left side of the fibro-cartilage between the tenth and eleventh thoracic rtebræ. The shadow of the curved pyloric portion of the stomach, after crossing ne left side of the vertebral column opposite the third and fourth lumbar vertebræ, scends as the pyloric canal to join the duodenum at or a little to the right of the nedian 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 tubular form, and the axis of its body becomes more oblique. In the infant and young child the stomach is flask-shaped rather than J-shaped, and its axis is less vertical than in the adult. The elongated form of the adult stomach is acquired as a result of the erect posture.

It must be remembered that the only really fixed part of the stomach is the region of the cardia, so that the form and position of the organ may be considerably influenced by the condition of the neighbouring organs. For example, it may be displaced downwards and to the left by enlargement of the liver, upwards by distension of the intestines, and to the right by distension of the left colic flexure.

Overlying the stomach is an important surface area known to clinicians as the semilunar space of Traube. This space, which yields a deeply tympanitic note on percussion, is bounded, above, by the inferior margin of the left lung; below, by the left costal margin; to the right, by the anterior margin of the left lobe of the liver; behind and to the left, by the anterior border and anterior basal angle of the spleen. The line of the costo-diaphragmatic pleural reflection crosses the space about midway between its superior and inferior limits. The tympanitic area of the space is diminished superiorly by pleuritic effusion, towards the right by enlargement of the liver, and towards the left by enlargement of the spleen.

Perforation of an ulcer on the anterior wall of the stomach leads to extravasation into the greater sac of the peritoneum, while if the perforated ulcer is on the posterior wall, extravasation takes place into the omental bursa. The close relation of the splenic artery and its branches to the posterior wall of the stomach explains the severe hæmorrhage which is sometimes caused by a posterior gastric ulcer. The surgeon may reach the posterior wall of the stomach through the gastro-colic ligament, or, after throwing upwards the greater omentum and transverse colon, by traversing the transverse mesocolon ; by the former route the posterior wall of the stomach is reached through the anterior wall of the omental bursa, in the latter through its posterior wall.

When a partial resection of the stomach, for malignant disease, is performed, the bleeding is controlled by ligaturing the main vessels at an early stage of the operation. These are the right and left gastrics at the lesser curvature, the gastroduodenal behind the first part of the duodenum, and the right and left gastroepiploics at the greater curvature. The left gastric should be ligatured as near the cardia as possible, so that the whole chain of lymph glands along the lesser curvature may be removed. Care is taken to remove also all the glands which lie behind the first part of the duodenum in relation to the gastro-duodenal artery and head of the pancreas, as well as those along the right half of the greater curvature in relation to the right gastro-epiploic artery. If the disease has spread to the retro-peritoneal lymph glands, surrounding the cæliac artery, above the pancreas, the chances of a permanent recovery are very remote.

In the classical “no-loop” gastro-enterostomy operation a longitudinal opening in the commencement of the jejunum is anastomosed by suturing it to an opening in the posterior wall of the stomach, near the greater curvature. The jejunum is applied to the stomach in such a way that it maintains its normal direction, namely, obliquely upwards and to the left. To bring the surfaces of the two organs in contact, surgeons are in the habit of protruding the posterior wall of the stomach through an opening made in the transverse mesocolon, on the proximal side of the arch formed by the middle and left colic arteries. A better plan, however, is tu make an opening also into the omental bursa through the gastro-colic ligament : little below the gastro-epiploic vessels, and then to bring the jejunum into contact with the posterior wall of the stomach by pushing it (the jejunum) upwards through the opening in the transverse mesocolon. By this plan the posterior wali of the stomach along with the jejunum can be protruded through an opening in the gastro-colic ligament, and can be more easily delivered out of the abdominal cavity.

When the posterior wall of the stomach and transverse colon are held down by adhesions, a long loop of jejunum is brought up in front of the greater omentum and transverse colon and anastomosed to the anterior wall of the stomach.

