301 
 
 CORNELL 
 
 UNIVERSITY 
 
 LIBRARY 
 
 BOUGHT WITH THE INCOME 
 OF THE SAGE ENDOWMENT 
 FUND GIVEN IN 1 89 1 BY 
 
 HENRY WILLIAMS SAGE 
 
The original of tliis book is in 
 tine Cornell University Library. 
 
 There are no known copyright restrictions in 
 the United States on the use of the text. 
 
 http://www.archive.org/details/cu31924024790861 
 
The Clinical Anatomy of the 
 Gastro-Intestinal Tract 
 
 BY 
 
 T. WINGATE TODD, M.B., Ch.B., 
 
 Henry Willson Payne Professor of Anatomy in the Western Reserve 
 University, Cleveland, Ohio; late Lecturer in Anatomy, 
 University of Manchester. 
 
 Cornell University Library 
 QM 301.T63 
 
 3 1924 024 790 861 
 
 MANCHESTER 
 
 At the University Press 
 
 LONGMANS. GREEN3JX»r- 
 LoNDON, New York, Bombay, &c. 
 
 1915 
 
 5 
 
A.'3ooU3'& 
 
 University of Manchester Publications 
 No. XCIX. 
 
 [ALL RIGHTS RESERVED]. 
 
TO 
 
 THE BRITISH STUDENTS IN MANCHESTER 
 
 AND THE AMERICAN STUDENTS OF RESERVE, 
 
 WHOSE ENTHUSIASM 
 
 STIMULATED THE COMPILING OF THIS BOOK 
 
PREFACE. 
 
 The contents of this volume embody the substance of 
 the course of lectures on the alimentary canal as given 
 in the Anatomical Laboratory of Western Reserve 
 University. Those elementary facts which a student 
 easily learns for himself have, in greater part, been 
 omitted. The mouth, pharynx, tongue and salivary 
 glands also have received no consideration in these 
 pages. My reason for making these omissions is the 
 necessity for condensing into small compass results of 
 recent investigation which are of value for clinical 
 purposes. Clinical research on the mouth and pharynx 
 has not progressed of late yearis so rapidly as has 
 investigation on the abdominal part of the alimentary 
 tract. Hence for the presentation of a comparatively 
 small amount of new material, it would have been 
 necessary to add much old matter to render the account 
 of mouth and pharynx readable and intelligible. It was 
 therefore deemed advisable to Ipave out altogether the 
 consideration of these parts. 
 
 The" volume was never planned as a handbook for 
 examination purposes. It is intended to give an outline 
 of recent work, which has not yet found its way into 
 anatomical text-books, to those who desire to know a 
 little more than is required for the pass examination. It 
 may be that in the' American schools, where the outside 
 examjnership is unknown, the teacher has a freer hand 
 than he has in Great Britain in the selection of those 
 parts of his subject which he considers of most value 
 for his students. Nevertheless it was the eagerness of 
 the classes in clinical anatomy in Manchester for more 
 advanced study and for the anatomical facts and theories 
 
 (vii) 
 
Vlll PREFACE 
 
 of more definitely clinical bearing which first suggested 
 to me the advisability of gathering the material together 
 into book form. 
 
 Inasmuch as the book is intended for the more practical 
 side of the subject of anatomy, no attempt has been made 
 to bring in the Basle nomenclature. Only a few care- 
 fully guarded terms are used, for the confusion introduced 
 by that premature and ill-considered attempt to revise 
 anatomical nomenclature is as great in America as it is 
 in Britain. 
 
 Some misunderstanding may arise over the lateral 
 inguinal line. It seems to me (see p. 3 and fig. i) the 
 happiest solution of the now considerable number of 
 "vertical " lines in the neighbourhood of the old mid- 
 Poupart line. 
 
 Illustrations have not been considered essential, as 
 every dissecting room and atlas present a profusion of 
 illustration. Nevertheless some have been added, 
 especially to assist the reader to grasp the new facts 
 brought to light by radiography. For practically all of 
 these radiograms I am indebted to Dr. A. E. Barclay of 
 Manchester, in whose laboratory I gathered the informa- 
 tion so valuable? to clinician and anatomist alike. 
 
 In drawing together the material into book form I had 
 help from both my British and my American colleagues, 
 many of whom I have not space to mention by name. 
 But to my chief. Professor Elliot Smith of Manchester, 
 to Professor Lorrain Smith of Edinburgh, and to 
 Professor Keith of London, I stand greatly indebted. 
 In England, Professor J. W. Smith, Messrs. Stopford, 
 Morley, Hughes, F. Craven Moore and Barclay, and in 
 America, Drs. Hamann, Macleod, Ingalls, Black and 
 F. C. Herrick have been unsparingin their help. To 
 
PREFACE IX 
 
 all of these gentlemen I desire to express my sincere 
 thanks. Prosector Leonhart of this department has 
 also put me under obligation for much assistance in the 
 preparation of dissections necessary to the work. 
 
 Although from considerations of space much has had 
 to be passed by, it is but fair to state that without the 
 untiring zeal of Mr. J. C. Miller, the departmental 
 librarian, the material now brought together could not 
 have been gathered. To Miss A. Parker, the steno- 
 grapher, also I wish to acknowledge my thanks for the 
 patience and care she has at all times bestowed on a 
 very tiresome manuscript. 
 
 I am also indebted to Dr. Stopford and Mr. H. M. 
 McKechnie, Secretary of the Manchester University 
 Press, for help given in passing the book through the 
 press. 
 
 T. WINGATE TODD. 
 
 Cleveland, Ohio, 
 
 igth March, igi^- 
 
CONTENTS. 
 
 Preface 
 
 List of Illustrations 
 
 Chapter 
 
 I. The Abdominal Wall and Diaphragm 
 
 Femoral and Inguinal Hernise 
 
 The Peritoneal Cavity 
 
 II. 
 III. 
 IV. 
 
 of the Gastro-Intestinal 
 
 Some General Features 
 Tract 
 
 V. The CEsophagus 
 
 VI. The Stomach 
 
 VII. The Duodenum ... 
 
 VIII. The Jejuno-Ileum 
 
 IX. The Caecum, Appendix and Proximal Colon 
 
 X. The Distal Colon) Rectum and Anus 
 
 XI. The Liver, Gall Bladder and Pancreas 
 
 Note on the Ileo-Pyloric Reflex 
 
 Bibliography 
 
 Subject Index 
 
 PAGE 
 
 vii 
 
 I 
 ^5 
 
 20 
 
 31 
 
 42 
 
 59 
 112 
 135 
 157 
 190 
 
 213 
 230 
 231 
 257 
 
 (X) 
 
LIST OF ILLUSTRATIONS. 
 
 PAGE 
 
 Fig. I. Guiding lines for the topography of the abdomen 4 
 Fig. 2. Right side of male pelvis showing certain 
 
 aponeurotic bands 15 
 
 Fig. 3. Supra- and infracolic portions of the peritoneal 
 
 cavity 31 
 
 Fig. 4. Subdivision of the infracolic portion of the peri- 
 toneal cavity as found in the cadaver 25 
 
 Fig. 5. Subdivisions of the supracolic portion of the peri- 
 toneal cavity 27 
 
 Fig. 6. Tracing of normal empty stomach from cadaver 
 
 embalmed with formalin 59 
 
 Fig. 7. Tracing of normal distended stom'ach from cadaver 
 
 embalmed with formalin 60 
 
 Fig. 8. Tracing of hypothetical stomach to illustrate the 
 
 nomenclature 64 
 
 Figs. 9, 10, II. Tracings from radiograms of the normal 
 stomach partially distended with bismuth food... 
 
 Fig; 9. Shows the relation which usually exists between 
 
 the stomach and the transverse colon 70 
 
 Fig. 10. Stomach pressed somewhat to the left by gas in 
 
 the proximal colon 71 
 
 Fig. II. Shows the pyloric vestibule well held up by the 
 
 fibres of the Hufeisenschlinge 72 
 
 Fig. 12. Tracing from radiogram of well filled normal 
 
 stomach 73 
 
 Fig. 13. Tracing from radiogram of atonic stomach ... go 
 
 Fig. 14. Tracing from radiogram of atonic stomach ... 91 
 
 Fig. 15. Tracing from radiogram of case of pyloroptosis ... 93 
 
 (xi) 
 
Xll LIST OF ILLUSTRATIONS 
 
 PAGE 
 
 Pig. i6. Tracing from radiogram of hypertonic stomach ... 93 
 Fig. 17. The distribution of perforated peptic ulcers ... 98 
 Fig. 18. Tracing from radiogram taken of patient suffering 
 
 from duodenal irritation 124 
 
 Fig. 19. Tracing from radiogram showing bismuth food in 
 
 the duodenum as far as the site of the crossing 
 
 of the transverse colon 130 
 
 Fig. 20. Chart to illustrate Monk's statements on the 
 
 localisation of the intestine in the cadaver ... 140 
 Fig. 21. Tracing of radiogram which shows a bismuth 
 
 shadow in the upper jejunum 149 
 
 Fig. 22. Tracing from radiogram showing bismuth shadow 
 
 in the lower part of the small intestine 150 
 
 Fig. 23. Tracing from radiogram showing bismuth shadows 
 
 in the terminal portion of the ileum 161 
 
 Fig. 24. Tracing from radiogram showing the csecum 
 
 dipping over the pelvic brim into the cavity of 
 
 the true pelvis ... 162 
 
 Fig. 25. Tracing from radiogram to show bismuth shadows 
 
 in the proximal colon ... .«. 184 
 
 Fig. 26. Tracing from radiogram to show bismuth shadows 
 
 in the proximal and distal colons 185 
 
 Fig. 27. Tracing from radiogram to show the course of 
 
 the colon 196 
 
 Fig. 28. Photograph of dorsi-ventral median section of 
 
 male pelvis to show the level of the great valve 
 
 of Houston and the rectal relations 199 
 
 Fig. 29. Photograph of the pelvis represented in Fig. 28 
 
 with the rectum drawn aside to expose the 
 
 combined rectal fascia and stalk 208 
 
 Fig. 30. Drawing of dorsi-ventral median section of male 
 
 pelvis 210 
 
 Fig. 31. Approximate surface topography of the gall 
 
 bladder and the bile ducts in the cadaver "... 217 
 Fig. 32. Surface topography of the pancreas as observed 
 
 in the cadaver 226 
 
CHAPTER I. 
 
 The Abdominal Wall and Diaphragm. 
 
 Since the wall of the abdomen is differentiated from that 
 of the thorax by the attached margin of the diaphragm 
 to the costal arches, portions of the seventh to the tenth 
 and the whole of the eleventh and twelfth ribs lie in the 
 wall of the abdomen. In respiration the last two ribs 
 are prevented from vertical movement by their muscular 
 attachments and simply tilt their ventral extremities 
 outward to accommodate the descent of the bulky 
 subphrenic organs in inspiration (176). 
 
 The term anterior or ventral abdominal wall is usually 
 restricted to the rhomboidal area between the costal 
 margins above and the inguinal (Poupart's) ligaments 
 below. 
 
 The lateral abdominal wall consists largely of the 
 costal arches, but between the costal margin and the iliac 
 crest is a small unprotected area, the flank, an incision 
 into which is properly termed laparotomy. The use of 
 this word has been extended to cover an incision through 
 the ventral abdominal wall into the peritoneal cavity, 
 which incision is correctly known as a coeliotomy. 
 
 The infrasternal fossa lies in the angle between the two 
 costal margins. The size of this angle varies with the 
 size of the chest and the stage of respiration. It is 
 greater in men than in women, and is very narrow in 
 cases of pigeon chest. Its apex lies approximately in 
 the plane of the disc between the ninth and tenth dorsal 
 vertebrae. With inspiration the costal margins separate 
 and increase the infrasternal angle. This is the result 
 
 1 
 
2 THE ABDOMINAL WALL AND DIAPHRAGM 
 
 of the action of the intercostal, scalene, trapezius and 
 sternomastoid muscles ; in other words, of the respiratory 
 musculature of the thoracic cone. The diaphragm which 
 on contraction tends to lessen the infracostal angle is 
 acting normally at a disadvantage and is thus overcome 
 by its antagonists. Should, however, the spinal cord be 
 injured below the origin of the phrenic nerves, the 
 infracostal angle becomes less in inspiration through the 
 unhampered action of the diaphragm. If one side of the 
 diaphragm is paralysed or pushed upward, the corres- 
 ponding costal margin flares more on inspiration than 
 the healthy one. Should the diaphragm be in spasm or 
 be pushed downward on one side and the healthy muscle 
 acting to greater advantage, it will cause the correspond- 
 ing costal margin to fall in toward the middle line during 
 inspiration, while the other costal margin may be maliing 
 its normal outward movement (155). 
 
 The umbilicus varies in prominence and in position 
 with age, sex and attitude. It is prominent and relatively 
 low in the infant, the latter fact probably resulting from 
 the large liver and small pelvis which together cause the 
 abdominal organs to bulge the ventral wall especially 
 above the umbilicus. In the adult the umbilicus lies 
 approximately at the junction of the middle and lower 
 thirds of a line joining the suprasternal fossa with the 
 symphysis pubis (165). The umbilicus is elevated 
 by an intra-abdominal tumour rising from the pelvis; 
 it is lowered by a tumour in the upper abdomen. 
 In the erect posture the umbilicus lies at a slightly lower 
 level than in the recumbent attitude. In the latter 
 position the umbilicus approximates the plane of the disc 
 between the third and fourth lumbar vertebra. It is 
 usually about 3 cm. above the iliac crests. 
 
THE ABDOMINAL WALL AND DIAPHRAGM 3 
 
 The most prominent point of tlie iliac crest is marked 
 by a tubercle 6 or 7 cm. distant from the anterior superior 
 spine. The crest between the spine and tubercle, together 
 with the posterior superior spine and the crest adjacent 
 to it, is subcutaneous. Between these areas fatty, sub- 
 cutaneous tissue covers the crest so that the iliac crease i 
 lies horizontally below the crest itself. In stout subjects 
 the tubercles also may be covered, thus reducing still 
 further the subcutaneous extent of the crest. The dimples I 
 over the posterior superior iliac spines are well marked 
 in both male and female. They indicate the level of the 
 second sacral spine. In the male there is also a second 
 depression above the dorsal part of the iliac crest, over 
 the space known as Petit's triangle, between the borders 
 of the latissimus dorsi and external oblique muscles. 
 The depression is known as the lateral superior lumbar J 
 fossa (282). It extends somewhat over the two musclesi 
 just mentioned. But in the female it is obliterated by/ 
 the fatty pad of the flank. 
 
 The pubic spine approaches the horizontal plane in 
 which lies the upper end of the great trochanter. It is 
 distinct in thin males, but in females and in stout males 
 it is hidden by subcutaneous fatty tissue. In men it can 
 be found by invaginating the scrotum, and in women by 
 following the tendon of the adductor longus to its origin 
 just beneath the spine. 
 
 Of arbitrary subdivisions in the abdominal wall the 
 following are of most frequent use. 
 
 The lateral inguinal, or Poupart, line, which replaces 
 the old mammary, and mid-Poupart lines, meets the 
 inguinal ligament midway between the anterior superior 
 spine and the symphysis pubis, and reaches the clavicle 
 midway along its length (or midway between the supra- 
 
4 THE ABDOMINAL WALL AND DIAPHRAGM 
 
 Sternal fossa and the outer border of the acromion). 
 Though often termed vertical, this line may be inclined 
 obliquely, the exact slope being determined by the 
 relative breadth of hips and shoulders. 
 
 Fig. I. Guiding lines for topography of tlie abdomen. 
 
 This figure, which is used throughout the volume as the basis on which 
 to plot the organs, itself represents the typical asymmetry of the body.' 
 
 A, Addison's transpyloric plane; S, subcostal plane; U, umbilical 
 plane ; T, intertubercular plane ; I, lateral inguinal line. 
 
 I. The left clavicle is quarter of an inch longer than the right, and the 
 left shoulder higher than the right. A slight Harrison's sulcus at the 
 level of the fifth rib on the left side is shown. The obliquity of the 
 sternum and slight scoliosis associated with asymmetry of sacrum and 
 pelvis generally are quite commonly seen. The lateral inguinal lines 
 
THE ABDOMINAL WALL AND DIAPHRAGM 5 
 
 Three horizontal planes, known respectively as the 
 inter-tubercular, the infracostal (or subcostal) and trans- 
 pyloric planes, are also used. 
 
 The inter-tubercular plane is indicated by a line drawn 
 round the body touching the tubercles which mark the 
 most prominent point of the iliac crests. The plane 
 passes through the spine of the fourth lumbar vertebra 
 and through or close to the disc between the fourth and 
 fifth lumbar vertebras. 
 
 The infracostal plane passes through the lowest point 
 of the costal margin {i.e., tenth costal cartilage) and in 
 or close to the disc between the second and third lumbar 
 vertebrae. 
 
 The transpyloric plane of Addison is that which passes 
 through the body midway between the apex of the infra- 
 sternal fossa and the umbilicus, a point equally well 
 
 have not the same slope and do not cross the cqstal margin at precisely 
 the same level on both sides. Several apparent inaccuracies are explained 
 by the fact that one cannot represent three dimensions in one plane. 
 The foreshortening at upper and lower ends ■ of the drawing is indicated 
 by the short vertical length of the manubrium and by the amount of the 
 cavity of the true pelvis exposed to view. Addison's transpyloric plane is 
 indicated at the site at which it actually did occur, but since the ventral 
 convexity of the thoracic and abdominal walls cannot be represented in 
 the drawing, the plane appears to lie at a lower level than it should when 
 direct measurement is made of the actual illustration. The tubercles of 
 the iliac crests do not indicate the summits of the crests ; nevertheless 
 they are not so far below the level of the summit as appears to be the 
 case in the drawing. This apparent error is necessary for the perspective. 
 As a result the intertubercular and umbilical planes appear at a lower 
 level than they should, relative to the iliac crests. As a matter of fact 
 the highest points of the crests in this individual are represented by the 
 prominence so plainly shown on the left crest dorsal to the tubercle. 
 Radiographers state that the umbilicus lies at or a little above the highest 
 point of the crests ; hence the drawing is in reality accurate, for according 
 to the plane in which the Rontgen rays strike the pelvis, 'the apparent 
 level of the crests will vary somewhat. The several horizontal planes 
 do not invariably strike intervertebral discs, but it will be recognised 
 that the practical levels of the planes given in the text are purely working 
 approximations. 
 
6 THE ABDOMINAL WALL AND DIAPHRAGM 
 
 indicated by the midpoint between the suprasternal fossa 
 'and the pubic symphysis. It indicates approximately 
 the level of the disc between the first and second lumbar 
 vertebrae, and cuts the costal margin at the same point 
 as does the lateral inguinal line, that is to say, on the 
 ninth costal cartilage., In the horizontally-placed cadaver 
 the pylorus lies in this plane. As the pylorus is not a 
 fixed point, but varies with posture, age, sex, distension 
 of the stomach, and other conditions, the plane does not 
 invariably mark its site in the living (see p. 80). 
 
 The skin of the ventral abdominal wall is thin and 
 delicate and of much finer texture and possesses much 
 smaller sebaceous glands than that of the back. In 
 young men the skin can easily be pinched up and moved 
 on the deeper fasciae and muscles, owing to the small 
 quantity of subcutaneous fat. In young women the fat 
 is more abundant and forms a pad around and below 
 the umbilicus, thus giving rise to a more rounded 
 appearance of the abdominal wall. The fat below the 
 umbilicus increases in amount with age, especially in 
 women who have passed the climacteric and in younger 
 women who have borne children. This subcutaneous- 
 ■fat sometimes reaches a thickness of six inches, and its 
 weight, together with an associated lack of muscular tone, 
 causes the abdominal wall to sag downward. 
 
 The fold of the groin is dependent for its existence 
 upon the presence of subcutaneous fat in the abdominal 
 wall and thigh. In infants the fat of the abdominal wall 
 extends downward over the thigh, thus determining a 
 lower level for the inguinal crease. It is this fact which 
 makes the incision for inguinal hernia in babies appear 
 relatively high in the abdominal wall. 
 
 In infants there is a transverse crease convex below, 
 
THE ABDOMINAL WALL AND DIAPHRAGM ^ 
 
 which passes across the abdominal wall between the 
 umbilicus and the pubis. This gives a better indication 
 of the site of the inguinal canal than does the so-called 
 inguinal crease itself. 
 
 In adults of both sexes a transverse crease above the 
 umbilicus is produced by leaning forward when sitting. 
 
 Atrophy of the skin from tension results in the produc- 
 tion, especially below the umbilicus, of line^ albicantes 
 or atrophica in pregnancy and ascites. The scars may 
 be pigmented. Incision through the abdominal wall in 
 the median line is frequently followed by a pigmented 
 scar. 
 
 Bulging of the. abdominal wall is produced in the 
 infant by the large size of the liver and by the distended 
 intestines, which usually contain a large amount of gas 
 from the swallowing of saliva. In young females bulg- 
 ing is frequeritly caused by intestinal distension, in older 
 females by subcutaneous fat. In male adults bulging is 
 usually produced by the accumulation of fat in the 
 mesentery and omentum. 
 
 Retraction of the entire abdominal wall occurs in 
 emaciation and in hysteria. In gastroptosis the wall 
 above the umbilicus is scaphoid ; that below is convex. 
 
 The recti muscles form well defined columns one on 
 each side of the middle line. Below the umbilicus only 
 a. very small interval exists between them. Above the 
 umbilicus the interval is greater. Each is enclosed in a 
 sheath formed from the lateral musculature of the 
 abdominal wall. Between the recti the fasciae blend to 
 form the linea alba, which is broader above than below 
 the umbilicus and is represented on the surface, in its 
 upper part at least, by a median groove. It may be 
 covered by fat below the umbilicus or, in its whole extent. 
 
8 THE ABDOMINAL WALL AND DIAPHRAGM 
 
 The skin overlying it below the umbilicus may be 
 pigmented to form the linea fusca. The outer margin 
 of the rectus forms the linea semilunaris, which reaches 
 the costal margin at the intersection of the lateral 
 inguinal and transpyloric lines, a site where the wall is 
 occasionally weak and may bulge on coughing. Below 
 the umbilicus the linea semilunaris is often obscured by 
 subcutaneous fat. At its tendinous intersections the 
 rectus is adherent to the ventral wall of its sheath. 
 Persistent contraction of one of the muscular subdivi- 
 sions of the rectus may occur in visceral disease {e.g., 
 appendicitis) or may cause the phantom tumour some- 
 times noted in hysteria. By giving tone to the ventral 
 abdominal wall, the recti fix the lower part of the chest 
 in breathing. Hence a jnan breathes mainly with the 
 lower chest when standing erect, but with the entire chest 
 when recumbent, the tonic action of the recti being no 
 longer necessary in the latter position. 
 
 Lateral to the rectus is the mass of the musculature 
 comprising the obliques and transversus, which forms a 
 prominence on the lateral abdominal wall, in the upper 
 portion of which digitations of the external oblique may 
 be visible. The prominence fades away below about the 
 level of the anterior iliac spine. 
 
 In rickets the fibrous tissue comprising the linese alba 
 et semilunares may become relaxed and bulge to form 
 the trifoliate abdomen. A similar condition occurs in 
 the atonic abdominal wall after repeated pregnancies, 
 though in the latter case the weakness is manifested 
 mainly in the linea alba. 
 
 The fibrous tissue of the abdominal wall especially 
 that of the linea alba is sometimes the site of a recurring 
 fibrous tissue growth called a desmoid tumour. 
 
THE ABDOMINAL WALL AND DIAPHRAGM 9. 
 
 At the time we are discussing the abdominal muscula- 
 ture, certain facts may be mentioned relative to the 
 diaphragm. 
 
 Keith ^177) gives the following description of the 
 position of the diaphragm. The xiphisternal line drawn 
 round the trunk at the junction of the body of the 
 sternum with the ensiform cartilage (xiphisternum) cuts 
 the lateral inguinal line on the fifth costal arch. If a 
 strip of tinfoil be placed round the body at this level and 
 the patient examined radiographically, the diaphragm is 
 seen to present a definite relation to the foil, thus : — 
 
 Patient upright. 
 
 Right lateral inguinal line — dome in xiphisternal 
 
 plane. 
 Midsternal line — central tendon lomm. below 
 
 xiphisternal plane. 
 Left lateral inguinal line — dome 5-10 mm. below 
 
 xiphisternal plane. 
 
 When the patient is laid horizontally the domes rise 
 about 10 mm. above the points mentioned. 
 
 In the thoracic type of respiration the movement of the 
 diaphragm is 10 mm. above the xiphisternal plane in 
 expiration and 25 mm. below it in inspiration. In the 
 abdominal type the corresponding figures are 25 mm. 
 above and 65 mm. below the plane. For practical 
 purposes the right dome may be indicated on the lateral 
 inguinal line in the fourth intercostal space and the left 
 on the corresponding line in the fifth space. If the 
 position of the dome is 25 mm. or more below the normal, 
 the diaphragm may be considered to participate in a 
 condition of visceroptosis. 
 
 The lower six dorsal nerves, which also supply the 
 
lO THE ABDOMINAL WALL AND DIAPHRAGM 
 
 abdominal alimentary canal, send branches to innervate 
 the abdominal wall. The seventh nerve reaches the 
 middle line at the infracostal triangle, and the tenth at 
 the umbilicus. The twelfth nerve reaches the middle 
 line just above the symphysis pubis. The general direc- 
 tion of the nerves must, be considered in all abdominal 
 incisions. It is to avoid wounding the nerves that the 
 kidney incision is made parallel to the last rib downward 
 and forward from the lateral edge of the erector spina. 
 Failure to observe this rule results in atrophy of the 
 musculature with consequent lumbar hernia. The 
 general direction of the nerves is indicated by " girdle 
 pains," in the distribution of herpes zoster, and in the 
 band of atrophic ichthyotic skin which results from the 
 paralysis of intercostal nerves in some cases of tubercu- 
 lous spine. 
 
 As these nerves all pass into the rectus sheath, vertical 
 incisions in the linea semilunaris are followed by paresis 
 and mistrust by the patient of the corresponding rectus, 
 and sometimes by a ventral hernia. For such a procedure 
 is therefore substituted, when possible, an incision 
 through the two walls of the rectus sheath, the muscle 
 with its nerves being displaced outward. 
 
 Kammerer's vertical incision for appendicitis at the 
 outer border of the rectus may result in damage to the 
 eleventh and twelfth dorsal nerves and to the iliohypo- 
 gastric branch of the first lumbar nerve. 
 
 It has been stated that Chevassu's incision for malig- 
 nant testicle and lymphatic nodes is not followed by an 
 abdominal hernia. It would be instructive, however, to 
 learn of such patients a considerable time after the 
 operation, supposing them to be still alive, for such a 
 statement is not credible without further evidence. 
 
THE ABDOMINAL WALL AND DIAPHRAGM II 
 
 A right inguinal hernia sometimes follows the ordinary 
 Bassini incision for appendicitis, but is more likely to 
 develop if the presence of abscess has required drainage. 
 The hernia results from paralysis of the musculature 
 following the involvement of the first lumbar nerve. 
 Happily for the patient this nerve, together with the last 
 dorsal, is usually double, so that even if a trunk is divided 
 all the fibres of the nerve are not severed. The ilio- 
 inguinal branch of the first lumbar nerve is frequently 
 laid bare in the Bassini operation, and if involved in the 
 scar gives rise to neuralgic pain or cutaneous hyper- 
 sensitiveness, and is hence removed on sight by some- 
 surgeons (151). 
 
 The fact that each nerve which distributes branches to 
 the abdominal wall, also supplies twigs to the alimentary 
 canal accounts for the hypereesthesia and local contrac- 
 tion found in a part of the abdominal wall in disease of 
 the canal. It accounts also for the alimentary reflex — 
 the relaxation of the abdominal wall associated with 
 distension of the alimentary canal. This is the reason 
 for the tightness of one's clothes after a heavy meal. 
 Owing to this reflex a dog can and often does double its 
 abdominal contents at a meal without inconvenience. 
 That the arc is completed in the alimentary mucosa and 
 not in the peritoneum is shown by the fact that the reflex 
 is not called forth by injection of air or saline solution 
 into the peritoneal cavity (187). 
 
 With the exception of the deep epigastric vessel below 
 and the superior epigastric above in the rectus sheath, 
 behind the muscle, the arteries of the abdominal wall are 
 not clinically important. 
 
 The veins present one of the series of anastomoses 
 between portal and systemic circulations, which become 
 
12 THE ABDOMINAL WALL AND DIAPHRAGM 
 
 important in portal obstruction. The veins around the 
 umbilicus have small anastomosing channels along the 
 ligamentum teres with the portal system in the hilum of 
 the liver. In portal obstruction portal blood passes in 
 the reverse direction through these veins and to the 
 abdominal wall and thence through anastomosing chan- 
 nels to veins in the axillas and groins. Frequently there 
 exists a large vein which joins the axillary and inguinal 
 areas along the flank. The umbilical veins in very rare 
 cases form a large mass known as the caput medusae. In 
 the Talma-Morison operation for hepatic cirrhosis it is 
 unlikely that good results are due simply to venous 
 anastomosis. 
 
 The lymphatic vessels of the abdominal wall pass to 
 nodes in the axillse and groins, the vessels of the several 
 areas anastomosing across the middle line and the 
 umbilical plane. 
 
 Certain developmental anomalies should receive notice 
 in passing. These are hernia, umbilical fistula and 
 ectopia vesicae. 
 
 Of the hernise, the inguinal and femoral varieties will 
 be considered separately. The others, such as obturator, 
 sciatic and diaphragmatic types, are rare, and as a rule 
 are not diagnosed until the abdomen is opened. The 
 diaphragmatic form may also be. acquired. Hamant and 
 1 hi^baut divide them into two groups, those without a 
 sac, which pass through the foramen of Bockdaleck — the 
 costo-lumbar hiatus, and are produced during the first or 
 second month of fcetal life, and those with a sac, which 
 are lodged in " diverticula " of the diaphragm, and are 
 produced between the second and fifth months of foetal 
 life. In the first variety the stomach is most frequently 
 herniated, in the second the intestine. The theory is, 
 however, based on very little evidence (122). 
 
THE ABDOMINAL WALL AND DIAPHRAGM 1 3 
 
 The umbilicus is the scar left by the closure of the 
 umbilical ring through which passed the umbilical veins 
 and the hypogastric arteries, the communication of the 
 gut with the yolk sac and the stalk of the allantois. 
 Occasionally a remnant of the artery of the yolk sac 
 remains, at any rate in monsters, its origin being from 
 the abdominal aorta or the superior mesenteric artery 
 (156). After the tying of the cord the vessels atrophy, 
 the neck of the yolk sac having already been changed 
 into Meckel's diverticulum and the stalk of the allantois 
 having disappeared as a patent tube. In the case of the 
 two last-named not having fully undergone their parti- 
 cular modification, a temporary urinary or fsecal -fistula 
 occurs, which as a rule soon closes spontaneously. A 
 congenital hernia of bowel may be present, and owing to 
 slow closure of the ring, weakly infants sometimes exhibit 
 an umbilical hernia for a long time. In the adult, 
 umbilical hernia occurs through the abdominal wall close 
 to the umbilical scar and is really a form of ventral 
 hernia. The umbilical skin is frequently drawn down- 
 wards into a pocket, which may admit three inches of a 
 probe, and which accumulates sweat products and 
 sebaceous secretion until a foul-smelling umbilical 
 abscess occurs. 
 
 . The linea fusca on the abdominal wall represents the 
 line of fusion between pubis and umbilicus. According 
 to Wood, Jones (350), distension of the allantois may 
 cause interference with its closure. Thus the umbilicus 
 is never formed, and with the loss of the outer ^vall of 
 : the allantois the bladder is freely open on the abdominal 
 wall, the condition being known as ectopia vesicas. 
 Associated with this condition may be one or two-fistular 
 openings of the bowel, the higher of the two being 
 
14 THE ABDOMINAL WALL AND DIAPHRAGM 
 
 Meckel's diverticulum, the lower a communication 
 between the urinary system and the hind gut, which also 
 exists in recto-vaginal, recto-vesical or recto-urethraJ 
 fistula (see p. 212). 
 
CHAPTER IL 
 Femoral and Inguinal Hernia, 
 
 Between the inguinal (Poupart's) ligament with its 
 continuation, Gimbernat's ligament, and the ilio-pectineal 
 line on the os innominatum a space is left, which is 
 subdivided into muscular and vascular compartments by 
 the ilio-pectineal ligament, of which the continuation 
 towards the pubic crest is known as Cooper's ligament 
 (207).- Through the muscular compartment pass the 
 
 Fig. 2. Right side of male pelvis showing certain aponeurotic bands. 
 I, inguinal (Poupart's) ligament; L, lacunar (Gimbernat's) ligament; 
 C, ligament of Cooper. 
 
 iliacus and psoas. The inner or vascular compartment 
 gives room for the iliac vessels, of which the vein lies 
 the more medially. Man's comparatively great pelvic 
 breadth has resulted in the relatively considerable size 
 
 15 
 
1 6 FEMORAL AND INGtJINAL HERNIA 
 
 of the inner compartment with, medial to the vein, a 
 potential passage into the thigh lodging merely areolar 
 tissue and a lymphatic node. It is called the femoral 
 canal ; its upper opening shows usually a small invagina- 
 tion of peritoneum; its lower end opens into the thigh 
 ..immediately beneath the saphenous opening, and the 
 canal is of greater diameter in the female than in the 
 male. Through the canal a femoral hernia passes to the 
 thigh. Frequently only a small knuckle of gut is present, 
 but a large amount of omentum or fatty subserous tissue, 
 which makes it difficult to distinguish from a lipoma. 
 If a larger, amount of gut traverses the canal, it is 
 supposed to pass toward the anterior superior iliac spine, 
 being directed thither by the sharp edge of the saphenous 
 opening and the furrow of the groin. This it does not 
 always do, and it may indeed mount upward over the 
 inguinal ligament to resemble closely an inguinal hernia. 
 The sac of the hernia frequently contains muscular fibres 
 derived from the gubernaculum. 
 
 The operative treatment is directed toward extirpating 
 the sac and then either to closing: the canal from above, 
 as in Lotheissen's operation^ in which the lower margins 
 of the internal oblique and transvefsalis are sutured to 
 Cooper's ligament (216), or obliterating the lower end of 
 the canal. The extirpation of the sac is probably the 
 more iniportant part of the operation. 
 
 In the region of the femoral canal there may be an 
 unimportant anastomosis between the deep epigastric 
 ^nd obturator arteries. This is dilated in some cases to 
 form an abnormal obturator vessel. Occasionally the 
 artery may run on the medial side of the femoral canal 
 and is then liable to injury if the strictured neck of the 
 
FEMORAL AND INGUINAL HERNUL 1 7 
 
 ■canal be opened by cutting toward Gimbernat's liga- 
 ment (159). Such accidents must be rare indeed. 
 
 The. inguinal canal is only slightly smaller in the 
 female than in the male. Its direction is inward- and 
 downward. It opens into the abdomen through the 
 internal abdominal ring which lies just lateral to the 
 junction of the lateral inguinal line with the inguinal 
 ligament. It opens externally at the external abdominal 
 ring, which is a narrow obliquely placed slit, 3 cm. long' 
 and bounded by two pillars, of which the lateral- is 
 attached to the pubic spine. The canal itself is bounded 
 below by the upper grooved surface of the inguinal 
 ligament : its outer wall by the external oblique fascia ; 
 its inner wall by the transversalis fascia, which lines the 
 abdomen deep to the muscle of the same name, and 
 behind the external ring by the conjoined tendon of the 
 two deeper muscles of the abdominal wall at its attach- 
 ment to the ilio.-pectineal line. The thickest parts of the 
 conjoined tendon are its medial and lateral borders. 
 
 ' Between these it is thin and much weaker. The weak 
 area is bounded medially by some aponeurotic fibres of 
 
 : the transversalis muscle, which run from the upper aspect 
 of the pubis to the rectus. They are called the falx 
 aponeurotica inguinalis. Laterally the weak area is 
 Bouiided by other aponeurotic fibres from the same 
 muscle, which, encircling the internal ring on its medial 
 side, are fused with the deeper part of the inguinal 
 ligament. They are termed the ligamentum interfoveo- 
 lare. The size of the weak area naturally depends on the 
 extent of its two strengthened boundaries. Above, the 
 inguinal canal ends indefinitely by the approximation of 
 the muscular layers forming its walls. The deep wall is 
 
 ^subdivided into three areas by the upward passage of 
 
1 8 FEMORAL AND INGUINAL HERNI-S! 
 
 two arteries beneath the subperitoneal coat. These are 
 the deep epigastric immediately medial to the internal 
 ring, and, a little more medially, the obliterated hypogas- 
 tric. Both vessels are directed toward the umbilicus 
 the subdivision between them being often termed the 
 triangle of Hesselbach on its peritoneal aspect. 
 
 An oblique inguinal hernia passes through the entire 
 canal; a direct one into the canal through a weakened 
 part of the middle or internal area of those defined above. 
 The oblique variety is probably always associated with 
 an imperfectly closed funicular process and is therefore 
 potentially congenital. The funicular process is patent 
 throughout in 30-40 per cent, of infants a few months 
 old (178). Often this form of hernia is associated with 
 an imperfectly descended testicle. Of cases of hernia 
 accompanied by such imperfect descent of the testicle, 
 35" I per cent, occur during the first year. Of cases of 
 hernia without this .association, only 77 per cent, com- 
 mence during the first year (87). 
 
 Because in early life the omentum is not developed to 
 the extent seen in the adult, its presence is rare in a 
 hernial sac in the young. The bladder is present in i per 
 cent, of hernial sacs, usually in children and on the right 
 side. The appendix, or even the caecum, also may be 
 found in the sac, in which case the appendix is as liable 
 to inflammation as in its normal situation, though inflam- 
 mation in a herniated appendix is often termed strangu- 
 lation. Hernia of the ovary with or without the Fallopian 
 tube is rare, but when present it occurs as a rule in young 
 infants and on the left side. 
 
 Interstitial hernia may occur in any of the areolar 
 layers of the abdominal wall in the region of the inguinal 
 canal. It probably depends upon the drawing of a 
 
FEMORAL AND INGUINAL HERNIA 1 9 
 
 pocket of peritoneum into the space by aberrant fibres" of 
 the gubernaculum (88). Three varieties are found : (i) 
 superficial to the external oblique, (ii) deep to the external 
 oblique, (iii) deep to all muscles and between them and 
 the peritoneum. 
 
CHAPTER in. 
 
 The Peritoneal Cavity. 
 
 It is not proposed in this chapter to describe in detail 
 the peritoneal cavity or the several mesenteries, omenta 
 and ligaments, for all of these are discussed at sufficient 
 length in the anatomical text-books. It is, moreover, 
 only in its relation to the alimentary canal that the 
 peritoneum finds a place here. Inasmuch, however, as 
 there is ^ tendency to lose sight of the functional, or more 
 correctly the clinical, subdivisions of the cavity in the 
 mass of detailed description usually given in text-books, 
 the subject of subdivision must be considered in this 
 chapter. 
 
 Foremost among what may be termed the partitions 
 of the peritoneal cavity is the transverse mesocolon. The 
 exact attachments and the variations in position of this 
 mesentery are given elsewhere (p. 176). At the moment 
 it is sufficient to note that it subdivides the cavity into 
 supra-colic and infra-colic portions, and in view of the 
 fact that its attachment to the dorsal wall lies for the 
 most of its extent above the plane of the transverse colon, 
 it follows that the infra-colic portion extends upward and 
 backward behind the supra-colic division. Subdivision 
 into upper and lower areas is completed by the transverse 
 colon and omentum lying in contact with the ventral 
 abdominal wall. 
 
 The transverse mesocolon becomes greatly shortened 
 at its extremities; indeed at the splenic and hepatic 
 flexures and for some 5 cm. adjacent to the latter, no 
 
 20 
 
THE PERITONEAL C.WITY 
 
 21 
 
 mesocolon exists. Hence supra- and infra-colic compart- 
 ments communicate in the neighbourhood of the flexures. 
 The splenic flexure lying lateral to the left kidney, there 
 is but a small communication on the left side. On the 
 
 Fig, 3. Supra- and infracolic portions of the peritoneal cavity and tlie 
 relation to each of the right kidney pouch (of Rutherford Morison). As. 
 the mesentery of the small intestine extends upward dorsal to the trans- 
 verse colon and mesocolon, its upper part is indicated by a broken line. 
 The arrows indicate the drainage into the pouch from gall bladder (G), 
 appendix (A), duodenum (D), and pyloric vestibule (P). 
 
 right side, however, the hepatic flexure lies in front of 
 the lower and medial part of the kidney, and the first 
 5 cm. of the transverse colon usually having no mesen- 
 tery, the connection between the upper and lower portions- 
 
22 THE PERITONEAL CAVITY 
 
 of the peritoneal cavity is of considerable extent. The 
 communication occupies that part of the abdomen in 
 front and to the right of the right kidney below the liver, 
 and extends downward to the region of the iliac crest. 
 Rutherford Morison has termed it the right kidney pouch 
 and has pointed out that it is large enough in the adult 
 to contain a pint of fluid (244). The right kidney pouch 
 is important because, as the patient lies on his back, there 
 is a tendency for it to become the drainage area of the 
 appendix, gall bladder, duodenum, and even of the 
 pyloric vestibule. It is because the duodenum and 
 appendix each drain into this area that the diagnosis 
 between appendicitis and acute perforation of the duode- 
 num may be difficult, since the area of local tenderness 
 and rigidity may be the same in both diseases. 
 
 As a rule a perforated duodenal ulcer produces 
 peritonitis localised to the right kidney pouch. On the 
 other hand, perforation of a gastric ulcer is more likely 
 to be followed by general peritonitis (248), because the 
 flow from the stomach is not so accurately localised. 
 
 When the cadaver is laid flat upon its back, a hand 
 placed in the peritoneal cavity readily determines that 
 the subdiaphragmatic (or subphrenic) area and the pelvic 
 cavity, respectively, form the lowest levels of the supra- 
 and infra-colic divisions. 
 
 The pelvic peritoneum has the least power of absorp- 
 tion, but the subphrenic area has a very considerable 
 absorptive faculty. It follows, therefore, that drainage 
 of toxic fluid into the latter must be prevented. Fowler's 
 position, in which the patient is propped on a bed rest, 
 is the natural result of this knowledge. The high rate 
 of absorption is stated to be due to several causes other 
 than the accumulation of toxic fluid through gravity. 
 
THE PERITONEAL CAVITY 23 
 
 Stomata have been said to connect the peritoneal cavity 
 with the lymphatic vessels of the diaphragm, but this 
 observation is discredited by Sabin (298). The piston 
 action of the diaphragm during respiration has been 
 stated to produce a flow of lymph toward the thorax. 
 Certainly pleurisy following peritonitis is not uncommon, 
 whereas peritonitis as a complication of pleurisy is 
 exceedingly rare. Also pleurisy may follow the ascites 
 which results from a variety of causes, and does not 
 necessarily indicate pleural and peritoneal tuberculosis 
 (46). Some believe that the lymphatic vessels of the 
 diaphragm are valved in an upward direction (18). 
 
 The statement that very little absorption occurs in the 
 pelvic cavity is illustrated by the fact that a patient with 
 a. pelvic appendicular abscess may show no symptoms 
 of toxic origin whatever. The only signs indicating J;Jie 
 lesion may be the diarrhoea, frequency of micturition and 
 possible hsematuria, all, of which are but the results of 
 local irritation. The natural tendency of all contained 
 fluid to gravitate to the pelvis results, in certain cases of 
 carcinoma in the upper abdominal organs, especially of 
 the stomach, in the formation of a secondary deposit in 
 the pouch of Douglas, palpable through the rectum 
 (33o)- Implantation metastases are produced in the same 
 manner on the ovary or uterus from carcinoma of the 
 breast. 
 
 Both supra-colic and infra-colic areas are partially 
 subdivided into right and left compartments by the 
 vertebral column and the great vessels lying upon it. 
 
 In the infra-colic section this subdivision is completed 
 by the mesentery of the small intestine, which is attached 
 to the dorsal wall along a line running from above and 
 to the left obliquely downward to the right iliac fossa 
 
24, THE PERITONEAL CAVITY 
 
 (see p. 141). Thus the infra-colic peritoneal cavity is 
 subdivided into right and left lumbar areas, of which the 
 former is directly continuous with the right kidney 
 pouch. The latter has a small connection, alongside the 
 splenic flexure, with the supra-colic division. It commu- 
 nicates over the pelvic brim with the third subdivision 
 of the infra-colic area, namely, the cavity of the true 
 pelvis. The infra-colic peritoneal cavity has been utilised 
 by Gushing as a drainage area in cases of congenital 
 hydrocephalus. He inserts a cannula through the fifth 
 lumbar vertebra to form a communication between the 
 spinal subarachnoid spac6 and the peritoneal cavity. 
 