The Duodenum.-The duodenum is the widest, thickest, and most fixed part

all intestine. For descriptive purposes it is divided by anatomists into 3. From the surgical standpoint it may with advantage be subdivided ra-colic and an infra-colic portion, the former, comprising the superior and

half of the descending part, being situated above the attachment of the e mesocolon; while the latter, comprising the lower half of the descending g with both subdivisions of the third part, being situated below this ent. To expose the supra-colic portion the greater omentum and the se colon must be pulled downwards, while to expose the infra-colic portion thrown upwards along with the transverse mesocolon. first portion proper (pars superior) lies in the right part of the epigastric medial to the gall-bladder, where it is overlapped by the quadrate lobe of er. As regards its blood-supply, it occupies the frontier zone between the and superior mesenteric vascular areas, and the vessels which supply it onsiderably in their size and mode of origin. is peculiarity of its blood-supply may partly account for the relative ncy with which this portion of the intestine is found to be the seat of tion. The first inch or so the duodenum possesses some degree of mobility,

surrounded by the same two layers of peritoneum which invest the stomach. and this it is in direct contact posteriorly and inferiorly with the pancreas,

descending behind it are the common bile-duct and the gastro-duodenal y. The relations must be borne in mind in performing the operation of rectomy. When an ulcer of the superior part perforates, extravasation takes e, in the first instance, into the supra-colic compartment of the peritoneum, ce into its hepato-renal pouch, and subsequently down along the ascending n into the right iliac fossa, —hence the possibility of mistaking the condition an acute appendicitis. Perforation of the ulcer, however, is often prevented the duodenum becoming adherent especially to the gall-bladder, to the omentum, to the transverse colon.

If the finger is passed upwards, backwards, and to the left, immediately above e first part of the duodenum and behind the right free border of the lesser mentum, it will pass through the foramen epiploicuin into the omental bursa of ne peritoneum.

The second portion of the duodenum (pars descendens) descends in the epigastric und umbilical regions a little medial to the right lateral plane. The attachment of the transverse mesocolon crosses it about its middle, while posteriorly it lies in front of the hilum and medial border of the right kidney, from which it is separated by loose areolar tissue. The procedure necessary to mobilise this portion of the duodenum has been referred to already.

The horizontal portion of the inferior part of the duodenum occupies the superior part of the umbilical region, and crosses the median plane about one inch above a line joining the highest part of the iliac crests; behind its commencement is the superior part of the right ureter.

The ascending portion of the inferior part of the duodenum crosses the infracostal plane, and ascends upon the left side of the vertebral column opposite the second and third lumbar vertebra.

The duodeno-jejunal flexure, which lies in the transpyloric plane one inch to the left of the median plane, is the landmark which the surgeon makes for when he wishes to identify the commencement of the jejunum (Fig. 946, p. 1204). To find the flexure the greater omentum and transverse colon should be thrown upwards and the finger passed along the inferior layer of the transverse mesocolon to the left side of the vertebral column. The flexure lies in the angle or recess formed by the left side of the second lumbar vertebra and the inferior surface of the body of the

pancreas. With the finger in this recess the commencement of the jejunum may be hooked forward a little to the left of the superior mesenteric vessels at the root of the mesentery. In connexion with the duodeno-jejunal junction is the inferior duodenal fossa of Jonnesco, formed by a fold of peritoneum which stretches from the left side of the fourth or ascending part of the duodenum upwards

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, the sac, as it enlarges, extending further and further into the te inguinal lig extra-peritoneal tissue on the posterior abdominal wall. Should strangulation peritoneum, and occur, the inferior edge of the orifice must be divided in a downward direction, in divered out of order to avoid the inferior mesenteric vein which curves round the anterior and simp

, the cæcu superior aspects of the orifice (Treves).