 The omentum and coils of small intestine assist in 
 further localising an area of infection below the trans- 
 verse mesocolon. 
 
 The omentum is a vascular fat-laden fold, develop- 
 mentally part of the dorsal mesentery of the stomach, 
 from the greater curvature of which it hangs down in 
 the abdomen in front of the transverse colon, which is 
 adherent to its deep aspect, and the coils of small 
 intestine. It is quite rudimentary at birth, when, in 
 common with other peritoneal folds it contains no fat. 
 During childhood it increases in size and becomes a fat 
 storehouse. No amount of starvation will then entirely 
 deprive it of its adipose tissue. The omentum has 
 important exudative and absorptive qualities, and also 
 has the power of itself travelling to an injured or infected 
 area, to which it becomes attached, and thus acts as a 
 protective or localising agent. It may reach anywhere 
 from diaphragm to pelvic floor, and is frequently found 
 in a hernial sac, especially of the femoral variety, but 
 usually it has more immediate relation to the infra-colic 
 subdivision than to the supra-colic area. The omentum 
 
THE PERITONEAL CAVITY 
 
 25 
 
 pours out first serum, then leucocytes into the affected 
 region, and glues itself to the injured gut or infected 
 
 Fig. 4. Subdivision of the infracolic portion of tlie peritoneal cavity 
 as found in the cadaver. The upper part of the mesenteric attachment 
 (M) is represented by a brolten line to indicate that it extends Upward 
 dorsal to the transverse colon and mesocolon, the latter of which with 
 the omentum is not represented. 
 
 The arrow H indicates the communication between the supra- and 
 infracolic portions of the peritoneal cavity in the region of the right 
 kidney pouch. The arrow G shows the comparatively small communica- 
 tion between the two portions of the cavity on the left side. 
 
 R, right lumbar area; L, left lumbar.area; P, pelvic area. 
 
 area to shut it off from the rest of the peritoneal contents. 
 Thus the omentum adheres to the deep surface of a 
 wound in the abdominal wall, or may act as a plug for 
 
26 THE PERITONEAL CAVITY 
 
 a hernial opening or perforated viscus. Torsion of the 
 omentum occasionally occurs as a sequel in this protec- 
 tive function. In such cases the omentum is often 
 adherent to the sac of an old standing hernia or less 
 frequently, as in Vick's case, to an inflamed appendix 
 {333)- Absorption of fluid is not so marked a function 
 of the omentum. For Wilkie found that in deomentised 
 animals the rate of absorption of fluid from the peritoneal 
 cavity is still two-thirds of the rate in normal animals 
 (344). The omentum does, however, absorb solid parti- 
 cles, as Wilkie showed experimentally with charcoal. 
 In some more obscure way the omentum is of material 
 assistance in resisting infection. Although the cellular 
 reaction occurs as readily in deomentised animals as in 
 normal animals, yet the former succumb more easily to 
 a sublethal dose of staphylococci (344). Disease of the 
 omentum, such as tubercle or endothelioma, causes it to 
 roll up into a mass which often lies transversely in the 
 abdomen above the umbilicus. It may sometimes be 
 palpated through the abdominal wall (228). 
 
 The supracolic portion of the peritoneal cavity, like 
 the infra-colic division, is also subdivided. The vertebral 
 column and great vessels partially separate this area into 
 t\\o spaces, in each of which the roof is formed by the 
 corresponding diaphragmatic cupola. Thus, as Picque 
 described it, there are right and left subphrenic or 
 hepato-phrenic and perisplenic fossae. But the hepatic 
 diverticulum of the lesser sac of peritoneum also lies 
 immediately under the diaphragm, and hence Picque 
 speaks of this as the middle or hepato-gastro-phrenic 
 fossa (271). A similar but more elaborate subdivision 
 was suggested by Barnard (18). He subdivided the 
 right subphrenic area into ventral and dorsal pouches, 
 
THE PERITONEAL C.W'ITY 2^ 
 
 the incomplete partition being the right coronary 
 (trio^ngular) Hgament. Of these the ventral pouch is 
 
 Fig. 5. Subdivisions of the supracolic portion of the peritoneal cavity. 
 The falciform ligament (F) together with the liver subdivides the 
 subphrenic aica into right and left areas. The middle fossa of Picqu^ 
 (omental bursa, lesser sac) lies behind liver and stomach, and cannot be 
 shown. But clinically this is an area of the supra-colic peritoneal cavity 
 isolated more completely than the others. The subhepatic channel is 
 indicated by tlie long broken-lined arrow. It lies between the liver and 
 stomach ventral to the gastro-hepatic omentum, and passes behind the 
 falciform ligament. It is the communication between the left subphrenic 
 area and the right kidney pouch. 
 
 R, right subphrenic (hepato-phrenic) fos.sa ; L, left subphrenic (peri- 
 splenic) fossa ; K, right kidney pouch. 
 
 separated from the left .subphrenic fossa by the falciform 
 ligament. That which Picqu*^ calls the left fossa, 
 Barnard termed the left ventral pouch, and he used the 
 
28 THE PERITONEAL CAVITY 
 
 designation left dorsal pouch for Picqu^'s middle fossa. 
 Barnard's subdivision into ventral and dorsal pouches by 
 the right coronary ligament is, however, incorrect, for the 
 right coronary ligament merely acts as an incomplete 
 partition between the renal aspect of the liver, that is, 
 a boundary of the right kidney pouch, and the sub- 
 diaphragmatic surface of the liver, namely, a boundary 
 of the right subphrenic area. Barnard's most important 
 suggestion is the term subhepatic channel for the area 
 between liver and stomach, the floor of which is directed 
 downward and to the right to connect the left subphrenic 
 fossa with the right kidney pouch. 
 
 The vagus, phrenic, splanchnic, intercostal, lumbar, 
 and sacral nerves supply the peritoneum with fibres. It 
 is useful at this point to refer to Kocher's summary of 
 Lennander's experiments (191) regarding nerve-supply 
 and sensations of the peritoneum. Lennander (200) 
 made the following observations : — 
 
 (fl) The only sensitive tissues are the peritoneal coat 
 of the diaphragm and abdominal walls. 
 
 (b) The peritoneum between the sympathetic cords in 
 front of the fourth and fifth lumbar vertebrae and over 
 the front of the sacrum is insensitive; here there are 
 anatomically no afferent nerves. 
 
 (c) The parietal peritoneum as above defined is sensi- 
 tive only to pain, not to touch or temperature. 
 
 (d) The normal and inflamed peritoneum are equally 
 sensitive. 
 
 (e) Probably the intercostal, lumbar and sacral nerves 
 (possibly the phrenic also) conduct pain impulses, while 
 the vagus and sympathetic do not. 
 
 (/) Inflammation of an abdominal organ entails pain 
 when the parietal peritoneum is involved by the spread 
 
THE PERITONEAL CAVITY 29 
 
 of toxines and infliimraatory processes along subserous 
 lymphatics in the dorsal abdominal wall. Colic is the 
 result of muscular action producing traction on the 
 cerebrospinal nerves of the abdominal Wall. 
 
 (g) Unless the parietal peritoneum is involved, there 
 is no pain. The visceral peritoneum, mesenteries and 
 omenta are devoid of sensation even when hypersemic 
 and inflamed. According to the recent experiments of 
 Kappis, pain is keenly felt in the omenta and mesenteries 
 (171). 
 
 (h) Adhesions between visgera and the parietal 
 peritoneum produce pain by tension, but adhesions 
 between viscera, alone are devoid of pain. 
 
 (i) Pain is felt at a distance from the seat of disease, 
 and results from the stimulation of the nerves of the 
 abdominal wall by chemical, bacterial or mechanical 
 irritation. 
 
 (/) Nausea and vomiting are produced when traction 
 is made upon an abdominal organ such as the omentum, 
 and are due to the irritation of the cerebro-spinal nerves 
 in the abdominal wall. 
 
 Referred pain is due then to stimulation of the visceral 
 branch, but is apparently localised in the somatic branch 
 of a spinal nerve. Local tenderness is consequent, on 
 localised inflammation or adhesions to the parietal 
 peritoneum. It is because they both may produce local 
 tenderness over the right kidney pouch that appendicitis 
 and perforated duodenal ulcer may be confused. 
 
 The peritoneal nerves take no part in the reflex which 
 exists between the alimentary mucosa and the muscles 
 of the abdominal wall. Injection of fluid or air into the 
 peritoneal cavity immediately raises the intra-abdominal 
 pressure (see p. ii). 
 
30 THE PERITONEAL CAVITY 
 
 Stimulation of a local area of parietal peritoneum 
 results in the reflex contraction of the abdominal muscu- 
 lature immediately overlying. Hence one segment alone 
 of the right rectus may be found contracted in inflamma- 
 tion of the gall-bladder or appendix. 
 
 It is to be observed that the lower six thoracic nerves 
 which supply the abdominal wall and viscera supply 
 thoracic viscera as well. Head states that the seventh, 
 eighth and ninth dorsal segments send branches to the 
 lungs (131), (132). Hence local tenderness or hyper- 
 assthesia, it may be, accompanied by visceral symptoms 
 .such as vomiting, inhibition of intestinal movement and 
 constipation, may occur at the commencement of 
 broncho-pneumonia, phthisis, bronchitis or pleurisy. In 
 the last-mentioned disease the tenth and eleventh nerves 
 also may be involved. The signs may be localised to 
 the right hypochondrium to simulate gall bladder disease, 
 or to the left side when a perforated gastric ulcer may be 
 suspected (18). 
 
 The blood vessels of the peritoneum, with the exception 
 of those of the omentum, are not clinically important. 
 Rough handling or ligature of the omentum is said to 
 cause thrombosis of its veins which, spreading to the 
 gastro-epiploic veins, results in venous engorgement of 
 the stomach with consequent post-operative haematemesis 
 (248). 
 
CHAPTER IV. 
 
 SoiiE General Features of the Gastro-Intestinal 
 
 Tract. 
 
 In embryonic life the alimentary canal is subdivided into 
 tlie fore-, mid- and hind-gut. The fore-gut corresponds^ 
 to the canal from the pharynx to the duodenum at the 
 point of entry of the common bile duct. The mid-gut; 
 consists of proximal and distal portions, the former of 
 which lies above and the latter below the junction of 
 Meckel's diverticulum with the bowel. The proximal 
 portion becomes the small intestine between the duode- 
 num at the site already mentioned and the entry of 
 Meckel's diverticulum which is situated at a variable 
 distance from the ileo-csecal junction. The distal portion 
 corresponds to the terminal segment of ileum with tlae 
 c£ecum and colon as far as the splenic flexure. The 
 hind-gut becomes the colon from the splenic flexure 
 onward with the rectum and anus. One or other of these 
 embryological subdivisions may fail to develop. The 
 portion beyond the splenic flexure may, for instance, be 
 represented by a mere impervious cord. In ectopia 
 veSiciB the portion, distal to the entry of Meckel's 
 diverticulum may be greatly shortened (35°)- O" t^® 
 other hand, the failure to develop may be localised to 
 the site of junction of successive portions, resulting in 
 constriction or occlusion. Such a condition is most 
 frequent in the duodenum at the entrance of the common 
 bile duct (74) and in the colon at the splenic flexure. In 
 the subdivision just outlined the proximal part of the 
 
 31 
 
32 FEATURES OF THE GASTRO-INTESTINAL TRACT 
 
 duodenum falls within the same subdivision as the 
 stomach, and it is interesting to note that surgical and 
 radiographic aspects of the adult canal have led Mayo 
 and Cole respectively to believe that this portion of 
 duodenum should be considered with the stomach (66). 
 There is also some evidence, which will be taken up in 
 the appropriate place, that the colon should be divided 
 functionally into proximal and distal parts which are 
 continuous with each other at or near the splenic flexure. 
 
 In disease one of these subdivisions may be involved, 
 the others being unaffected. Thus, as Barnard pointed 
 out, acute urasmia attacks the fore-gut, lead-colic the 
 small intestine, chronic ureemia the proximal or distal 
 colon, tabetic crises the fore- or the hind-gut (20). This 
 is by no means a complete list, nor does it indicate that 
 even smaller portions of gut may be affected, picked out 
 sharply by disease, but it serves to emphasise the natural 
 subdivision of the alimentary canal. 
 
 If one scans the parts played in digestion by the 
 subdivisions mentioned, it is obvious that the secretory 
 function is most pronounced in the upper part of the 
 canal, and progressively decreases in the downward 
 direction until in the distal colon it is reduced to a 
 minimum. On the other hand, the absorptive power 
 increases progressively in the downward direction if one 
 except the distal colon, in which this function also is 
 reduced to a minimum. 
 
 The importance of the relation of absorptive to secre- 
 tory areas is apparent in considering the faecal vomiting 
 which is diie to intestinal obstruction. While it is 
 possible that antiperistalsis may occur in the small 
 intestine under certain conditions, such action is not 
 necessarily called into play, nor indeed is the so-called 
 
FEATURES OF THE GASTRO-INTESTINAL TRACT 33 
 
 reversed axial current essential for the production of 
 fa£cal vomiting, the fluid of which, is dark-brown and 
 foetid in odour, not because it contains faecal matter, but 
 because it is infected by the bacteria present in the bowel. 
 As it is of a gushing character and not projectile in type, 
 it is quite possible that it simply wells up into the mouth 
 when the gut proximal to the site of obstruction becomes 
 waterlogged (20). The vomiting in gall stone obstruction 
 is also instructive in this connection. When the stone 
 ulcerates through into the duodenum, profuse gushing 
 vomiting occurs, since the area of canal above the site 
 of obstruction- has large secretory and but low absorptive 
 power. During' the next two or three days, that is, as 
 the stone passes down the small intestine, the vomiting 
 becomes less frequent and less severe, for not only does 
 a larger area of gut come to lie proximal to the site of 
 obstructioh, thus providing a greater capacity, but the 
 area has a progressively higher absorptive power. 
 Indeed once the stone has passed the ileo-cascal orifice, 
 the vomiting usually ceases entirely. 
 
 While discussing the subject of mechanical obstruction 
 it is well to observe the sites of anatomical constriction 
 of the canal. Three of these are to be found in the 
 oesophagus, namely at the commencement, at the crossing 
 of the left bronchus, and at the termination, and three 
 occur elsewhere in the canal, at the pylorus, at the ileo- 
 c£ecal junction, and at the anus. Of these the constric- 
 tion at the commencement of the oesophagus has the least 
 diameter. If an object vrtthout sharp angles or other 
 special adaptations for entanglement in the mucosa, is 
 swallowed and successfully passes this narrowed site, it 
 will usually traverse the- rest of the tract without 
 difficulty. 
 
34 FEATURES OF THK GASTRO-INTESTINAL TKACT 
 
 The anatomy of the several coats of the canal will be 
 described in the succeeding chapters, but it may be 
 mentioned at once that the submucosa alters but little 
 throughout the alimentary tract, and that it is the most 
 important site in the spread of carcinoma. 
 
 Lymphoid tissue is present in the canal in two forms, 
 namely, solitary follicles and agminated or Peyer's 
 ' patches. The latter are most numerous in the lower part 
 of the small intestine, and as they form the vulnerable 
 spot in typhoid fever, most of the ulcerations and per- 
 forations in that disease occur in the lower ileum. 
 Peyer's patches are not found in the large intestine and 
 but rarely in the stomach. They are more numerous in 
 the child than in the adult (i66). Solitary follicles, while 
 occurring throughout the gut from stomach to anus, are 
 in greatest number in the caecum and appendix. 
 
 Lane and his co-workers have drawn attention to 
 certain kinks which may be found associated with 
 chronic intestinal stasis in the continuity of the gut. 
 That these should actually be responsible for the stasis 
 does not seem probable, for even when the splenic flexure 
 is surrounded by adhesions, the kink thus formed pro- 
 duces no delay in the onward passage of the food. 
 Indeed even in Guy's Hospital itself opinion is divided, 
 for while Lane regards the kinks as the cause of intestinal 
 stasis, others consider them to be rather the result of 
 local peritonitis induced by the stasis (see 240). The 
 sites at which Lane has localised kinks are the follow- 
 ing (197) : 
 
 1. Upper part of duodenum between transverse colon 
 and gall bladder. It is to be noted that this is the site 
 of the cysto-colic or cysto-duodenal ligament (see p. 122). 
 
 2. Lower part of duodenum. The probable explana- 
 
FEATURES OK Till--. CASTRO-lNTESTIXAl. TRACT 25 
 
 tion of the appearances at this site is the compression of 
 the gut between the superior mesenteric vessels and the 
 aorta (see p. 119). 
 
 3. Near the termination of the ileum. This kink may- 
 be produced by adhesions in chronic appendicitis. 
 
 4. At the hepatic flexure. 
 
 5. At the splenic flexure. 
 
 6. In the pelvic mesocolon. 
 
 All of these may be due to pericolitis. Perhaps also 
 it is well not to lose sight of the fact that kinks which 
 are obvious at one time in a screen examination may 
 have disappeared in half an hour. 
 
 Inspection of the abdomen may give some information 
 concerning the site of the lesion in intestinal obstruction, 
 for while the small intestine lies in the centre of the 
 abdomen, the ascending and descending colons occupy 
 the flanks. If obstruction occur in the ileo-csecal region 
 with consequent distension of the small bowel, the central 
 part of the abdomen will be prominent, the flanks, .which 
 are occupied by the colon, being collapsed. 
 
 Obstruction at the splenic flexure causes distension of 
 the right flank, but as the proximal colon is very disten- 
 sible little or no effect is produced in the small intestine ; 
 hence the central part of the abdomen remains un- 
 changed. Should obstruction be present in the pelvic 
 colon, both flanks may be distended. Acute obstruction 
 produced b}- volvulus of the pelvic colon causes great 
 abdominal protrusion, which commences in the hypo- 
 gastrium. For the pelvic colon is the most distensible 
 part of the gut, and in a very few hours may become so 
 dilated as to occupy most of the abdominal area. 
 
 In thin and emaciated individuals and in persons 
 with chronic intestinal obstruction, peristalsis in the 
 
36 FEATURES OF THE GASTRO-INTESTINAL TRACT 
 
 alimentary tract may be observed through the abdominal 
 wall. When the patient is in the recumbent posture, a 
 wave of peristalsis above the umbilicus is suggestive of 
 stomach movements. It is unlikely that any such waves 
 are referable to the transverse colon, for even when 
 sought by the use of the Roentgen rays movement in 
 this part of the canal has been only rarely observed. 
 Active peristalsis of the small intestine results in a 
 zig-zag movement from the upper, central to the lower 
 central part of the abdomen. Indeed sometimes actual 
 ladder coils, of small intestine stand out in relief on the 
 abdominal wall. Peristaltic waves pass so slowly or so 
 rapidly along the large bowel that it is unlikely that they 
 could ever be observed clinically through the abdominal 
 wall (ii). It is howeter well to avoid, or at any rate to 
 limit, the use of the term peristalsis. So-called peristalsis 
 of the stomach, segmentation movements in the small 
 intestine, and antiperistalsis in the proximal colon are 
 all similar and are responses of tonically contracted 
 organs to stretching by contents. They constitute 
 examples of a local response which does not require for 
 its exhibition the integrity of the myenteric plexus ; they 
 are therefore independent of the myenteric reflex. Their 
 function is to break up masses of food and to bring the 
 nutritive material into closer association with the 
 absorptive mucosa of the gut. Hence they pass food 
 up or down the alimentary tract for a few centimetres 
 only. 
 
 On the other hand, true peristalsis differs from the 
 foregoing in that the stimulus is probably chemical 
 rather than mechanical, and that a wave of inhibition 
 always precedes the contraction, which, moreover, 
 invariably progresses in the distal direction. Such a 
 
FEATURES OF THE GASTRO-INTESTINAL TRACT 37 
 
 movement depends upon the integrity of the nervous 
 arc. If repeated encircling incisions be made through 
 the musculature of the small intestine to interfere with 
 the function of the myenteric nerve plexus which lies 
 between the muscular coats, the movement is abolished 
 (47). Such incisions in the stomach do not interfere 
 with " peristalsis " in that organ for the reason already 
 given. 
 
 Recently Kuntz has shown on morphological grounds, 
 that these circular incisions need not interfere with the 
 strictly local reflex response in the sympathetic arc, for 
 he observed complete afferent and efferent neurones in 
 the bowel wall so closely associated with each other (195) 
 that the circular incisions could not interfere with their 
 mechanism, which is of a more local character than that 
 styled by Cannon the m}enteric reflex. 
 
 Under certain conditions the true peristaltic (diastaltic) 
 wave may advance at a very rapid rate. This is called 
 the peristaltic rush. It is in some such way that intus- 
 susception is induced. When the nervous co-ordination 
 breaks down in the death agony, reversed peristalsis and, 
 in consequence, reversed intussusceptions may occur. 
 The function of the true peristaltic wave is to pass on 
 the nutritive material some considerable distance in the 
 distal direction in order that fresh areas for digestion 
 and absorption may be reached. Each kind of food is 
 absorbed at different rates in different portions of the 
 tract. Protein is absorbed most in the upper part of the 
 absorptive area of the canal, though to a less extent in 
 more distal situations. "Starch and fat are absorbed in 
 greater quantity in the lower part (213). Each portion 
 of the gut absorbs of a particular food a constant 
 percentage, which is independent of the amount taken 
 
^8 FEATURES OF THE GASTRO-INTESTINAL TRACT 
 
 (212). But whether given in large or small amount, the 
 entire absorptive area is active in the absorption of any 
 particular variety of food stuff (211). The foregoing 
 account indicates the reason for two distinct functions of 
 the muscular coat of the alimentary canal, the move- 
 ments in which have both been termed peristalsis. 
 Cannon, therefore, proposes to use the word diastalsis 
 for the true peristaltic wave, which is always preceded 
 by a wave of inhibition and depends upon the myenteric 
 reflex in the bowel wall. He would call the other move- 
 ment, which has no preceding wave of inhibition, and 
 which is independent of the myenteric reflex, anastalsis 
 if it occur in the proximal direction, or katastalsis if 
 directed distally (47). The term peristalsis is still useful, 
 however, to indicate movement without definitely stating 
 the character of the movement. 
 
 The nei've supply of the abdominal alimentary tract 
 comes from the vagi, the splanchnics and the visceral 
 pelvic trunks. The fibres in the vagi probably originate 
 from the sympathetic nucleus of the vagus. The splanch- 
 nic fibres come from the sixth to the twelfth dorsal nerves 
 inclusive, other branches of which supply the abdominal 
 -wall. The visceral pelvic trunks originate from the third 
 and fourth sacral nerves, occasionally from the second 
 also. These and the splanchnics reach the gut through 
 the medium of the sympathetic plexus. The vagi and 
 the pelvic trunks are tonic nerves, and the splanchnics 
 are tonic inhibitory in function. Hence while the former 
 increase the tone of the gut wall and cause the muscular 
 coat to exercise a tension on the contents, the latter group 
 has the opposite function. In man the vagi extend only 
 to the neighbourhood of the termination of the ileum. 
 These fibres are stated by some authors to terminate in 
 
FEATURES OF THE GASTRO-INTESTINAL TRACT 39 
 
 special nerve-endings, not in the myenteric, plexus. But 
 the pelvic nerves, which exercise a similar function on 
 the distal colon, have not been proved to terminate 
 otherwise than in the plexus. Whether in man the 
 proximal colon receives any tonic nerves is doubtful. 
 On the other hand, the inhibitory splanchnics extend 
 throughout the tract. 
 
 Sensation in the alimentary canal (see 138) differs 
 completely from that of the skin. The oesophagus and 
 anal canal are both sensitive— to thermal stimulations, 
 while tactile sensation is p'i^sent in the latter only. The 
 sensations peculiar to the alimentary tract are burning, 
 fulness, cramp, and hunger. Of these the burning 
 sensation is that produced by alcohol. It is localised to 
 the oesophagus and stomach, or possibly to the former 
 alone, and is absent from the colon. It is probably the 
 sensation felt in pyrosis. Fulness is caused by disten- 
 sion of the tract by gas. It is frequently associated with 
 pyrosis in gastro-intestinal fermentation, and usually is 
 produced by the evolution of carbon dioxide. Cramp- 
 like spasms are due to the stimulating influence of gas, 
 the most powerfully acting being carbon dioxide. 
 Probably this is a stimulating factor in the production 
 •of multiple intussusceptions in the death agony (139). 
 Hunger senscition is produced by muscular waves in a 
 tonically contracted stomach (52). Its sudden onset and 
 periodicity are thus explained. In duodenal ulcer the 
 stomach is hypertonic and hence the presence of hunger 
 pain in this disease. 
 
 In the alimentary canal three other responses to 
 stimulation, which are reflex in character, must be 
 mentioned. One of these, the abdominal wall reflex, is 
 discussed in the first chapter (p. 11). But there are also 
 
40 FEATURES OF THE GASTRO-INTESTINAL TRACT 
 
 circulatory and respiratory responses.. If the patient be 
 not fully under the influence of the anesthetic, manipu- 
 lation of any part of the tract causes a fall in blood 
 pressure, which is sudden in onset and which may reduce 
 the patient to a very dangerous condition. It is probably, 
 like the respiratory response, dependent upon the 
 integrity of the vagi and pelvic, nerves (48). Mechanical 
 stimulation of stomach or anal canal under the same 
 conditions produces in addition a deep inspiration or 
 expiration, which calls for care on the part of the 
 anaesthetist. Such a response does not occur in the small 
 intestine or colon. 
 
 Localising sensations occur only in those parts of the 
 tract which are relatively permanently fixed, that is, the 
 stomach, duodenum, and large intestine. They are 
 produced by local peritonitis of the parietal peritoneum, 
 the involvement of which follows a focal lesion of the 
 mucosa in a fixed portion of the tract. Lennander 
 explains pain from ulcer of stomach or intestine as the 
 result of inflammation of the lymphatic vessels and nodes 
 which drain the affected area (200). Sensation in the 
 small intestine is vague and is referred to the neighbour- 
 hood of the umbilicus, which is supplied by the tenth 
 dorsal nerve, one of the main nerves which supply the 
 jejunum and ileum. Hence when a gall stone is obstruct- 
 ing the duodenum, the pain is fixed and localised to the 
 epigastrium, but as the stone passes through the jejunum 
 and ileum, the pain "loses its fixed character and is 
 referred vaguely to the region of the umbilicus. 
 
 The vascular supply of the abdominal tract is simple. 
 The stomach and the proximal part of the duodenum as 
 far as the entry of the bile duct are supplied bv the 
 coeliac axis artery and its corresponding veins. The 
 
FEATURES OF THE GASTRO-INTESTINAL TRACT 4I 
 
 remainder of the duodenum, the jejunum, ileum, caecum, 
 and colon as far as the splenic flexure receive their supply 
 from the superior mesenteric vessels. The distal colon, 
 including the rectum, is supplied by the inferior mesen- 
 teric vessels and their branches. It is to be observed 
 that, contrary to the usual belief, valves are present in 
 the veins of the portal system. These are best marked 
 in infancy and tend to become incompetent in adult age. 
 Wilkie recently redirected attention to this fact and 
 showed the presence of competent valves in the gastric 
 and omental veins of some adults and even in the veins 
 from the large intestine of the new-born child, in which 
 they are most numerous in the veins of the pelvic colon 
 (346). 
 
CHAPTER V. 
 
 The CEsophagus. 
 
 The oesophagus, as the continuation of the pharynx, 
 coijimences in front of the body of the sixth cervical 
 vertebra, and terminates in the cardiac orifice of the 
 stomach at the left side of the body of the eleventh dorsal 
 vertebra. The precise sites just given for commencement 
 and termination are those usually found in the adult 
 male. The course of the oesophagus lies in the lower 
 part of the neck, in the superior and posterior mediastina 
 of the thorax, and for a distance of about 2*5 cm. in the 
 abdomen. The length of the gullet is usually stated to 
 be 20 to 25 cm. in the normal adult, varying with the 
 length of body. There are, however, considerable 
 individual differences in the length of the oesophagus. 
 Besides having relation to the height of the vertebral 
 column, these differences depend, in addition, upon the 
 exact level of the pharyngo-oesophageal junction and 
 upon the site of the cardia. In the infant the oesophagus 
 commences opposite the lower border of the fourth 
 cervical vertebra. The level of its commencement 
 gradually sinks during childhood, and attains the adult 
 position at puberty. During the first two years of life, 
 the oesophagus is very long compared with the height of 
 the body. After the twentieth year the ratio between the 
 length of the oesopha.gus and that of the body becomes 
 stationary. In later life there is again a relative lengthen- 
 ing, of the gullet. The average length of the oesophagus 
 is given by Kolster as 22-26 cm. in the adult female, and 
 
 42 
 
THE (ESOPHAGUS 
 
 43 
 
 25-30 cm. in the adult male. More variable than either 
 the length of the vertebral column or the level of the 
 commencement of the gullet, is the site of termination of 
 the latter at the cardia. In a series of adult females 
 Kolster found the highest site of the cardia at the left 
 side of the tenth dorsal vertebra in a woman of twenty- 
 four years, and the lowest in a female cadaver seventy 
 years of age at the level of the first lumbar vertebra. 
 The highest site among adult males was at the level of 
 the ninth dorsal vertebra in a man of thirty-one years, 
 and the lowest opposite the first lumbar vertebra in a 
 man of eighty-two years. Generally speaking, there is 
 a sinking of the cardia with increasing age. This 
 lowering of its position does not progress regularly, but 
 is somewhat more regular and earlier in males than in 
 females. There is also a very small variation which 
 depends upon the state of distension of the stomach. 
 
 As a rule the cardia lies slightly higher in females 
 than in males. 
 
 The surface markings for the oesophagus in the adult 
 may be expressed in a general manner as follows : — 
 
 Front, from the cricoid cartilage to a point on the 
 seventh costal cartilage of the left side 2*5 cm. from the 
 median plane. 
 
 Back, from the spine of the sixth cervical vertebra in 
 the middle line to the left side of the spine of the eleventh 
 - dorsal vertebra. 
 
 Allowance must be made, however, for the individual 
 differences already mentioned. (For further information 
 see Kolster (192).) 
 
 Practically the only curve shown by the oesophagus 
 in an ^c-ray examination during life is an antero-posterior 
 ■one which corresponds with the curve oi the vertebral 
 
44 THE (ESOPHAGUS 
 
 column. In the cadaver it is seen that from its com- 
 mencement to the cervico-dorsal . junction the gullet 
 inclines somewhat to the left. It again reaches the 
 middle line at the level of the disc between the fourth and 
 fifth dorsal vertebrae. This level is indicated on the 
 surface by the angle of Ludwig between the manubrium 
 and the body of the sternum. From this point down- 
 ward the gullet again passes slightly to the left to reach 
 its termination at the cardia. 
 
 In the neck the gullet lies in front of the bodies of 
 the lower two cervical vertebra, and has the trachea as 
 a ventral relation. On each side lies the carotid sheath 
 with its contained vessels and nerves and the sympathetic 
 chain immediately dorsal. The thyroid gland also over- 
 laps the oesophagus laterally, while the recurrent laryn- 
 geal nerve passes upward on each side between the 
 trachea and the gullet. Enlargements of the thyroid 
 gland may interfere with swallowing. As the gullet lies 
 slightly toward the left at the cervico-dorsal junction, 
 oesophagotomy in the neck is usually performed on this 
 side. In cervical oesophagotomy care must be taken of 
 the inferior thyroid artery behind the carotid sheath. 
 In the thorax the oesophagus also lies on the vertebral 
 bodies, inclining somewhat toward the left above and 
 below the fifth dorsal vertebra. In front of the oesopha- 
 gus above the fifth dorsal vertebra lies the trachea. 
 Below this point the pericardium forms an immediate 
 ventral relation to the gullet, and separates it from the 
 left atrium (auricle). Opposite the fifth dorsal vertebra 
 the left bronchus passes in front of the gullet, and may 
 be involved in or perforated by oesophageal carcinoma 
 in this situation. Here also the commencement of the 
 descending aorta courses over the left side of the 
 
THE (ESOPHAGUS 45 
 
 cesophclgus to pass downward as a left lateral and 
 somewhat dorsally-placed relation of the gullet. The 
 descending aorta prevents the left pleura from coming 
 into close relation with the oesophagus. The gullet is 
 clothed on its right side and partly on its dorsal aspect 
 by the parietal layer of the right pleural sac, from the 
 fifth dorsal vertebra as far as the diaphragm, the oesopha- 
 geal opening in which is usually stated to lie opposite 
 the tenth dorsal vertebra. The intimate relation of the 
 gullet to the left bronchus, aorta and right pleural sac at 
 the level of the fifth dorsal vertebra is very important 
 in view of the occurrence of oesophageal carcinoma at 
 this site. Such a growth may involve or ulcerate into 
 any of the three cavities with disastrous results. The 
 aorta may be the seat of an aneurysm which ultimately 
 leaks into the gullet. Immediately surrounding the 
 oesophagus is the cellular tissue of the superior and 
 posterior mediastina, which may be the site of a fatal 
 cellulitis or of a localised abscess resulting from an 
 oesophageal lesion. On each side of the thoracic oeso- 
 phagus lies the vagus nerve, which forms the oesophageal 
 plexus in the pvosterior mediastinum. In the lower part 
 of the thorax the left vagus comes to lie on the ventral 
 aspect of the gullet, while the right vagus inclines toward 
 the dorsal surfa,ce. 
 
 F"or operative purposes the relations of three other 
 structures are important. The azy gos vein ascends on 
 the right side of the gullet to the level oTthe fifth dorsal 
 vertebra, where it passes forward above the root of the 
 right lung to terminate in the superior vena cava. 
 Between the azygos vein and the gullet lies the th oracic. 
 duct, which gradually inclines toward the middle line 
 to lie dorsal to the oesophagus in the adjacent parts of 
 
46 THE (ESOPHAGUS 
 
 the posterior and superior mediastina. It ultimately 
 reaches the left side of the gullet at the root of. the neck. 
 Last, on a posterior plane lie the sympathetic chains, one 
 on each side, ventral to the necks of the ribs. 
 
 Certain anomalies, when they occur, may present an 
 important relation to the oesophagus. These are' acces- 
 s pry thyroid glands lying dorsal to the gullet, and an 
 abnormal right subclavian artery arising from the left 
 portion of the aortic arch and passing to the right. The 
 latter structure may present a ventral or dorsal relation 
 to the oesophagus, passing between it and the trachea 
 or vertebral column (166). 
 
 If a pe rioesoph ageal, absce ss exists in the dorsal region, 
 yet does not extend below the level of the third dorsal 
 vertebra, Kocher advises that cervjeal. medisstinotomy 
 be performed. Both heads of the sternomastoid are 
 divided. If the incision is made on the left side, one 
 proceeds behind the sterno-clavicular articulation along 
 the lateral aspect of the vessels of the neck. If on the 
 right side, the abscess is reached between the carotid 
 artery and the internal jugular vein. 
 
 In dorsal m ediast i notom y Bryant believes in perform- 
 ing the operation on the left side if the oesophagus above 
 the level of the aortic arch is to be reached. The aortic 
 arch corresponds on the back with the spine of the fourth 
 dorsal vertebra. If below this level but above the ninth 
 dorsal vertebra, Bryant would do the operation from the 
 right side. Rehn and Potard point out that the imporT 
 tant relation is the aorta, which is best avoided by 
 operating from the right side. The wrapping of the 
 pleura round the oesophagus on this side is of little 
 consequence, for injury to the pleura, as pointed out by 
 Heidenhain, is not a matter to cause anxiety. In doing 
 
THE (ESOPHAGUS 47 
 
 the operation it is necessary to watcli for the azygos vein, 
 for the vagus nerve and for the sympathetic chain, the 
 last of which, at this level, lies close to the lateral aspect 
 of the vertebral bodies. 
 
 Below the level of the ninth dorsal vertelara, the 
 oesophagus is too deep to be reached without difficulty. 
 
 The thoracic oesophagus between the levels of the fifth 
 and ninth dorsal vertebrae can be reached by traversing 
 the pericardium. Jaboulay's method for doing this is 
 to incise the ventral wall of the pericardium throughout 
 its whole length and to piish the heart aside. The gullet 
 may also be reached by a trans-pleural operation. 
 
 Sauerbruch's method is to make an incision in the 
 third right intercostal space to reach the oesophagus 
 above the root of the right lung (fifth dorsal vertebra). 
 To reach the lower oesophagus he makes the incision in 
 the fourth or fifth left space. In performing resection 
 of the thoracic oesophagus^ Sauerbruch states that the 
 vagi must be carefully avoided (but see p. 107). 
 
 (Further information on oesophageal operations is to 
 be obtained from Kocher (191).) 
 
 The oesophageal orifice of the diaphragm in the adult 
 is usually at the level of the ninth dprsar spine. 
 
 The standard measurements of different sites in the 
 gullet from the upper incisor teeth are the following : — 
 
 Commencement, 15 cm. (6 in.). 
 Crossing of left bronchus, 22 cm. (9 in.). 
 Diaphragmatic opening, 35-37 cm. (14-15 in.). 
 Cardiac orifice, 40 cm (16 in.). 
 
 All of these, but especially the last two, are liable to 
 considerable variation. 
 
 The distances along the oesophagus from the upper 
 
48 THE CESOPHAGUS 
 
 incisor teeth to the levels of the various dorsal spines 
 are thus given by Kocher (191) : — 
 
 I St dorsal spine 8 in. 
 
 and „ . „ ..., 8|in. 
 
 3rd „ „ 9iin. 
 
 4th „ „ ... loiin. 
 
 5th „ „ II in. 
 
 loth „ „ iSi.in- 
 
 One has only to compare this table with the previous 
 one to see how very unsatisfactory are all arbitrary 
 measurements. 
 
 The lumen of the oesophagus in the neck is compressed 
 dorso-ventrally to form a transverse slit. In the thorax 
 the lumen is more circular. This is said to be due to 
 the negative pressure in the chest. 
 
 The calibre varies in different situations. It is nar- 
 rowest at the commencement, where indeed it forms the 
 most constricted part of the alimentary canal (20). Other 
 narrow places in the oesophagus are at the level where 
 the left bronchus crosses the organ, and where the gUllet 
 traverses the diaphragm. The former of these sites is 
 indicated on the chest wall by the angle between the 
 manubrium and body of the sternum, and on the back 
 by the fourth dorsal spine. The topography of the 
 latter site is, ventrally, the xiphoid process, and dorsally, 
 the overlapping ninth thoracic spine. Mehnert (232) 
 cites as many as thirteen constrictions in the oesophagus, 
 but these, no doubt, are due to physiological waves of 
 peristalsis fixed in death. Mehnert concluded that the 
 average minimuin diameter of the gullet is about 14 mm., 
 but that it may be reduced in a normal adult to 1 1 mm. 
 
 The site of the junction of the upper and the lower 
 
THE (ESOPHAGUS 41) 
 
 gullet lies practically at the bronchial constriction 
 throughout life. In adults and children, foreign bodies 
 are liable to lodge there. Two cases of the presence of a 
 coin in the iwsophagus are recorded bv Haslam. Thus in 
 one of these, a child aged five years, the coin could be 
 seen by radioscopy to lie at the level of the sternal end 
 of the second costal cartilage (angle of Ludwig). In the 
 other, a child aged three years, the coin could be plainly 
 seen behind the upper part of the manubrium (129). 
 
 The diameter of the oesophagus below the constriction 
 at the level of the bronchus is often much greater than 
 the diameter above this level even in quite normal bodies. 
 This is so marked that one may distinguish an upper 
 and a lower gullet, which, furthermore, present marked 
 differences in the muscular coat, the upper gullet muscu- 
 lature being striped, while that of the lower gullet 
 consists of unstriped fibres. Mehnert cites a case in 
 which the lower gullet possessed a diameter double (i.e., 
 37 mm.) that of the upper oesophagus {23,2). 
 
 The dilatation of the lower gullet is better marked in 
 apes than in man, and is stated to be absent in the foetus, 
 although I have seen indications of its presence in late 
 foetal life. According to Cunningham it appears only 
 when the oesophagus is functionally active (77). The 
 dilatation was called by Cunningham the phrenic 
 ampulla. Luschka, Blasius and others have written 
 concerning this portion of the oesophagus, the former 
 having mentioned its occurrence in " ruminating men " 
 (J19). It is stated to consist of the last 3-4 cm. of the 
 oesophagus above the diaphragm. A similar instance 
 has been recorded by Keith and Wood Jones as a hernia 
 of the cardiac part of the stomach (186). This peculiar 
 formation of the lower gullet has been discussed by 
 
50 THE (ESOPHAGUS 
 
 Strecker under the title of Vormagen (319X ^ t^*""^ which 
 is undesirable in • consequence of its being used' with 
 different meanings' by various writers. 
 
 The exact significance of the lower gullet is not yet 
 fully understood. Indeed it would seem that it presents 
 different characters and functional value in different 
 individuals. In cardiospasm it frequently becomes 
 greatly distended, and in some cases of so-called gaseous 
 distension of the cardiac end of the stomach, it is 
 probable that the palpitation is due in part to the 
 presence of gas in the lower gullet in virtue of its position 
 relative to the left atrium. The occurrence of distension 
 in this portion of the gullet can more readily affect the 
 heart's action than can the presence of gas in the 
 stomach. So important may the lower gullet become in 
 clinical work that Strecker pleads for its inclusion in the 
 stomach' system. Rupture of the wail of the healthy 
 oesophagus is very rare, but when it does occur, the wall 
 gives way just above the diaphragm (335). 
 
 In structure the oesophagus is a muscular tube, pre- 
 senting an outer coat of longitudinal fibres and an inner 
 coat composed of circular fibres. 
 
 The short intra-abdominal portion possesses a serous 
 covering of peritoneum. The right side and part of the 
 dorsal aspect of the thoracic portion are covered by the 
 serous parietal layer of the right pleural sac. 
 
 In the upper gullet both muscular coats are composed 
 of striped fibres. The circular bundles are continuous 
 with those of the inferior constrictor. The longitudinal 
 fibres form two bundles more or less lateral in position 
 in the upper part of the tube, and are attached to the 
 cricoid cartilage as a fixed point (i). There are weak 
 places where the muscular fibres are few, in V-shaped 
 
THE (ESOPHAGUS 51 
 
 areas just below the inferior constrictor behind and the 
 cricoid cartilage in front. 
 
 Associated with these weak places is the occasional 
 presence of hernial pouches or diverticula at the upper 
 end of the gullet. As a rule, the pouch is on the dorsal 
 wall, and when distended with contents, it may block the 
 passage of food along the cesophagus. A pouch in this 
 situation may sometimes be identified by x-raj examina- 
 tion (140). According to Butlin the condition is more 
 frequent than has been supposed, and becomes clinically 
 important, as a rule, in men beyond the age of forty (45). 
 
 According to Killian, the globus hystericus is caused 
 b}' the spasmodic contraction of the circular fibres at the 
 upper orifice of the oesophagus, and is the chief cause of 
 the diverticulum just mentioned (189). A certain thicken- 
 ing of circular muscular fibres at the commencement of 
 the oesophagus forms a functional sphincter, and except 
 in swallowing, keeps the orifice of the gullet closed by 
 approximating, the dorsal wall to the cricoid cartilage. 
 According to Killian, this "sphincter," like the cardia, 
 contracts through the influence of the sympathetic nerves. 
 Relaxation is brought about by the action of the vagus. 
 
 A diverticulum is occasionally found on the ventral 
 wall near the bifurcation of the trachea, and is stated to 
 be due to traction on the gullet consequent on the cicatri- 
 sation of adhesions to inter-tracheo-bronchial lymph 
 nodes. 
 
 One other malformation of the oesophagus may be 
 mentioned besides the diverticula. This is produced by 
 abnormal conditions of the tracheo-cesophageal septum. 
 The trachea and bronchi are developed from a groove 
 in the ventral wall of the cesophagus, and are ultimately 
 separated by lateral ridges which meet and divide off 
 
52 THE (ESOPHAGUS 
 
 the groove from the dorsal part of the oesophagus ; the 
 latter becoming the true gullet. These riilges may, 
 however, pass dorsalward and shut off a small pocket 
 above from a lower tube which represents both trachea 
 and oesophagus. Hence food in such cases can only 
 reach the stomach by passing along the common tube, 
 which represents trachea and oesophagus combined. The 
 condition is incompatible with life, and has been dis- 
 cussed by Keith and Spicer (185). 
 
 In contradistinction to that of the upper oesophagus, 
 the musculature of the lower gullet is composed of 
 smooth fibres. The transition between the two forms of 
 musculature occurs in the heart region, and in this 
 respect the oesophagus of man corresponds with that of 
 the' cat (262). In considering the results of experiments 
 on the oesophagus of animals in relation to homo, one 
 must always .bear in mind the different anatomical 
 characters of the oesophagus in the various laboratory 
 animals. In the dog, for example, the musculature of 
 the gullet is striated thr6ughout its length, and thus 
 differs from that of the cat and of homo. 
 