Jejunum and Ileum.-To expose the coils of the jejunum and ileum completely, The position the greater omentum, along with the transverse colon and the greater curvature the medial ang of the stomach, must be turned upwards. On account of the oblique attachment rice of the ve of the mesentery, the greater number of the coils lie in the left infra-colic peritoneal and of the ileunc compartment, where they extend upwards to the left of the vertebral column asins are prolo far as the attachment of the transverse mesocolon and the inferior surface of the mangements pancreas; here they lie in front of the inferior pole of the left kidney, in the angle redisposing ca of the left colic flexure.

ampe intestine The only certain means which the surgeon has of distinguishing the superior d (3) the free from the inferior coils of small intestine is by their relation to the duodeno- Vermiform jejunal flexure and the ileo-cecal junction. Occasionally the plicæ circulares which springs

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with the anterior abdominal wall immediately above the lateral half of al ligament. In the normal condition it is completely surrounded by 1, and can, therefore, along with the vermiform process, be readily out of the abdomen. In chronic constipation, associated with intestinal

cæcum is thin-walled, dilated, abnormally movable, and often prolapses elvis. osition of the ileo-cæcal valve corresponds, on the surface of the body, to al angle between the intertubercular and right lateral lines, while the the vermiform process is one inch lower. It is to be noted that the lower) ne ileum protrudes somewhat into the cæcum, and that its circular muscular ce prolonged into the flaps of the colic valve. Both of these anatomical ments favour the occurrence of intussusception. In infants, other osing causes are: (1) the relatively rapid enlargement of the lumen of the testine as compared with the small; (2) the greater mobility of the cæcum ;

the frequent presence of a mesentery to the ascending colon. rmiform Process.—The vermiform process (O.T. vermiform appendix),

springs from the postero-medial aspect of the cæcum, one inch below the
ecal junction, is provided with a well-developed “meso-enteriole” derived from
sterior aspect of the lowest part of the ileac mesentery. It is this portion of
posterior layer of the mesentery which sometimes develops a band - like
ening, which, by dragging upon the inferior end of the ileum, produces the kink
hich attention has been directed by Arbuthnot Lane. The artery of the
niform process is the only vessel which supplies the process; it occupies the
border of the meso-enteriole and gives off several branches which pass between
wo layers to reach the organ. In amputating the vermiform process the artery
igatured on the proximal side of its first branch in order to control the blood-
ply to the stump of the process. The fact that the vermiform process is supplied
a single artery predisposes it to
mgrene should the vessel become
rombosed, or should the circulation

it be interfered with by kinking ILEO-COLIC ARTERY-
s a result of adhesions.
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generlly be found to pass either upwards and medially, behind the lower end of the ileum,ordownwards and medially, 80 as to overhang the external iliac vessels at the superior aperture of the pelvis minor; less frequently it ascends in the pouch behind the commencement of the ascending colon. ARTERY OF THE When, as not infrequently happens, the retro-cæcal fossa is prolonged upwards to form a pouch behind the colon, the vermiform process almost

Fig. 1105.—THE BLOOD-SUPPLY OF THE CÆCUM AND VERinvariably ascends into it, and should

MIFORM PROCESS. it be diseased, it may give rise to a The illustration gives a view of the cæcum from behind. retro-cæcal abscess. The abscess may The artery of the vermiform process, and the three perforate the posterior wall of the tänia coli springing from the base of the process, should

be specially noted. (Modified by Birmingham from cæcum, or it may ulcerate through

Jonnesco.) the posterior peritoneum; in the latter case the suppuration may spread upwards, in the loose fatty sub-peritoneal tissue behind the colon, into the lumbar and perinephric regions, and it may reach even the under surface of the diaphragm and form a subphrenic abscess. When, in the course of its development, the cæcum has failed to complete its descent, the vermiform process may lie in the lumbar region in relation to the inferior pole of the kidney. When it dips downwards into the pelvis minor it may become adherent to the pelvic colon, the rectum, or the bladder, and in the female to the uterine tube or the ovary. To find the vermiform process, the best plan

ILIAC BRANCH

POSTR CAECAL A

VERMIFORM

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