 The oesophagus exhibits muscular tendrils, which pass 
 from its walls to neighbouring structures, vertebrae, 
 aorta, bronchi and pleural sac. Some of these tendrils 
 are grouped together to form definite bundles as in the 
 case of the broncho-oesophageal and the pleuro-oesopha- 
 geal muscles. Of these the latter connects the gullet 
 with the left pleural sac and is said to be constant; 
 These tendrils consist of smooth muscle or elastic tissue, 
 and spring from the longitudinal muscular coat of the 
 gullet. They are homologous with similar fibres found 
 throughout the mesentery of the small intestine. 
 
 At the termination of the oesophagus there is a slight 
 
THE CESOPHAGUS 53 
 
 reduplication, of circular muscular fibres which forms a 
 rudimentary sphincter. Regurgitation from stomach to 
 oesophagus is prevented by the sharp angle at the cardiac 
 orifice and by the muscular tissue of the diaphragm in 
 addition to the action of the so-called cardiac sphincter 
 just mentioned (150). 
 
 The mucous membrane of the oesophagus is rose- 
 coloured during life. It presents longitudinal rugas, 
 which are much better marked in the cadaver than in the 
 living. It is lined by stratified squamous epithelium- 
 The presence or absence of glands in the mammalian 
 oesophagus is apparently connected with the chemical 
 constitution of the food rather than with its physical 
 character. Often demilunes are present. Hence serous 
 secretion occurs as well as mucous. In man there is 
 great variability in the number of glands, with cyst 
 formation and atrophy, which are interpreted by Goetsch 
 as a suggestion of the gradual disappearance of oesopha- 
 geal glands (114). In this respect man again resembles 
 the cat which possesses no glands rather than the dog 
 which has many glands throughout the length of the 
 gullet. In man the oesophageal glands are more 
 numerous as a rule in the lower gullet (301). Schaffer 
 has claimed an amylolytic action for the glands in the 
 lower gullet (302). 
 
 The vascular supply of the oesophagus presents no 
 points of clinical significance other than the dilatation 
 of veins near the cardia, which will be considered in the 
 chapter on the stomach. 
 
 The lymphatics of the cervical portion of the gullet 
 pass to the .substernomastoid nodes. Those of the 
 thdracic portion drain into the mediastinal (perioesopha- 
 geal) nodes. The nodes along the lesser curvature of 
 
54 THE OESOPHAGUS 
 
 the stomach extend in a chain continuous with those of 
 the posterior mediastinum through the oesophageal, 
 orifice in the diaphragm. 
 
 The lymphatic network of the cardiac portion of the 
 .stomach is continuous with that of the lower gullet (272). 
 On the other hand, there is no corresponding free com- 
 munication between the lymphatic plexuses of adjacent 
 parts of the pharynx and upper gullet (272). 
 
 The oesophagus is supplied by branches from the 
 glossopharyngeal and vagus nerves, and also by sym- 
 pathetic filaments. According to Head, most of the 
 .sympathetic fibres going to the thoracic oesophagus arise 
 from the fifth dorsal segment, but this part of the gullet 
 receives in addition fibres. from the sixth, seventh and 
 eighth dorsal segments (133). This explains the referred 
 pain produced by oesophageal lesions in the area 
 supplied by the fifth dorsal spinal nerve. The vagus is 
 the tonic nerve, and the glossopharyngeal the tonic 
 inhibitory nerve to the gullet. By the influence of the 
 vagus the normal tone of the oesophagus is maintained, 
 and waves of peristalsis are produced. The severing of 
 both vagi results in complete temporary paralysis of the 
 oesophagus. The animal used in this experiment was the 
 ■cat, the oesophagus of which corresponds closely to that 
 of homo, as already indicated. After an interval of a 
 day or two complete peristaltic activity was restored in 
 the lower gullet; the upper oesophagus remaining 
 paralysed. Cannon investigated the conditions in the 
 monkey {macacus rhesus) as well as in the cat, with 
 similar results. The lower gullet, the wall of which is 
 composed of smooth muscle fibres, is capable of 
 .exhibiting peristaltic waves in the absence of extrinsic 
 jiervous mechanism. Apparently the activity is roused 
 
THE (ESOPHAGUS 55 
 
 by local stretching of the oesophageal wall. The' capacity 
 for exhibiting tension wh^n stretched is ordinarily 
 maintained by vagus influences, but may be intrinsically 
 developed when these influences are lost. Similar 
 experiments in the dog and the rabbit do not give the 
 results obtained in the case of the cat. In these animals 
 the oesophageal wall consists throughout of striped 
 fibres (48). 
 
 The cervical oesophagus obtains its tonic nerve supply 
 from the recurrent branches of the vagus. Hence if 
 these nerves are left intact in the above experiments, 
 food is still normally passed as far as the commencement 
 of the thoracic oesophagus. 
 
 The capability of development in the lower gullet of 
 peristalsis independent of extrinsic nerve influences 
 enables the operation of partial oesophagectomy to be 
 performed without a consequent paralysis resulting in 
 stagnation of food in the gullet and stomach (see also 
 p. 107). 
 
 The glossopharyngeal nerve, as already mentioned, 
 exercises a -tonic inhibitory influence on the gullet. If 
 this nerve is cut, the oesophagus undergoes temporary 
 tonic contraction. Radiographic examination shows 
 that rapid peristalsis occurs in the upper portion of the 
 oesophagus, while slow peristalsis only is exhibited by 
 the lower gullet. This is to be' expected from the 
 character of the muscular fibres in the two parts. 
 
 Food passes through the oesophagus in from four to 
 nine seconds (4^/5 to 8^/5 seconds. Hertz). Half of this 
 period is occupied by the passage of food from the lower 
 gullet into the stomach (141). . According to Hertz, the 
 first food sound is produced by the impact of fluid 
 against the dorsal pharyngeal wall, or the contraction of 
 
56 THE (ESOPHAGUS 
 
 the muscles in swallowing a mass of food (142). The 
 secojid sound, as a rule, is heard only after the swallowing 
 of fluids. It occurs occasionally after sohds have been 
 taken, but this is probably due to the bolus being 
 semi-fluid through admixture with saliva. It occurs 6"7 
 seconds after swallowing, and is heard in maximum 
 intensity through the stethoscope placed against the back 
 to the left of the ninth dorsal spine, that is to say, at 
 the level of the oesophageal orifice in the diaphragm. 
 As the second sound is heard only after all trace of fluid 
 has left the oesophagus, its explanation is difficult. 
 Hertz suggests that it may be due to the forcing of gas 
 from the stomach into the gullet in consequence of the 
 raised pressure in the former and the lower pressure in 
 the latter organ (142). 
 
 The function of the circular muscular fibres at the 
 lower extremity of the gullet are (i) tonic contraction, 
 (2) rhythmic alternate contraction and relaxation. 
 
 Stimulation of the vagus results in inhibition of the 
 "cardiac sphincter" with subsequent increase in tone. 
 There is, however, some evidence to show that the cardia 
 has a sympathetic supply which causes relaxation (48). 
 
 A number of successive swallows will cause relaxation 
 of the cardia. Relaxation with contraction of the 
 stomach in the dog occurs also when the intragastric 
 pressure rises to 25 cm. of water (188). 
 
 When the cardia is irritated mechanically or chemi- 
 cally, the tonic contraction of the "sphincter" is 
 increased and cardio-spasm occurs. When this condition 
 is present, cold drinks and carbonated water have greater 
 difficulty than warm water in entering the stomach (237). 
 
 Normally the rather low degree of tonic contraction of 
 the cardiac ring is assisted in the locking of food in the 
 
THE (ESOPHAGUS 57 
 
 Stomach by local mechanisms. Just as the presence of 
 acid in the duodenum results in the closure of the pyloric 
 sphincter, acid contents in the cardiac sac may keep the 
 cardia closed (48). With deficiency of hydrochloric acid 
 in the stomach, there is a corresponding relaxation in 
 the cardiac ring. For this reason certain consumptives 
 easily regurgitate gastric contents during a coughing 
 bout (234). The peristaltic waves of the lower gullet 
 assist in retaining food in the stomach. In the intervals 
 of gastric digestion and during the night, relaxation of 
 the cardia is more marked. Kast observed that after 
 the night's sleep the bad taste in the mouth, and the 
 coating of the tongue in gastric disturbances are pro- 
 duced by the return of partly digested bits of food, 
 leucocytes and epithelial cells along the oesophagus 
 through a relaxed cardia. These are spread to the mouth 
 by the pump action of the diaphragm and the intra- 
 cesophageal alterations of pressure produced by respira- 
 tion and the heart beat (172). There is no antiperistalsis 
 in the oesophagus. 
 
 As Cannon points out, the coated tongue is found 
 especially in cases of abnormal fermentation of gastric 
 contents, which results from deficient hydrochloric acid. 
 This is precisely the condition for a relaxed cardia. 
 
 The eructation of gas with regurgitation of fluid is 
 produced by the effect of the gas in keeping acid contents 
 away from the stomach wall in the region of the cardia. 
 The cardia relaxes and permits the passage of gas, while 
 acid fluid may also escape before the " sphincter " again 
 closes. Attention has already been called to the possibly 
 important effect upon the heart which results from the 
 presence of gas in the lower gullet, especially in condi- 
 tions of extreme weakness. 
 
58 THE (ESOPHAGUS 
 
 Sensations in the oesophagus may be summarised in 
 •the following manner. The gullet has no tactile sensi- 
 bility. Carminatives, hydrochloric, lactic and acetic 
 acids produce no sensation in it. The oesophagus is 
 sensitive to thermal stimulation. Indeed the sensations 
 of heat and cold experienced in the epigastrium on the 
 swallowing of hot and cold fluids respectively are 
 produced in the lower part of the oesophagus. Alcohol 
 produces a burning sensation in the gullet. Heartburn 
 may be produced by the regurgitation of the alcoholic 
 products of fermentation into the lower gullet through 
 a relaxed cardia (138). 
 
CHAPTER VI. 
 
 The Stomach. 
 
 When seen in the operating theatre or post-mortem 
 room, the stomach frequently presents the appearance of 
 a saccular viscus. This does not represent the normal 
 condition during life. It is the result of atony in the 
 
 Pig. 6. Tracing of normal empty stomach from cadaver emtalmeJ 
 with formalin. i • n' 
 
 The typical narrow tubular appearance of the empty stomach is well 
 seen. 
 
 59 
 
6o THE STOMACH 
 
 muscular tissue of the stomach wall (12). On occasion, 
 however, the normal shape of the stomach as observed 
 in jc-ray examinations is preserved at autopsy ; it is most 
 likely to be encountered in post-mortems conducted 
 within a very short time after death has occurred. Such 
 a stomach was figured recently by Stopford (318). The 
 organ presents a shape like the letter J. The greater 
 part of the stomach is contracted to form a narrow tube. 
 
 Fig. 7. Tracing of normal distended stomach from cadaver embalmed 
 with formalin. 
 
 Comparison with fig. 6 shows that on distension of the stomach the 
 greater curvature does not descend to any great extent ; the organ distends 
 laterally through the burrowing of the greater curvature between the 
 layers of the greater omentum. 
 
THE STOMACH 6 1 
 
 At the upper end of the longer limb of the J, is a small 
 saccular portion distended by the gas which it always 
 contains (Magenblase). 
 
 The J-shaped stomach occurs in about 80 per cent, of 
 adult individuals. Groedel calls it the syphon-form. He 
 distinguished descending and ascending limbs, with an 
 intermediate " Magensac " corresponding to the pyloric 
 vestibule, to which reference will be made later. Groedel 
 further points out that the form of the stomach depends 
 in part upon the position of the body. The organ 
 presents a syphon-form if the patient is standing erect, 
 while it assumes a sandal-shape, when the individual is 
 in the recumbent posture (117). The stomach is observed 
 in its usual and most natural working position if the 
 patient is examined standing up. Many variations in 
 both site and form occur in the normal organ, and for 
 this reason exact measurements cannot be given. The 
 descending limb always lies to the left of the middle 
 line; it is placed almost vertically when looked at from 
 the front, although if observed from the side it will be 
 seen to be directed somewhat forward. In many cases 
 there is a slight inclination to the right. The shadow of 
 the lesser curvature, as pointed, out by Rieder, frequently 
 coincides with the left border of the shadow cast by the 
 Vertebral column (284). The ascending limb (pyloric 
 canal) usually lies to the right of the middle line in x-ray 
 examinations. It may, however, lie to the left of the 
 middle line, especially when the caecum and ascending 
 colon are distended with gas. The position of the 
 stomach is much influenced by gaseous distension of the 
 proximal colon or splenic flexure. According to Groedel, 
 two-thirds of the magensac (pyloric vestibule) lie to the 
 left, and one-third to the right of the middle line (117). 
 
62 • THE STOMACH 
 
 In most individuals, the pylorus does not form the lowest 
 portion of the stomach as was stated to be the case by 
 Holzknecht (152). The stomach is movable round an 
 axis which passes through the cardia and the pylorus. 
 Rieder further points out that the most dependent 
 portion of the stomach in females may be considerably- 
 lower tha,n in males, and that the site and form of the 
 organ are by no means stationary in any individual (284). 
 The slight differences to be noted between the account 
 given by Stopford and those quoted from Rieder and 
 Groedel are accounted for by the fact that whereas 
 Stopford 's example was a practically empty stomach, 
 the organs examined in life by the two latter authors 
 were of necessity partially filled with bismuth-containing 
 food. That the presence of bismuth in the stomach has 
 no effect in producing distortions in the shape of the 
 organ has been shown by Groedel and Hasse in their 
 experimental feeding of powdered bone instead of 
 bismuth to the patient. The sc-ray appearances were 
 exactly similar whichever of these substances was used 
 (99). A less frequent though still normal form of 
 stomach is that known as the Holzknecht type, or 
 coisihorn stomach. In this variety (20 per cent, of 
 individuals) the pylorus is the lowest part of the organ. 
 There is no sharp distinction between the normal 
 organ and a pathological stomach. Neither relative 
 enlargement of the pyloric vestibule nor the size of the 
 stomach can be depended upon for diagnosis of a 
 pathological state. There is a gradual progression from 
 the normal to a pathological form without the develop- 
 ment of a new type (117). The form of the normal 
 stomach is not by any means constant, and it frequently 
 requires considerable experience to decide whether a 
 given organ is normal or not. 
 
THE STOMACH 6^ 
 
 Some general directions for the recognition of the 
 normal organ will be given later. 
 
 Recently there has been much controversy over what 
 is to be considered the " normal " subdivision of the 
 stomach. The views of different writers have been 
 biassed by their methods. Some have occupied them- 
 selves solely with foetal stomachs ; some with post- 
 mortem appearances of the adult organ; others again 
 have based their descriptions upon x-ray examinations. 
 These partial investigations have resulted in the descrip- 
 tion as normal of a variety of appearances. Wernstedt 
 regards the time-honoured simple saccular stomach of 
 the older anatomists as the real shape of the organ, and 
 classes all other appearances as " contraction forms " 
 (341). Paterson, going to the other extreme, regards the 
 stomach as being normally a four-chambered organ (267). 
 The recent article by Schwalbe gives the inost complete 
 account of the stomach, and is based on the observation 
 of material from foetus, child and adult; the x-ray 
 appearances of the living organ being carefully har- 
 monised with the condition of the organ in the dissecting 
 room and post-mortem theatre. Schwalbe regards the 
 stomach as consisting essentially of two portions : — 
 
 (a) the saccus digestorius; 
 
 (b) the canalis egestorius. 
 
 Of these the saccus digestorius further presents a sub- 
 division into : — 
 
 (i) a saccus cardiacus; 
 
 (ii) a corpus ventriculi or tubus gastricus. 
 The canalis egestorius (which Schwalbe also terms the 
 pars pylorica) may present a dilated portion correspond- 
 ing to the Magensac of Groedel and a more contracted 
 portion, the pyloric canal (305). 
 
64 THE STOMACH 
 
 Reference to the. accompanying figure will rendef more 
 clear the somewhat complicated nomenclature of the 
 stomach. 
 
 The extreme upper portion or dome of the cardiac sac 
 is formed by the fundus proper.' This is always dis- 
 tended with gas and is known as the Magenblase. 
 
 Fig. 8. Tracing of hypothetical stomach to illustrate the nomenclature. 
 
 A, saccus digestorius ; B, canalis egestorius (pars pylorica), (i) saccus 
 cardiacus, (ii) corpus ventriculi or tubus gastricus ; b, magenblase ; s, 
 magensac or pyloric vestibule ; p, pyloric canal ; P, pylorus ; I, incisura 
 angularis ; U, sulcus intermedius ; D, Duodenal cap or bulb. 
 
 The fundus proper merges insensibly into the main 
 portion of the cardiac sac, although occasionally a slight 
 indentation of the greater curvature may indicate the 
 junction of the two. 
 
 Beyond the cardiac sac the gastric tube (tubus gastri- 
 cus — Schwalbe), a more or less narrowed portion, is to 
 be observed. This leads to the Magensac of Groedel, 
 otherwise known as the pyloric vestibule of Cunningham 
 (77). The gastric tube becomes more capacious with 
 
THE STOMACH 65 
 
 the filling of the stomach, and may show smaller inden- 
 tations along the greater curvature. These are post- 
 mortem indications of the waves of peristalsis. It has 
 been suggested by Schwalbe that they are analogous but 
 not homologous with the sacculations found in the large 
 intestine. 
 
 As the gastric tube is the portion of the stomach in 
 closest relation to the upper pole of the left kidney, it is 
 possible that the latter organ may have some mechanical 
 relation to a dorso-ventral flattening of the walls with 
 consequent diminution of the lumen in the region of the 
 gastric tube. There would seem to be some basis for 
 such a suggestion in the radiographic appearances noted 
 in certain cases of gastroptosis (13). 
 
 Distal to the gastric tube, the stomach presents a 
 portion which may or may not be distended according 
 to its relative fulness, and for which Cunningham's term 
 pyloric vestibule would seem on the whole the happiest. 
 This is separated distinctly from the preceding portion 
 of the stomach by the incisura angularis on the lesser 
 curvaturel There is, as a rule, no special subdivision on 
 the greater curvature. But here a spasmodic constriction 
 may be present, and is thought by some writers to be a 
 constant feature of the stomach in certain stages of 
 digestion. It is especially emphasised by Gray (115). 
 The pyloric vestibule is succeeded by the pyloric canal, 
 a frequently contracted and tube-like portion of the 
 stomach with a length in the adult of 3 cm. It is marked 
 off from the pyloric vestibule by an indentation along 
 the greater curvature known as the sulcus intermedius. 
 There is no delimitation of the pyloric canal from the 
 pyloric vestibule on the lesser curvature. 
 • In addition to these subdivisions of the stomach, it is 
 
66 THE STOMACH 
 
 necessary to mention a peculiar formation termed by 
 Waldeyer the Magenstrasse (336). Retzius, in 1857, 
 pointed out tliat there is a portion of the stomach lying- 
 along the lesser curvature which can be separated off 
 from the remainder of the organ. Thus a kind of tube 
 is produced along which fluids and soft food may pass 
 direct to the pyloric part without necessarily going 
 through the cardiac sac, and the observation was con- 
 firmed by Luschka. The tube was supposed by Retzius 
 to be homologous with the oesophageal groove in the 
 stomach of ruminants (280). Sisson and the workers in 
 his laboratory, however, throw doubt upon this function 
 of the oesophageal groove of ruminants (310), believing 
 rather that the muscular limbs bounding the groove have 
 the function of drawing the oesophageal orifice and the 
 reticulo-omasal opening together. Kaufmann showed 
 that there is no indication of this Magenstrasse in the 
 empty stomach, but that it can be found in the artificially 
 contracted organ. How far contraction of the limiting 
 muscular fibres of this groove can cut it off from the rest 
 of the stomach is not at present known. Luschka stated 
 that a complete tube may be formed, and Kaufmann 
 mentions that he has no evidence to disprove Luschka's 
 assertion (174). 
 
 Cohnheim was the first to show (in the dog) that after 
 the stomach is filled, water swallowed by the animal does 
 not mix with the acid gastric contents, but flows by a 
 short path along the lesser curvature directly from the 
 cardia to the pyloric part, and even through the pylorus 
 into the intestine (65). But no shortening of the lesser 
 curvature is noticed during this act. 
 
 All the foregoing description has been based upon the 
 examination of adult stomachs. But the investigation of 
 
THE STOMACH 6f 
 
 the organ in the foetus and new-born child confirms the 
 principal points to which reference has been made. That 
 the form assumed by the living organ is not entirely due 
 to muscular contraction is shown by Lewis, who states 
 that the mucous membrane in the stomach of embryos 
 between lo and 45 mm. in length has already the 
 characteristic shape to which the other layers subse- 
 quently conform (202). Lewis also remarks that the 
 subdivision of the stomach into cardiac and pyloric 
 portions long ago described by Home (153) is well 
 marked, in embryos in which the muscl^ layers are 
 scarcely differentiated. While the Magenstrasse may be 
 shown as early as this, it is not to be found in all embryos 
 (202). The earliest embryonic stomachs merely contain 
 clot mixed with epithelial cells; later fluid contents 
 distend the organ, and in the' post-mortem appearance of 
 such a specimen, even the limitation between cardiac and 
 pyloric parts may be lost (embryo at 125mm. stage — 
 Schwalbe), the gastric tube formation being entirely 
 wanting (305). 
 
 In the stomach of the new-born child, the x-ray picture 
 and the post-mortem condition may closely resemble the 
 appearance illustrated by His's model of the adult 
 stomach. It. approximates to the sandal- form which is 
 seen in the adult when the recumbent posture is assumed. 
 The stomach of the infant, however, may present the 
 features already described as characteristic of the adult 
 organ. This does not indicate a tendency to.bilocular 
 formation, as was thought to be the case by Delamare 
 and Dieulaf(5 (80). Congenital bilocular stomach has 
 frequently been recorded and as often refuted. It was 
 stated by Moynihan to be invariably pathological (249). 
 Brook, however, recorded a case in which the isthmus 
 
68 THE STOMACH 
 
 possessed a muscular coat no thicker than that of any 
 other neighbouring portion of the stomach. The peri- 
 toneum, omenta and mucous membrane and the pylorus 
 showed no thickening, puckering, cicatrix or other 
 evidence of a pathological condition. For this reason, 
 Brook regarded congenital bilocular or hour-glass 
 stomach as a possibility (42). Moynihan admits that 
 the hour-glass stomach may have been congenital in 
 Brook's case (250). But the condition, in this instance 
 also, was probably pathological. The statement of 
 Lewis that the occurrence of an accessory pancreas on 
 the lesser curvature may account for a permanent 
 stricture between the cardiac and pyloric parts of the 
 stomach, is particularly suggestive in this connection 
 (202). 
 
 Alteration in Shape of the Stomach dependent upon Age, 
 Sex, Position, Digestion and other Factors. 
 
 The shape of the stomach varies considerably even 
 within normal limits, so much so that, as previously 
 stated, no measurements can safely be given for the 
 limitation of the normal organ. The portion which 
 alters least in shape (although even it changes its 
 position) is the pyloric canal. 
 
 The stomach in the infant approximates more to the 
 sandal-shape than to any other form mentioned. In view 
 of the relatively small capacity of the abdomen, the 
 comparatively large size of the liver, the distension to 
 a greater or less degree of the various portions of the 
 alimentary canal with gas, and because the action of 
 gravity has rjot yet been fully exerted in the erect posture 
 on the organ, the stomach does not present the syphon- 
 form, nor even the cowhorn-shape so typical of the adult. 
 
THE STOMACH 69 
 
 It is pressed high up in the abdomen under the dia- 
 phragm and liver by the other viscera. The pyloric part 
 is more horizontal than in the adult, and the incisura less 
 marked. The incisura is only formed toward the end 
 of foetal life through the bend in the lesser curvature 
 becoming sharper (305). The difference in extent between 
 the cardiac and the pyloric portions of the stomach, as 
 indicated by the site of the incisura angularis, is not so 
 marked in the new-born child as in the adult, and in the 
 former the condition seen is reminiscent of that in the 
 anthropoid apes (343). With the enlargement of the 
 abdomen, the relative decrease in size of the liver and the 
 increasing influence of the action of gravity, the stomach 
 assumes its characteristic adult shape.^ 
 
 The J- or syphon-form is more exaggerated, and all 
 parts of the stomach except the cardia tend to lie at a 
 slightly lower level in the adult female than in the male. 
 In the male the stomach is shorter and more obliquely 
 placed ; in the female it ' is more vertical, the proximal 
 limb of the J is longer, the pyloric vestibule broader and 
 the distal limb (pyloric part) shorter. Irregularities in 
 form are more common in females, particularly an 
 indentation in the proximal limb, said by Groedel to 
 correspond to the waist (117). These remarks refer, 
 naturally, to the radioscopic appearance of the stomach 
 when the patient is standi.ng erect. When the patient 
 is examined in the recumbent posture, both shape and 
 situation of the stomach are altered. The shape approxi- 
 mates to the sandal-type, .and the whole organ lies at a 
 higher level. The pylorus may be as much as 5 cm. 
 above the level at which it lies in the erect attitude. 
 
 I. The influence of gravity is on the abdominal organs as a whole, and 
 not on the several viscera individually. 
 
70 THE STOMACH 
 
 The examination of the stomach by radioscopy neces- 
 sitates the presence of some contents. Of the absolutely 
 
 Figs. 9, 10, II. Tracings from radiograms of the normal stomacli 
 partially distended with bismuth food. The duodenum and colon are 
 outlined where shadows are present. Compare with figs. 25, 26. 
 
 There is great variety in shape and position among stomachs which 
 can be classed as normal. Neither, within limits, indicates that the organ 
 is pathological. The text should be consulted for the evidence which 
 indicates the- normal or abnormal condition. In every normal partially 
 filled organ one can distinguish magenblase, cardiac sac, gastric tube, 
 pyloric vestibule, pyloric canal, pylorus and often the duodenal bulb. 
 There is a sharp demarcation at the pylorus between the contents in the 
 pyloric canal and the duodenal vestibule, although, on account of over- 
 lapping of the shadows, this is not always evident. 
 
 Fig. g. This illustration shows the relation which usually exists 
 between the stomach and the transverse colon. 
 
THE STOMACH 
 
 71 
 
 empty organ in the living, we have at present but little 
 information, and that not at first hand. 
 
 Fig. 10. Stomach pressed somewhat to the left by gas in the proximal 
 colon. The transverse colon lies in an erratic position above the pars 
 pylorica. 
 
 The positions of the two limbs of the stomach vary 
 with the state of distension of the small and large 
 intestines. The presence of gas in the hepatic flexure 
 tends to push all parts of the stomach to the left. On 
 the other hand; gas in the splenic flexure displaces the 
 stomach to the right. A distended small intestine may 
 press upward the greater curvature of the stomach, so 
 turning the organ round an axis which passes through 
 
72 
 
 THE STOMACH 
 
 the cardia and the pylorus (Schwalbe, 305)- This also 
 may occur from distension of the transverse colon with 
 gas (117). Presumably the empty stomach is tube-like, 
 with the exception of the fundus part of the cardiac sac 
 
 Fig. II. The pyloric vestibule is well held up by the fibres of the 
 Hufeisenschlinge. 
 
 (Magenblase), and the incisura angularis is less marked 
 than when the organ contains food. Schwalbe states 
 that the ventral wall is almost horizontal in certain cases, 
 and the pyloric part may even descend somewhat toward 
 the right. When the first portions of food are swallowed, 
 the mass passes down the lesser curvature into the 
 
THE STOMACH 
 
 73 
 
 pyloric vestibule in a continuous stream. This part of 
 the stomach enlarges; tl^e, cardiac fundus, with its 
 contained , gas, and , the pyloric, vestibule, now distended 
 wit;h food, are connected by the narrower gastric tube. 
 As more fqod enters th,e stomach, it. passes in "blobs " 
 through the contents of the pyloric vestibule to the 
 lowest pa,rt , of the prgan.-. ,The incisura angularis 
 
 Fig. 12. Tracing from radiogram of well filled normal stomach. • 
 Note that the pyloric ve.stibule has not descended to any great extent 
 in spite of the large amount of material which it contains. The stomach 
 distends laterally. Peristaltic waves are indicated by the indentations on 
 the greater curvature. 'The vertical height of the magenblase is practi- 
 cally the same in the filled organ as in the empty ong. 
 
74 THE STOMACH 
 
 becomes more marked, and the pyloric canal, at first 
 horizontal, becomes inclined upward and toward the 
 right. The lowest part of the pyloric vestibule does not 
 descend to any great extent. Waves of peristalsis 
 commence on the greater curvature and progress towards 
 the pylorus. As the stomach continues to fill, the 
 ventral wall becomes more obliquely placed, and the 
 gastric tube is gradually distended so that the longer 
 limb of the J-shaped stomach widens laterally, but does 
 not increase in length. The peristaltic waves commence 
 nearer and nearer the cardiac fundus on the greater 
 curvature. Sometimes spasm of the circular musculature 
 of the gastric , tube causes an hour-glass appearance of 
 the organ. This spasm can, however, be massaged 
 away in most instances in which it appears. The 
 Magenblase does not decrease in vertical height as the 
 Stomach fills: it merely 'broadens (see figs. 9-12). 
 The height of the transparent area of the Magenblase 
 remains almost invariably the same (3*0 cm.). The 
 ventral wall of the fully distended stomach is almost 
 vertical. 
 
 Throughout the process of digestion the pyloric canal 
 alters but little. As digestion proceeds, the most depen- 
 dent part of the pyloric vestibule rises so that finally the 
 pylorus itself may be the lowest part of the stomach. 
 The first part to empty is the pyloric vestibule (corpus, 
 ventr iculi), which gradually contracts again as food 
 passes onward until the typical gastric tube is once more 
 formed, with the air-distended cardiac fundus at the 
 upper end and the food-filled pyloric vestibule at the 
 lower end. Further references to the passage of food 
 through the stomach will be made later in the chapter. 
 
THE STOMACH 75 
 
 Situation and Relations of the Stomach. 
 
 The normal empty stomach is situated within the 
 limits of the left hypochondriac and the left half of the 
 epigastric regions. Only the pylorus and adjacent part 
 of the pars pylorica encroach in some cases on the right 
 epigastric region. The stomach probably does not 
 descend below the subcostal plane. When food is 
 present in the organ, it traverses the subcostal plane, so 
 that the lower part (pyloric vestibule) lies in the left 
 umbilical, or possibly the left lumbar region also, 
 descending as low as the umbilicus when the patient is 
 erect. Even the filled stomach is frequently found above 
 the subcostal plane when the individual is examined in 
 the recumbent posture. 
 
 In cases of gastroptosis the lower part of the pyloric 
 vestibule (greater curvature) descends below the level of 
 the umbilicus, and may even be found in the pelvis. In 
 the cadaver the pylorus is usually found at the right 
 side of the first lumbar vertebra (level of Addison's 
 plane). In the normal individual the pylorus in life is 
 shown by radioscopy to lie to the right of the second or 
 third lumbar vertebra in the erect posture, but rises 
 somewhat when the individual lies down; In gastro- 
 ptosis the pylorus may be found even as low as the 
 pelvis (223). A hypertonic condition of the stomach is 
 present, in some instances of gall bladder disease and 
 chronic appendicitis (140), and in duodenal irritation or 
 ulcer. It is rare in gastric ulcer (140). Hypertonus of 
 the stomach wall results in a higher position of the 
 pylorus, and a considerable elevation of the greater 
 curvature even in the erect position. 
 
 The cardia differs from the rest of the stomach in being 
 comparatively stationary in position. It lies as a rule 
 
76 THE STOMACH 
 
 on the left side of the body of the eleventh dorsal 
 vertebra, but its site is liable to individual variation (see 
 p. 43). It is lowered slightly in changing from the 
 horizontal to the erect position, and in general viscero- 
 ptosis. It lies, as a rule, about 10 cm. (4 inches) behind 
 the ventral body wall. 
 
 The relations of the stomach may be conveniently 
 grouped under three headings : — 
 (i) Above and in front : 
 
 Visceral surface of liver. 
 Ventral abdominal wall. 
 Fundus of gall bladder (in front of pyloric 
 
 portion). 
 Subhepatic channel of peritoneum intervenes. 
 
 (2) Above fundus : 
 
 Apex of heart. 
 
 Base of left lung. 
 
 Left dome of diaphragm. 
 
 Left subphrenic pouch of peritoneum intervenes. 
 
 (3) Below and behind : 
 
 Organs composing the stomach bed, i.e., the 
 following fi'om before backward : 
 (a) Transverse colon. 
 
 {b) Transverse mesocolon (separating stomach 
 from duodenum and commencement of 
 jejunum), 
 (c) Pancreas. 
 
 {d) Left crus of diaphragm, left adrenal, 
 
 upper part of left kidney, spleen (in this 
 
 order from right to left). 
 
 Middle subphrenic pouch of peritoneum 
 
 {bursa omentalis) intervenes. 
 
 Apart from malignant disease, fibrous stricture, and 
 
THE' STOMACH 77 
 
 pyloric Stenosis, which is a frequent thc^ugh unrecognised 
 cause, of gastric dilatation in young adults (2^), general 
 dilatation 'of the stomach may be produced by mechani- 
 cal obstruction of the duodenum (sefe p. rig) or the 
 pylorus. . In orle case operated upon by Burgess, gastric 
 distension was' due solely to mechanical obstruction of 
 the pyloric canal by pressure i from a dilated' gall bladder. 
 Emptying of the gatll bladder imrhediately relieved the 
 distension of the stomach (44). 
 
 Adhesions, which are common ' in peptic ulcer and in 
 carcinoma, may involve any 'of the orgkns miCntioned in 
 the table given abovei The more ijsual Viscera to which . 
 the stoniach is adherent in such cases are the liver, gall 
 bladder and' pancreas. 
 
 The relation 6f the stomach to the left kidney has 
 previously been mentioned. In certain cases, bor- 
 borygmi occur in the stomach. In sbme instances of 
 atonic stomach, riiore especially in those which possess 
 adhesions of the pyloric vestibule to 'adjacent parts, 
 Barclay has; observed that' by certain abdominal move- 
 ments air bubbles are sucked up through the narrowed 
 neck (gastric 'tube) of the stomach ' where it lies in 
 relation to the left kidney, and thus the curious rattling 
 sounds are produced (13). 
 
 Perigastric abscess may occur in any of the three 
 peritoneal subdivisions rnentioned. (For further details 
 see p. 26.) After evacuation or drainage of the abscess, 
 there is considerable danger of starvation oi ;the patient 
 if the interior 'of the stomach cornmunicates with the 
 abscess cavity into which food, tends to pass from the 
 stomach. 
 
 Reference has already been made to the stomach of the 
 infant. ' Soine fabts riegarding its relations and capacity 
 
^8 THE STOMACH 
 
 may be recorded here. At birth it is entirely hidden by 
 the great development of the left lobe of the liver and by 
 the transverse colon. This is characteristic only of the 
 first few days of life, when the capacity of the stomach 
 is about 35-43 cc. (i-i^oz.). During the first and second 
 weeks the increase in size of the stomach is very marked. 
 By the fifteenth day the capacity is almost doubled (75- 
 80 cc), and part of the ventral wall of the stomach has 
 come to lie in immediate relation to the abdominal wall. 
 The empty organ in the infant appears from dissection 
 to have practically the same position as in the adult. 
 Generally speaking, the levels of the cardia and pylorus 
 are those found in adult life. But the radiographic 
 picture of the food-filled stomach of an infant shows the 
 organ to be much more horizontally placed than in the 
 adult. 
 
 At the end of the first year the capacity of the stomach 
 is about 300 cc. (166, p. 276), but the amount of the 
 infant's meal does not correspond with this. It would 
 appear that some of the milk passes at once into the 
 intestine. 
 
 As previously stated, the size and capacity of the adult 
 stomach are so variable that reliable measurements can- 
 not be given. 
 
 Topography and Surface Investigation of the Stomach. 
 
 In mapping out the position of the stomach on the 
 surface of the body, due allowance must be made for sex 
 and age, position of the patient, state of distension of the 
 organ and other factors controlling the shape and 
 position. 
 
 The topography of the stomach when the body is 
 
THE STOMACH 79 
 
 placed horizontally on its back is given as follows : — 
 Cardia. 
 
 Front : Seventh left costal cartilage 25 cm. from the 
 median line. 
 
 Back : 2'5 cm. to the left of the eleventh dorsal spine. 
 Pylorus. 
 
 Front : at or to the right of the median line on a 
 horizontal plane midway between the suprasternal fossa 
 and the pubic symphysis (Addison's plane, see p. 5) 
 (2). This is three to four inches below the inf-rasternal 
 notch and midway between it and the umbilicus. 
 
 When the stomach is empty, the pylorus may lie in 
 the median line. As the organ becomes filled with food, 
 the pylorus travels, toward the right along Addison's 
 plane. With a very distended stomach, the pylorus may 
 be as mtich as 7'5 cm. to the right of the median line. 
 Occasionally the pylorus may be found to the left of the 
 median line (284). The causes of this have previously 
 been outlined. 
 
 Back : At a point on the level of the first lumbar spine 
 in, or less than 8 cm. to the right of, the median line, 
 according to the state of distension of the organ. 
 
 Lesser Curvature. This margin of the stomach is 
 indicated by a line joining cardia and pylorus, drawn 
 on the abdominal wall with a downwardly directed 
 convexity on which a point about 5 cm. to the left of the 
 pylorus represents the site of the incisura angularis. 
 
 The Fundus of the stomach lies under the left cupola 
 of the diaphragm. It reaches as high as the fifth inter- 
 costal space in the left lateral inguinal line. It rises a 
 little above and behind the surface marking for the apex 
 of the heart. 
 
 The Greater Curvatnire usually passes behind the inter- 
 
80 THE STOMACH 
 
 section of !Addison's plane with the left lateral inguinal 
 line, a point which coincides, as a rule, with the ninth 
 costar cartilage. , . 
 
 The lowest part of the greater curvature lies near the 
 median line, and extends down' to or 'a little above the 
 infra-costal plane, about 5 cm. above the umbilicus. 
 
 The iatiove described markings represent the outline 
 of the' stomach, as seen in the dissecting room and give 
 a fair indication of its delimita'tioh in "iradiog'raphic 
 examiiiatibins when the patient is recumbent ; they cannot 
 be utilised as giving ah accurate representation of the 
 stoniach when tlie patient is standing up.' 
 
 When the' stomach is examinee!' in an adult standing 
 erect, the pylorus and greater curvature are seen to 
 occupy a lower level. The cardia also descends but to a 
 less degree. The shape of the stomach more closely 
 approximates the syphon-forrfi. 
 
 In the erect attitude the previously given level of the 
 cardia may be retained, but other portions of the stomach 
 feq^iiire to be but'liried afresh. The fbllotving markings 
 are those for an adult with a moderately filled stomach : 
 
 The Pylorus. Front : At or a little to the right of the 
 median line, at the level of the infracostal plane. 
 
 Back : At or a little to the right of the median line, 
 between the' levels of the' second and third lumbar 
 vertebr^. 
 
 The pylorus in the female tends to lie at a slightly 
 lower level than in the male. 
 
 The Lesser Curvature presents a more aciite incisura 
 angularis as the syphon'-stiape of the stomach becomes 
 inore marked. 
 
 The Fundus rises to the highest point of the left cupola 
 of the diaphragm, which is 5 to 10 mm. above the inter- 
 
THE STOMACH 8 1 
 
 sectidrt'of the left lateral ifigflinal line with a line drawn 
 round the b'bd;^ at the level' of the lower end of' the body 
 of the' sternum' (Keith, see pv 9) (i77)'. ' ■ ' ■ 
 
 The Greater Curvature' descends as low as the umbili- 
 cus. This rfiost depdnddnt portion of the 'greater curva- 
 ture is foi^med'by' the pyloiric Vestibule. 
 
 Of the classic methods for' investigation of the stomach, 
 inspectidri is far the best. In many cases the outline of 
 the greater curvature may be seen, and occasionally 
 waives of jieristalsii 'passing albh'g' it can ' be . observed 
 even through the' thickness 'Of the abdbmihal wall. 
 
 If gastr'optosi's ' be present,' the' otitline of the lesser 
 curVatiii'e can be observed. In cases of marked gastro- 
 ptosis the abdominal wall above the umbilicus may be 
 actually scaphoid, the' stomach givi rig the lower abdomen 
 an abnormal prOniiheriefe. 
 
 In cases of gastroptosis the lesser curvature cdn usually 
 be' pfalpated through the abdOmiiial wall. In many 
 individuals the normal pyloriis. may be palpated if care 
 is taken to get 'the abdominal iHuscles relaxed. Percus- 
 sion arid auscultation are less accurate than the previously 
 mentioned methods of investigation (143). The real size 
 of the organ is hot indicated ; by the fornlfer method only 
 the area occupied by the gas present is butliried, and this 
 gives no information concerning the actual size of the 
 stomach (140). The Magenblase, which is so obvious 
 in the erect patient, disappears as such when the 
 individual lies dowri, because the gaS present in the 
 fundus 'comes ' to lie in the 'cardiac 'part' under the 
 abdoniinal wslll instead of uiider the' left dome of the 
 diaphragm. 
 ' The "so-called semtluwar' space of'Traube is a well- 
 known clinical surface area, which yields a deeply 
 
82 THE STOMACH 
 
 tympanitic note on percussion, and wliich depends for 
 its existence upon the presence of gas in the stomach. 
 The semilunar space is an area bounded below by the 
 left costal margin, above by the inferior border of the 
 left lung, to the right by the anterior margin of the left 
 lobe of the liver, and to the left by the anterior border 
 and anterior basal angle of the spleen. This tympanitic 
 area is crossed about midway between its upper and 
 lower limits by the costo-diaphragmatic line of pleural 
 reflection. It is diminished in its upper part by pleuritic 
 effusion, on the right by enlargement of the left lobe of 
 the liver, and on the left by enlargement of the spleen. 
 
 In certain cases of pyloric stenosis a highly tympanitic 
 area about 3 cm. in diameter is found over the pyloric 
 vestibule to the right of the median line near the site of 
 the pylorus. It is due to gaseous distension of the pars 
 pylorica (60). 
 
 The relation of the stomach to the transverse colon 
 can be demonstrated by filling both organs with bismuth 
 and attempting to separate them by palpation through 
 the abdominal wall. In the presence of dense adhesions 
 between the two organs, such as occur in carcinoma of 
 the body of the stomach, it is impossible to separate 
 them by this method (99). 
 
 The Structure and Functions of the Stomach Wall. 
 
 The Serous Coat. The stomach is almost entirely cov- 
 ered by peritoneum. On the ventral aspect of the organ 
 are the subhepatic channel and left subphrenic pouch of 
 the greater sac. On the dorsal aspect is the middle sub- 
 phrenic pouch (omental bursa) (lesser sac). Along the 
 lesser curvature the gastrohepatic and gastrophrenic 
 ligamients (lesser omentum) are attached. Along the 
 
THE STOMACH 83 
 
 greater curvature the lieno-gastric and gastro-colic 
 ligaments (great omentum) obtain attachment* In the 
 moderately distended organ, there is a small area to the 
 left and below the cardia which is devoid of peritoneum. 
 Here the stomach is in direct contact with, the diaphragm, 
 and occasionally also with the upper part of the left 
 kidney and the left adrenal gland (34). 
 
 Over the surface of the stomach the serous coat is 
 firmly adherent to the underlying muscular tissue. 
 Along the curvatures it is more loosely bound to the 
 muscularis, as the great vessels supplying the stomach 
 intervene between the two coats. When it fills with 
 food, the organ mainly enlarges along the greater curva- 
 ture, pushing its way between the approximated layers 
 of the great omentum. 
 
 The transverse mesocolon intervenes between the 
 stomach and the small intestine. HenCe in performing 
 gastro-enterostomy by the posterior method, one must 
 tear through the transverse mesocolon in order to 
 approximate the stomach and jejunum. 
 
 The Muscular Coat. 
 
 The muscular coat of the stomach is a complicated 
 structure. Generally speaking, there are three layers, 
 an outer longitudinal, a middle circular and an inner 
 set of fibres. But these are very unequally developed in 
 different areas of the stomach. The longitudinal fibres 
 are continuous with those of the oesophagus, and are 
 massed along the lesser iand greater curvatures.^ Those 
 which pass over the greater curvature become thin and 
 
 I. The longitudinal fibres are massed on the dorsal and ventral aspects 
 of the stomach alongside the lesser curvature, rather than along the 
 lesser curvature itself. 
 
84 The stomach 
 
 spread but over the fuftdus. Between the ctirvatures the 
 lorigitudihal fibres of the oesophag'uS spread out over the 
 vefttral and 'dorsal aSp'ectfe of the' st6ftia;chto f6rm the 
 outef 'oblique! coat of Stir6bker. In the region of the 
 gastric tube and 'the pyloric part, the longitudinal fibres 
 of 'the"greate'r curvature ar6 well devdoped. They are a 
 new set of muscular fibres- quitei independent of those 
 which gradually tapered off on the fundus. 
 
 In "the j-egion of tlie pyloric canal the longitudinal 
 fibres fbrm a complete coat ' rather thicker along the 
 greater than along the lesser ciirvature. A few of the 
 more superficiail' fibres are usually carried on to the 
 adjacent part of the duodenum, biit soon ' terminate and 
 give placfe to the longitudinal fibres of the duodenum 
 itself. The greater part of the longitudinal fibres pass 
 into the circular coat of the pyloric canal to terminate 
 among its fibres; some, however, even reaching the sub- 
 mucosa'. ' The circular fibres are most thickly massed in 
 the pyloric part ^nd in the gastric tube. They biecome 
 much less numerous toward the cardiac sac, on which 
 they thin out and disappear. Forssell described alternate 
 thickening and thinning of the circular muscular coat 
 over the. region of the gastric tube, but this observation 
 was not confirmed by Schwalbe. 
 
 There is no special thickening of circular, fibres to 
 form a middle sphincter. A longitudinal section of the 
 pyloric sphincter frequently shows a terminal triangular 
 mass of circular fibres at the greater and a rounded mass 
 at the lesser curvature; The circular fibres of the pyloric 
 sphincter are not continuous with those of the duodenum. 
 The latter are separated from the former by a hiatus of 
 connective tissue, which may in the adult be 3 mm. thick. 
 The duodenal circular fibres start on a plane internal to 
 
THE. s;roM^CH 85 
 
 tliat of the pyloric sphincter. The cirpuki; fijareg of the 
 pyloric canal are muqh more numerous than those, of -the 
 pyloric vesti]l:?ule along the greater, eurvatijr,^, Hence, the 
 sudden increase in thickness is well ma,rked at the sulcus 
 intermedius. , , 
 
 Descriptions of the arrangement qf the oblique .fibres 
 are frequently misleading, These fihres form a taenia 
 on each side of the, lesser curvature. The, two taeniae 
 blend with each other rouiid the left side of the cardiac 
 orifice, to present a horse-shoe-shaped appearance. The 
 taeniae, if followed toward the pyloric part, are found to 
 give off fibres which, bend toward the greater curvature 
 at an acute angle, and mingle with the fibres, of the 
 circular coat. At the level of the. incisura .angularis the 
 taeniae have disappeared, the whole of their fibres having 
 merged with the circular fibres. This, curious formation 
 of the so-called oblique fibres in the region of the lesser 
 curvature is . known to veterinary surgeons as the 
 Hufeisenschlinge. It forms the oespphageal groove, or 
 Magenstrasse, to which reference has previously been 
 made. It is entirely limited, to the cardiac part of the 
 stomach, i.e., it is not prolonged beyond the incisura 
 angularis. These fibres function physiologically as a 
 second and deeper longitudinal set, although they are 
 continuous with the circular fibres of the oesophagus, 
 and should, according to Schwalbe, be considered mor- 
 phologically part of the circular coat of the stomach- 
 
 The so-called oblique fibres of the fundus proper form 
 a thin and sparse layer encircling it parallel to its base. 
 The muscular coat of the cardiac sac, more especially 
 that of the fundus proper, is rudimentary, and has little 
 power of independent contraction. This portion of the 
 Stomach is subject to the contractions of the diaphragm 
 
S6 THE STOMAdH 
 
 iind abdominal walls as in respiration and vomiting; 
 The neighbourhood of the incisura angularis on the 
 lesser curvature is provided with a certain amount of 
 elastic tissue among the muscular fibres. In some 
 animals it forms a distinct plaque (Retzius), but as yet 
 its function is unknown. 
 
 The above account is mainly taken from the articles 
 Ijy Schwalbe (305) and Cunningham (77), to which 
 reference may be made if a fuller description is desired. 
 
 In hypertrophic stenosis of the pylorus, either or both 
 of the longitudinal and circular coats may be afifectedl 
 If the former alone is involved, there results a conical 
 lumen with great stenosis. If the latter only is affected, 
 a thick swelling is produced, but the lumen is not reduced 
 (289). The condition is not a single entity. Certain 
 instances are due to spasm of the muscular coat, as in the 
 case recently recorded by Davis (78). 
 
 Besides the congenital and infantile forms of stenosis, 
 there is a type found in young adults. Two cases were 
 recently recorded by Barling, one in a man of 27, the 
 other in a girl of 17 (17). For previous reference to this 
 subject, see Robson and Moynihan (289). 
 
 Movements. 
 
 The following synopsis of the movements of the 
 stomach is based on Cannon's account (48, Ch. V.). 
 
 Early in gastric digestion the greater curvature may 
 lie several centimetres below the umbilicus when the 
 patient is standing erect. Later it is drawn upwards, ■ 
 and the pylorus may even become the lowest point. The 
 stomach is not emptied by gravity. In an active alimen- 
 -tary canal, gravity has not enough influence to cause the 
 food to pass onwards. Even when the body is erect and 
 
THE STOMACH 87 
 
 a large opening connects the stomach, with the intestine, 
 food will not pass through the stoma into the bowel. 
 Nor is the stomach emptied by any form of syphon- 
 action, as Groedel imagined (117). The muscular 
 activity differs in the two parts of the stomach. Peri- 
 staltic waves take origin near the middle of the organ, 
 and progress toward the pylorus. As digestion pro- 
 ceeds, the pyloric part alters little. The first region to 
 decrease in size is the body of the stomach (gastric tube). 
 As food is discharged into the intestine, the circular 
 musculature of this middle region of the stomach 
 contracts tonically until a tube is formed with a full 
 cardiac sac at one end and an active pyloric vestibule at 
 the other. The circular muscular fibres of this part 
 (gastric tube) are collectively known to certain authors 
 as the transverse band or middle sphincter. Shallow 
 peristaltic waves pass along the gastric tube as the food 
 passes into it. The tube shortens slightly, and con- 
 tinues its peristaltic waves until all food has entered the 
 pyloric vestibule. The stomach is never completely 
 divided into two by the so-called transverse band in the 
 course of normal digestion, but by powerful stimulation 
 at this point, it may be cut in two to form an hour-glass 
 condition. 
 
 The peristaltic waves of the stomach never pass on to 
 the duodenum. They always cease at the pyloric ring. 
 This is what one would expect in view of the hiatus 
 between the circular muscular fibres of the two organs. 
 It is to be remembered that "peristalsis " in the stomach, 
 being a wave of contraction in circular fibres only and 
 accompanied by no advance ring of inhibition, is not a 
 true peristalsis (diastalsis) like that of the bowel. It 
 corresponds to the segmentation movements of the small 
 
88 ,THE, STOMACH 
 
 intestine, and is .a local ireflex dependent upon the 
 presence of pontejits, i,e„ ..intragastric pressure. (Cf. 
 " secondary peristalsis " of, the.cesophagu;s.) Stomachic 
 " peristalsis V, starts with the coming of food into the 
 organ, and ceases only when all food has passed on into 
 the duodenum., .When, the pylorus is closed, the peris- 
 talsis acts in thoroughly mixing the food and gastric 
 secretion, and reducing it from a lumpy coherent mass, 
 such as is present in the, cardiac sac, into a thin. fluid., 
 
 Antiperistaltic waves haye been observed in the 
 stomach, but their exact significance is not known. 
 They are held by some to indicate pyloric obstruction. 
 By others, however, this is, denied, and they are said to 
 occur with pyloric ulceration (gg). Antiperistaltic waves 
 start at the pylorus and progress, to the incisura angularis, 
 where they cease. In vomiting, the cardiac sac is 
 emptied by the action of, the diaphragm and abdominal 
 muscles. In, addition to peristalsis, the stomach adapts 
 itself to the contained food so that the intragastric pres- 
 sure is never raised. This pressure is much less at the 
 cardiac end than near the pylorus, the two parts of the 
 organ being different in function. In the adjustment of 
 intragastric, pressure, the abdominal reflex assists (see 
 p. ii). 
 
 Variations in Tone of the Musculature. 
 
 The two properties of the gastric musculature are : 
 (i) peristalsis; (2) tone. 
 
 In many cases peristalsis and tone are mutually 
 dependent upon each other, and if one is absent, the 
 other disappears. Both are controlled by the same nerve- 
 influence. Nevertheless, clinicians find that either may 
 
THlE STOMACH 89 
 
 be present without the other. Some cases of very dilated 
 atonic stomach show vigorous peristalsis in the pyloric 
 portion. Indeed in such patients no food may reach the 
 pyloric sphincter at all, in spite of good peristaltic waves, 
 so long as the patient remains standing. The condition 
 is relieved on assuming the horizontal posture. 
 
 In view of the complicated musculature of the stomach 
 and the possibility of one set of fibres acting without 
 the others, we have not yet a clear idea of the causation 
 of the very different clinical pictures obtained in various 
 pathological conditions. At any rate, stagnation of food 
 in the stomach as the result of a primary, purely func- 
 tional, weakness of the rriusculature probably does not 
 exist. In such cases pyloric obstruction is stated always 
 to be present, and it would seem that two forms of atony 
 exist,, one affecting the circular fibres alone or for the 
 greater part, and the other involving the longitudinal 
 fibres and those of the Hufeisenschlinge. Most cases 
 present combinations in which both types of atony exist, 
 but in which one or the other predominates. In the 
 former type the lower part of the pyloric vestibule does 
 not descend to any great extent, but the stomach dilates 
 laterally, and as the circular fibres, on the integrity of 
 whose function alone peristaltic movements depend, are 
 atonic, peristalsis is infrequent or wanting. In the latter 
 type the Atomach maintains its narrow tubular form, 
 which may even be accentuated, but the pyloric vestibule 
 is greatly lowered, even into the pelvis. In such cases 
 peristalsis may be apparently normal or even exaggerated. 
 
 In association with the latter type the pylorus may 
 also be lowered, but this is not always the case. When 
 it does occur, the stomach is said to present the condition 
 of pyloroptosis. Reference to figures 13, 14 and 15 will 
 
90 THE STOMACH 
 
 assist the reader to understand the distinction between 
 the forms of atony. 
 
 Fig. 13. Tracing from radiogram of atonic stomach. 
 
 This figure illustrates the type of organ in which the circular fibres are 
 most affected. Observe the differences between this organ and the one 
 illustrated in fig. 11. With lack of tone in the circular fibres peristaltic 
 waves are not observed. Owing to the fact that the longitudinal fibres and 
 those of the Hufeisenschlinge remain less affected than the circular 
 fibres, the lower border of the pyloric vestibule is not dropped as in 
 fig- M- , _ 
 
 Spasmodic Conditions of the Stomach. 
 
 Hypertonus of the stomach is present in cases of 
 duodenal irritation or ulcer. The longitudinal fibres 
 
THE STOMACH 9 1 
 
 seem most affected, and the lower border of the pyloric 
 vestibule is drawn upwards. 
 
 A like condition is present in stenosis of the cardia, 
 especially in cases of organic obstruction at that site. 
 The appearance of the stomach in hunger is very similar. 
 Hunger pain has been, shown by Cannon to be caused 
 by spasmodic contractions in a small hypertonic organ 
 (52). 
 
 Fig. 14. Tracing from radiogram of atonic stomach. 
 
 This illustrates the type in which the longitudinal fibres and those of 
 the Hufeisenschlinge are most affected. Inasmuch as the circular fibres 
 remain wholly or comparatively normal in function, the stomach is not 
 distended laterally, and also the peristaltic waves are present,, for they 
 are dependent only on the functional integrity of the circular fibres. 
 Compare with fig. 15. 
 
92 
 
 THE STOMACH 
 
 Spasm of the whole stomach is sometimes present in an 
 acute attack of gall-stone colic or acute cholecystitis 
 (Schlesinger, 303). Presumably it may also occur in 
 other acute abdominal conditions, such as nephrolithiasis, 
 pancreatitis, and appendicitis. 
 
 Fig. 15. Tracing from radiogram of case of pyloroptosis. 
 In this specimen the site of the pylorus is lowered. Compare with 
 fig- 16. 
 
 Spasmodic contraction of the stomach in the region 
 of the gastric tube may be massaged away (12). As a 
 rule, it will disappear after the administration of atropine- 
 (Rieder) (see 99). But sometimes a persistent form of 
 hour-glass stomach, which is purely spasmodic in nature 
 
THE STOMACH 93 
 
 and yet uninfluenced by atropine, is found in the 
 presence of ulcer (Faulhaber). It would seem that the 
 circular musculature of the stomach is very easily thrown 
 
 Fig. 16. Tracing from radiogram of hypertonic stomach. 
 
 Both sets of fibres are involved so that the stomach is placed high in 
 the abdomen, well up under the diaphragm. The indentations produced 
 by peristaltic waves are plainly shown. With contraction of the pars 
 pylorica, there is receptive relaxation of the duodenum, the contents of 
 which can be seen as far as the site of crossing of the colon (i.e., position 
 of Lane's first kink). 
 
 into contraction in this region. The so-called Nischen- 
 symptom — the filling with bismuth of an ulcerous 
 excavation — in association with localised hour-glass 
 constriction is pathognomonic of ulcer (99). 
 
94 THE STOMACH 
 
 Intermittent hour-glass stomachs are caused by spasms 
 which indent the greater curvature, and which are 
 probably due to superficial ulcerations of the mucosa 
 or to neurosis (99). The hour-glass condition stimulated 
 by the ulcer may become permanent (cicatricial), and 
 remain after the ulcer has healed (12). The Rontgen 
 picture often shows a greater degree of constriction than 
 actually exists. That is, spasmodic constriction is 
 present over and above the actual organic stenosis (304). 
 Very frequently in cases of cicatricial hour-glass con- 
 striction, waves of peristalsis may be seen passing over 
 the surface of the cardiac portion of the stomach. This 
 is rarest in the spasmodic form. 
 
 Time occupied by the passage of Food through the 
 ■ Stomach. 
 
 If a bismuth meal remain in part in the stomach more 
 than five hours after it was taken, and this in spite of 
 good peristalsis, pyloric obstruction may be diagnosed. 
 If the stomach be emptied in ten hours, careful dieting 
 is probably all that is required. Should, however, the 
 organ still present a bismuth shadow at the end of 
 twenty-four hours, surgical interference will be necessary 
 (12). No delay in the passage of food through the 
 pylorus occurs in cases of duodenal ulcer (see note on 
 p. 230). 
 
 The Subm,ucous CoaU 
 
 The submucosa in the stomach consists of a lax 
 connective tissue which unites the muscular coat with 
 the mucosa. It is readily stripped off the former, but 
 is quite adherent to the latter, with which its tissue is 
 continuous. In it pass the vessels and nerves for the 
 supply of the mucous membrane. Its laxity enables the 
 
THE STOMACH 95 
 
 mucosa to become rugous when the muscular coat 
 contracts. It is the site of election for the spread of 
 carcinoma. In malignant disease of the stomach, the 
 muscular and serous coats are found to be involved no 
 further from the starting point of the carcinoma than is 
 the mucosa. The subniucous coat, however, may be 
 involved a full inch beyond the furthest extension in the 
 mucous membrane. In the pyloric region the muscular 
 fibres are bulkier and more separated from each other 
 than in the cardiac portion of the stomach. Hence the 
 tissue of the submucosa penetrates farther between the 
 fibres of the muscularis in the pars pylorica than in the 
 rest of the organ. 
 
 The submucous coat is the chief site of the disease 
 known as linitis plastica, to which attention has recently 
 been directed by Lyle (220). It is of unknown cause, 
 and characterised by a diffuse hypertrophy of the con- 
 nective tissue of the submucosa, and to a less degree of 
 the other coats also. It may occur in plaques or in more 
 or less generalised form. The edge of the affected area 
 fades off into normal stomach tissue, but is always 
 sharply demarcated from duodenal tissue when it 
 involves the region of the pyloric sphincter. This is 
 the more remarkable when it is remembered that the 
 submucous connective tissue of the two organs is con- 
 tinuous, and even forms a barrier between the circular 
 fibres of the pyloric and duodenal muscular coats. A 
 similar sharp clinical demarcation is found in the 
 lymphatics of the adjoining areas (see p. 103). 
 
 The Mucous Membrane. 
 
 The mucous membrane' of the stomach is thinnest in 
 the region of the fundus, where it is only -5 mm. in 
 
96 THE STOMACH 
 
 thickness. It becomes progressively thicker from cardia 
 to, pylorus, measuring '5 to I'S mm. in depth at the 
 former situation, and 2'o to 2'2 mm. at the latter. 
 
 Its colour is rose-pink, but becomes deeper with the 
 congestion which occurs during the digestive period. 
 
 It consists of an epithelium of cylindrical cells, a 
 basernent membrane, a corjum into which the glands 
 extend, and a double muscularis mucosae, the inner layer 
 being circular, the outer longitudinal, as in oesophagus 
 and intestine. This last separates it from the submucous 
 coat. The tissues of the mucosa and submucosa are, 
 however, continuous. 
 
 Rugse are found in the mucous membrane of the 
 contracted stomach ; they disappear on distension of the 
 organ. The rugae are, as a rule, stellate in the cardiac 
 portion and parallel with the. long axis in the pyloric 
 part. The mucosa, differs considerably in different 
 portions of the stomach. Many animals show a special 
 gland formation along the lesser curvature, but this has 
 not been described in homo. In the human stomach 
 certain authors have described a villous appearance of 
 the mucous membrane in. the pyloric part and along the 
 lesser curvature to the cardia. This character is not to be 
 found in the region of the greater curvature (Ulmann, 
 
 330- 
 
 It is not necessary here to dwell on the special 
 characters of the pyloric and fundus cells and glands. 
 Suffice it to say that the pyloric type of gland occurs 
 only in the pyloric canal. Some cells similar to but not 
 identical with the parietal cells of the fundus glands are 
 to be found in the pyloric glands and even in Brunner's 
 glands, of the duodenum (301, p. 530). The fundus type 
 of gland with its central and parietal cells is found over. 
 
THE STOMACH 
 
 97 
 
 Uie whole extent of the stomach except where the pyloric 
 and the cardiac types (see later) occur. 
 
 It is important to remember that Bensley and Harvey 
 have recently shown that the acid-forming parietal cells 
 do not produce actual hydrochloric acid, but that they 
 secrete within themselves an alkaline forerunner of the 
 acid, which becomes changed in reaction outside the cell 
 
 (27)-\ 
 
 Adjoining the cardiac orifice of the stomach is a zone 
 extending some 3 mm. from the cardia which presents 
 a special form of gland known as the "cardiac type, 
 which has no pepsin secreting- action, but in the pig, at 
 any rate, produces an amylolytic ferment. (Cf. glands 
 of lower gullet, p. 53) (301,, p. 529). 
 
 The anlage of this type of gland is found in the 
 embryonic mammalian stomach. The area over which 
 it occurs is less in animals which have an exclusively 
 protein diet, and greater in those whose diet is of a 
 carbohydrate nature. Hence the, cardiac glands are 
 frequently absent in carnivora, and .are well marked in 
 truly herbivorous animals. In man the area over which 
 this type of gland is found varies" greatly in extent in 
 different individuals; The stomach mucosa shows 
 occasional crypts of Lieberkuhn. The site in which 
 these are most numerous is the intermediate zone between 
 the fundus and the pyloric area. 
 
 Whatever the mode of origin of peptic ulcer (see 
 Bolton, 36) it is apparent that the site of disease bears 
 
 I. Just as the volume goes to' press, an article has appeared by 
 Hamijiett (" The source of the Hydrochloric Acid found in the Stomach," 
 Anat. Rec, Phila., 1915, vol. 9, p. 21), in which the author disputes the 
 interpretation put by Bensley and Harvey upon their results (see Biol. 
 Bull., 1912, vol. 23, p. 225), and reaffirming on considerable evidence the 
 previous belief that actual hydrochloric acid is produced in the parietal 
 cells. 
 
98 
 
 THE STOMACH 
 
 a very definite relation to the character of the mucous 
 membrane of the pyloric part and the lesser curvature. 
 Fig. 17 represents in modified form the distribution of 
 peptic ulcer as given in Morley's recent article (245). 
 When one considers the difficulty of defining exactly 
 the site of ulcer at operation, and of accurately recording 
 it in the notes, the relation of distribution of the disease 
 to the specific characters of the mucosa is very striking. 
 
 The distribution of perforated peptic ulcers according to 
 
 Fig. 17. 
 Morley. 
 
 Note the definite relation to the lesser curvature, especially of the pars 
 pylorica and to the duodenal vestibule. 
 
 Dots represent perforations on ventral surface ; circles, perforations on 
 dorsal aspect. 
 
 Other facts which indicate physiological differences 
 between the mucous membrane of the several parts of 
 the stomach are the chemical stimulation of gastric juice 
 and the action of acid in the stomach on the pyloric 
 orifice. These mechanisms are operated from the mucosa 
 of the pars pylorica only (48, Ch. VI). The action of 
 
THE STOMACH 99 
 
 acid in the cardiac portion closing the cardia has already 
 been discussed (see p. 57). 
 
 The Arteries of the Stomach. 
 
 The arterial supply of the stomach comes from the 
 coeliac trunk. This short wide vessel lies behind the 
 omental bursa, and runs forward for 12 mm. between 
 the caudate lobe of the liver above and the upper border 
 of the pancreas and the splenic vein below. It terminates 
 by dividing into the left gastric, the hepatic and the 
 splenic. The left gastric (coronary) artery runs upward 
 and to the left behind the omental bursa, and passing 
 forward in the left gastro-pancreatic fold, reaches the. 
 lesser curvature adjacent to the cardia. It courses along 
 the lesser curvature close to the stomach wall, and 
 anastomoses with the right gastric (pyloric) branch of 
 the hepatic artery. It gives branches to the lower gullet 
 and to both surfaces of the stomach. Many of these 
 pierce the circular musculature of the Magenstrasse and 
 form a plexus in the submucosa. 
 
 In 15 per cent, of cases a branch runs also to the left 
 lobe of the liver (286). In such cases ligature of the left 
 gastric artery in partial resection of the stomach would 
 result in necrosis of the liver area supplied by it. 
 
 The hepatic artery runs along the upper border of the 
 head of the pancreas and between the layers of the right 
 gastro-pancreatic fold of peritoneum to reach the first 
 part of the duodenum. From here it passes upward 
 between the layers of the hepato-duodenal ligament to 
 reach the liver. Its branches to the stomach are the 
 right gastric and the gastro-duodenal vessels. 
 
 The right gastric artery arises from the hepatic trunk 
 in the gastro-hepatic ligament above the pylorus, to 
 which it passes, whence it courses to the left, supplying 
 
100 THE STOMACH 
 
 both sides of the pyloric part of the stomach, and anasto- 
 mosing with the left gastric artery in the region of the 
 incisura angularis. Like the left gastric vessel, it is 
 closely applied to the stomach wall. 
 
 The gastro-duodenal artery descends behind the first 
 part of the duodenum, on the under aspect of which it 
 divides into the right gastro-epipldic and superior 
 pancreatico-duodenal vessels. 
 
 It frequently happens that this subdivision is closely 
 related to the pyloric canal. 
 
 The right gastro-epiploic artery passes to the left 
 behind the first part of the duodenum and above the 
 head of the pancreas to reach the gastro-colic liganient 
 (part of great omentum) between the layers of which it 
 runs parallel to but some distance from the greater 
 ctjrvature (unless the stomach is full) to supply the 
 pylbric canal and vestibule with branches. It anasto- 
 moses with the left gastro-epiploic vessel near the 
 junction of the gastric tube with the pyloric vestibule. 
 
 The splenic artery, which is large and tortuous, passes 
 to the left, behind the omental bursa along the upper 
 border of the pancreas. It reaches the hilum of the 
 spleen by running between the layers of the lieno-renal 
 ligament, and its branches to the stomach pass onward 
 between the layers of the gastro-splenic ligament (part 
 of great omentum). These are the vasa brevia, which 
 supply the fundus proper and adjacent parts of the 
 cardiac sac, and the left gastro-epiploic, which gives off 
 branches' to the gastric tube and adjacent part of the 
 cardiac sac. Like the right gastro-epiploic artery, the 
 latter lies some distance from the greater curvature when 
 the stomach is empty. 
 
 The vessels from which haemorrhage occurs in gastric 
 
THE STOMACH lOI 
 
 ulcer are the two gastrics, the splenic and the sujperior 
 pancreatico-duodenal (21). These are the arteries which 
 present a close relation to the stomach wall whether the 
 organ be empty or distended. As previously mentioned, 
 the stomach dilates by burrowing between the folds of 
 the gastro-colic and gastro-splenic ligaments. Hence 
 the gastro-epiploic vessels lie in these ligaments at some 
 distance from the greater curvature of the empty stomach, 
 and are practically never ulcerated. The left and right 
 gastric vessels are those from which haemorrhage most 
 frequently occurs. The splenic artery is exposed by 
 ulcers of the dorsal wall laying bare the pancreas. 
 
 The superior pancreatico-duodenal artery is invaded 
 where it lies in contact with the dorsal surface of the 
 pyloric canal. 
 
 Only the terminal vessels of the mucosa are end 
 arteries. The submucous plexus allows free communi- 
 cation between the different arterial channels (82). 
 
 The Veins of the Stomach. 
 
 The veins of the stomach follow the course already 
 described for the corresponding arteries, but their 
 termination is different in some cases. The short gastric 
 and the left gastro-epiploic veins terminate in the splenic 
 trunk. The right gastro-epiploic ends in the superior 
 mesenteric vein. This and the splenic by their union 
 form the portal vein. Into the portal vein itself is poured 
 the blood from the left gastric or coronary and the right 
 
 gastric veins. 
 
 Bleeding from the veins of the stomach rarely occurs, 
 in gastric ulcer, as the vessels readily thrombose. On 
 the other hand, venous haemorrhage into the stomach 
 does take place in the congested state of the portal 
 
102 THE STOMACH 
 
 system consequent on the obstruction to the portal vein 
 found in cirrhosis of the hver. In these cases the bleed- 
 ing results from the bursting of swollen anastomotic 
 veins at the cardiac orifice. These small vessels form 
 communications between the oesophageal veins which 
 pour their blood into the systemic circulation through 
 the azygos veins, and the gastric vessels which drain 
 into the portal system. Haemorrhage from the veins of 
 the stomach also occurs occasionally after abdominal 
 operations and occasions post-operative haematemesis. 
 The bleeding is said by some to result from a congested 
 state of the mucous membrane produced by thrombosis 
 of the gastro-epiploic veins following on ligature or 
 rough handling of the omentum. The gastro-epiploic 
 veins and arteries send branches into the greater 
 omentum as well as to the stomach. According to von 
 Eiselsberg, thrombosis of the omental arteries proceeds 
 to involve the gastro-epiploic arteries just as happens in 
 the case of the veins (90). 
 
 But all investigators do not agree that ligature of 
 omental blood vessels causes bleeding from the mucosa. 
 Engelhardt and Neck proved that bleeding certainly 
 does not occur in all cases. Owing to the submucous 
 arterial and venous plexuses the blocking of one or 
 several branches cannot cause any considerable disturb- 
 ance in circulation since numerous collateral branches 
 exist (95). 
 
 A fact of considerable significance concerning the 
 veins of the embryonic stomach has been discussed by 
 Broman. This author describes branches of the ductus 
 venosus to the stomach in embryos of 5 to 16 mm. 
 Obviously the ductus venosus would be carrying arterial 
 blood. Hence the stomach, which at this stage is rapidly 
 
THE STOMACH IO3 
 
 developing its characteristic appearance, would obtain 
 the necessary pure blood in contradistinction to the 
 greater part of the abdomen, which receives only the 
 relatively impure blood from the abdominal aorta. 
 
 One little vessel of some practical importance, when 
 it exists, is the pyloric vein, described by Mayo and by 
 Moynihan (248). It joins the veins of the greater or 
 lesser curvature and runs over or close to the pyloric 
 sphincter. Thus it may be used to define the pyloro- 
 duodenal junction, but does not do so accurately. 
 
 The Lymphatics of the Stomach. 
 
 This subject has been discussed in great detail by 
 various authors (see 160), but for practical purposes the 
 description can be greatly simplified. The lymphatic 
 vessels of the stomach drain into the coronary, pyloric, 
 and splenic groups of nodes. 
 
 The coronary group lies along the lesser curvature 
 and forms a chain of nodes continuous with those in the 
 posterior mediastinum along the lower gullet, whose 
 lymphatic vessels form a common plexus with those of 
 the stomach. 
 
 The coronary group drains the cardiac part of the 
 lesser curvature and adjacent portions of the ventral and 
 dorsal surfaces. 
 
 The pyloric group of nodes is arranged in front, 
 behind and below the pyloric canal and vestibule, and 
 drains the whole of the pyloric portion of the stomach. 
 According to many observers the lymphatic plexus of the 
 pyloric part of the stomach is not anatomically con- 
 tinuous with that of the first part of the duodenum. 
 Hence carcinoma of the pyloric region is stated not to 
 spread distally into the duodenum, but always toward 
 
104 T^'^ STOMACH 
 
 the body. of the stomach. Most considered that there 
 is eine scharfe lymphscheide between the pyloric canal 
 and the duodenum (247). Lately ComoUi has reinves- 
 tigated the subject and takes the view that the lymphatic 
 plexuses of the pyloric canal and duodenum are con- 
 tinuous. He quotes the statement of Borrmann that in 
 20 out of 65 cases of carcinoma of the pyloric region, 
 there was extension to the duodenum by both submucotis 
 dnd subserous lymph tracts (69). 
 
 No lymph nodes are present in the gastro-splenic 
 ligament. All the vessels of the fundus proper and 
 adjacent part of the cardiac sac drain into the splenic 
 group of nodes situated along the splenic artery. 
 
 As in other parts of the gastro-intestinal tract, the 
 lymphatic vessels of the stomach are arranged at right 
 angles to the curvatures so that when injected with 
 Prussian blue or some other dye the colour is observed 
 to flow round the gut in a circular direction more readily 
 than in the longitudinal. Following on this lymphatic 
 distribution, carcinoma of the stomach tends to form an 
 annular growth in the wall of the organ. 
 
 The reason for the rarity of the spread of pyloric 
 carcinoma to the duodenum, as is observed by the 
 majority of investigators, is probably explained by the 
 fact that the disease blocks the smallest lymphatics and 
 tracks along those of medium size (see Sampson Handley 
 
 There is little or no clinical^ anastomosis between the 
 lymphatics of the fundus and those of the rest of the 
 
 I. Because the smallest lymphatic vessels are choked by the growth 
 and thus prevent its extension along them, the lymphatics of one area, 
 though anatomically continuous with those of adjoining districts, may yet 
 be clinically isolated, there being no medium-sized vessels along which 
 the carcinoma may spread. 
 
THE STOMACH 105 
 
 organ. Consequently, carcinoma of the fundus has a 
 better post-operative prognosis than malignant disease 
 elsewhere in the stomach. For this reason the fundus 
 and adjacent parts of the cardiac sac are together known 
 as the isolated area. The amount of gastric wall which 
 it is necessary to extirpate in carcinoma of the fundus 
 is delimited toward the right by a perpendicular 
 (Hartmann-Mikulicz) line to the greater curvature meet- 
 ing the lesser curvature immediately to the right of the 
 cardiac orifice. The intersection of the perpendicular 
 with the greater curvature is termed Hartmann's point 
 (126). It is to be noted that this line is drawn on the 
 atonic organ as seen in the operating theatre. This line 
 may also be utilised in pyloric carcinoma. Thus the 
 fundus and two-thirds of the greater curvature are free 
 from lymphatic involvement in cancer of the pylorus 
 (231). 
 
 As inflammation does not occur in the mucous mem- 
 brane without the other coats of the stomach also being 
 involved, the presence of an ulcer can always be detected 
 by inspection of the peritoneal coat (248). Indeed an 
 enlarged and inflamed "sentinel" lymphatic node is 
 freiquently present in consequence of an ulcer in the 
 mucosa. 
 
 The Nerves of the Stomach. 
 
 The nerves of the stomach originate from the vagi 
 and the sixth, seventh, eighth, and ninth dorsal segments 
 of the spinal cord. The latter group are composed of 
 sympathetic fibres which reach the stomach through the 
 splanchnic nerves. Of these the sixth dorsal segment 
 supplies the cardiac orifice, while the pylorus derives its 
 nerve supply from the ninth dorsal segment. Referred 
 
■I06 THE STOMACH 
 
 -pain in the abdominal wall is therefore felt in the area 
 supplied by the cutaneous nerves from these same dorsal 
 segments. Ulcer near the cardia produces referred pain 
 in the infra-sternal region, while ulcer of the pylorus is 
 associated with referred pain just above the umbilicus. 
 But it is to be noted that Ducceschi observed that the 
 afferent fibres of each splanchnic nerve are connected 
 through filaments from the coeliac plexus with the entire 
 surface of the stomach (84, p. 525). 
 
 In the stomach wall itself there exist two nerve 
 plexuses, one in the submucous coat known as Meisner's, 
 and the other in the muscular coat. This latter is called 
 Auerbach's plexus. These plexuses are connected with 
 splanchnic netves and are jointly responsible for the 
 mechanism known as the local or as Cannon has named 
 it, the myenteric reflex (48). By this term is meant the 
 intrinsic response of the gut to stimulation by its 
 contents to ensure the orderly progression of the said 
 contents. The response consists of a contraction imme- 
 diately in front of and a relaxation beyond the point of 
 stimulation. The rela,xation may be marked or may be 
 very slight. It is probable, however, that the myenteric 
 reflex does not control the rhythmic waves of contraction 
 in the stomach, usually known as " peristalsis " (48, p. 
 195). The endings of the vagus fibres in the stomach 
 have not been traced. They probably ■ terminate in 
 association with outlying nerve cells in the gastric wall 
 which have no connection with the myenteric (Auer-. 
 bkch's) plexus (48, p. 198). •' 
 
 Rubinato at any rate has shown two distinctly different 
 types of nerve cells in the wall of the stomach (297). A 
 clearer description, which, however, does not harnrionisS 
 with that of Rubinato, is given by Kuntz of the nerv6 
 
THE STOMACH • lO^ 
 
 cells and fibres in the stomach wall (195). The function 
 of the vagus is that of maintaining a state of tone in 
 the gastric musculature.. The gastric contents may be 
 Said always to. exert a stretching effect on the stomach 
 wall. The vagus adapts the size of the organ to the 
 amount of iopd taken. Only if this tone is present are 
 peristaltic waves stimulated. For tone and peristalsis 
 are mutually dependent upon each other. It is obvious, 
 however, , from preceding clinical statements (p. 88) that 
 the tone spoken of here refers to the circular muscular 
 fibres and not necessarily to the longitudinal muscula- 
 ture, or the Hufeisenschlinge. The vagi are also 
 concerned in the production of. a psychic tone similar 
 to the psychic secretion (48, p. 240). The section of one 
 vagus has no effect upon the state of the stomach because 
 of the interweaving of the fibres on their way down the 
 cesophagus (300, p. 52). 
 
 , If both vagi are cut, the circular muscular tone and 
 peristalsis are inhibited for a time. Ultimately the 
 stomach recovers both tone and, peristalsis. This 
 restoration occurs much more quickly if the spknchmc 
 nerves also are severed (48, p. 201). For these act as 
 inhibitory nerves to the gut, stimulation of them causing 
 diminished-tone and weakened rhythmic contractions. 
 , The recovery of tone and peristalsis by the gastric 
 wall after section of the.vagi is most important clinically, 
 for in Sauerbruch's operation for resection of the cardia 
 it, is necessary to sever both vagi (300, p. 89). Indeed 
 they may already be damaged by the presence of local 
 malignant disease. • • 
 
 . Another important fact in the stoniach mechanism is 
 i^hat neither, tone of circular fibres nor peristalsis is 
 necessarily dependent ultimately upon the integrity of 
 
I08 • THE STOMACH 
 
 the myenteric reflex any more than they are on the 
 presence of vagus influence. Cannon cut rings through 
 both muscular coats, thus severing Auerbach's plexus. 
 In one case six rings were cut between the cardiac end 
 of the stomach and the pylorus, and after three weeks 
 the waves were seen passing with perfect regularity as 
 in the normal stomach (48, p. 193). 
 
 But it must not be thought that the rhythmic move- 
 ments of gastric peristalsis are necessarily of myogenic 
 origin. Cannon gives an excellent summary of the 
 work of Magnus refuting the evidence which Bayliss and 
 Starling brought forward in favour of the myogenic 
 theory (48, pp. 180, 181). More recently Kuntz has 
 presented anatomical evidence to show that the local 
 mechanism is that of an axone reflex. Kuntz's work 
 suggests that, however close together the circular 
 incisions be made through the muscular coat, it is 
 impossible to preclude the possibility of axone reflex. 
 The afferent impulse caused by the contact of food with 
 the mucous membrane results in a contraction of the 
 musculature in the immediate neighbourhood (195). 
 Hence the rhythmic wave is started and as the food is 
 necessarily pushed onward, it stimulates a similar 
 contraction as it passes with the production of the 
 so-called peristaltic movement. The important relation 
 to partial gastrectomy of this mode of production of 
 peristalsis in the stomach is obvious. 
 
 Kirschner and Mangold found the gastric functions 
 perfectly restored in dogs after circular resection of the 
 stomach. The tone of the pyloric sphincter, the rhyth- 
 mic opening and closing of the pylorus while the 
 stomach is emptying, the rise of intra-gastric pressure 
 in the pyloric vestibule and the rhythm and character 
 
THE STOMACH lOQ 
 
 of the contractions of this portion of the stomach, all 
 recover to a normal degree. The functional co-ordina- 
 tion of the. pyloric sphincter and of the wall of the pyloric 
 vestibule, and the reflex response of the pars pylorica 
 to chemical stimulation from the duodenal mucosa also 
 recover (190). 
 
 It would seem, however, that absence of tension by 
 contents may result in atony. Wilms has asserted his 
 belief that in cases where the stomach is divided and 
 both ends are closed by suture, there is resulting atony 
 of the excluded pyloric portion (348). 
 
 With regard to the cardiac and pyloric sphincters it 
 may be said that although they are affected by local 
 conditions, such as acidity, they are also controlled by 
 the central nervous system. Stimulation of the vagus 
 causes relaxation of the cardiac sphincter with subse- 
 quent increase in tone (see p. 56). But stimulation of 
 the vagus as a rule produces closure of the pyloric 
 sphincter (48, p. 207). 
 
 ' The splanchnic nerves act in the opposite way, closing 
 the cardiac orifice and relaxing the pylorus in some 
 animals. But the effect of stimulation of the splanchnics- 
 is not so uniform as that of vagus stimulation (48, p. 
 207) (see p. 56). 
 
 That the same mechanism which opens the cardia 
 should close the pylorus is of importance in vomiting. 
 It is interesting to observe that there is a receptive 
 relaxation of the cardiac sac dependent upon the stimu- 
 lation of the vagus nerve. This occurs with each 
 swallow. The oesophagus contracts pressing the food 
 into the stomach, while at the same time there is 
 temporary relaxation of the cardiac sphincter and of the 
 cardiac sac. Immediately the bolus has entered the 
 
no THE STOMACH 
 
 Stomach, the cardia doses and the intra-gastric pressure, 
 increases. The food Hes in the lower part of the cardiac 
 sac at the commencement of the gastric tube. The 
 slight incriease in tone of the cardiac sac produces the 
 tension necessary for the initiation of the peristaltic 
 wave, which carries the food along the gastric tube to 
 the pyloric vestibule (see Cannon, 48, pp. 198, 201). 
 
 Sensory impulses from the stomach are . probably 
 conveyed: by the vagi only (Miller, 238). Kast and 
 Meltzer (173), and recently Miller, have cast doubt upon 
 the insensibility of the alimentary canal to pain. But 
 this is not borne out by clinical observations. According 
 to Hertz (138), the organ is insentitive to temperature, to 
 tactile and cutting sensations. 
 
 Alcohol is said to excite a burning sensation, which 
 is the cause of the discomfort in heartburn, but this 
 sensation may equally well be caused in the lower gullet 
 by leakage through the cardia, and not in the stomach 
 itself (147). Other chemical stimulation, as by 
 hydrochloric or an organic" acid, produces no effect on 
 the normal stomach. The presence of even weak 
 hydrochloric acid gives pain when introduced into 
 the stomach of patients who are suffering from gastric 
 ulcer (37). 
 
 ; Distension of the organ produces , a sensation of 
 fulness. 
 
 Gastralgia is due to irregular spasmodic contractions 
 of the muscular wall. As these are increased by car- 
 bonised water, it is probable that cramp-like pains in the 
 stomach are stimulated by the presence of gas, especially 
 of carbon dioxide. They are relieved by eructation. 
 An instance of painful spasm is given by hunger pain, 
 which is produced by contractions in a nearly empty 
 
THE STOMACH III 
 
 Stomach. Hunger pain can be relieved momentarily by 
 swallowing. This is explai;ied by the temporary inhi- 
 bition of gastric contraction through vagus influence 
 (48, p. 204). 
 
 Pain in cases of gastric ulcer may be due to one of 
 two causes. It may be local tenderness which, is the 
 result of local peritonitis, or referred pain caused by 
 stimulation of the spinal fibres to the abdoininal wall. 
 The site of the referred pain is said by some writers to 
 bear in, its distribution a constant relation to the site of 
 the ulcer. Such a table is given by Mayo Robson and 
 Moynihan (289, Ch. VII), but as it is doubtful if such a 
 relation can be substantiated, the table has not been 
 included in this account. 
 
CHAPTER VII. 
 
 The Duodenum. 
 
 The duodenum is that part of the alimentary canal which 
 forms the commencement of the small intestine, and into 
 which open the bile and pancreatic ducts. It differs 
 from the remainder of the small intestine in that for the 
 greater part of its extent it is bound down by peritoneum 
 to the dorsal abdominal wall. 
 
 Unlike its termination, the site of its commencement 
 has always been definitely settled and is marked by the 
 pylorus. If the sphincter be relaxed and thus not 
 palpable during operation, the pyloric vein already 
 mentioned (p. 103) may indicate approximately its 
 position. The termination of the duodenuni has been 
 variously defined from time to time. At present we 
 regard it as occurring in a more or less well-marked 
 elbow of the gut at or about where the mesentery of the 
 small intestine commences, a distance of some 30 cm. 
 from the pylorus. It is quite easily discerned in the 
 operating room during an abdominal operation, for the 
 muscle of Treitz can be traced to it from the dorsal 
 abdominal wall. But at one time the junction of 
 duodenum and jejunum was held to occur at the site 
 where the superior mesenteric vessels cross what is now 
 termed the third part of the duodenum, and it was the 
 distance measured in finger breadths along the gut, 
 between the pylorus and this situation, which gave rise 
 to the name duodenum. In the early embryo there is no 
 flexure between duodenum and jejunum, and for this 
 reason the term duodenum, even in the adult, has been 
 
 112 
 
THE DUODENUM II3 
 
 limited to the segment of bowel between the pylorus 
 and the opening of the common bile duct. In the sixth 
 week of foetal life, however, the duodenum assumes a 
 curved form, and by the third month, it has the same 
 disposition as at birth (i66). Quite recently Villemin 
 has denied the duodeno-jejunal junction to be the distal 
 limit of the duodenum. He states that the real termina- 
 tion in the adult is located at a position some inches 
 higher. This site is identified by the presence of a 
 valvule composed mostly of mucous membrane, but into 
 which also the circular muscular coat enters, by the 
 cessation of Brunner's glands and by the attachment of 
 the muscle of Treitz (334). But these features are not 
 so distinct in the foetus or in lower animals. 
 
 In the foetus and infant the duodenum is ring-shaped ; 
 indeed even in the adult this type frequently occurs. 
 Jonnesco says that as a rule the ring-type is observed 
 only up to the age of seven. In the adult the duodenum 
 commonly is U-shaped, though, as one would expect, 
 there are intermediate conditions between the ring and 
 U forms (10). According to Dwight, the types just 
 mentioned are more characteristic of the male. In the 
 female a V-shaped duodenum quite commonly occurs, 
 and the most, dependent part of the duodenum tends to 
 lie lower in the abdomen than it does in the male. 
 Jonnesco states that the horizontal part of the U-shaped 
 duodenum lies as low as the fourth lumbar vertebra, and 
 that the V-shaped organ reaches the fifth {Progres 
 ■msdical, 1889); and these observations were confirmed 
 by Dwight (85). 
 
 In the cadaver the precise relation of the duodenum 
 to the jejunum, at the flexure, varies. Bishop Harman 
 differentiated the following groups :— 
 
114 THE DUODENUM 
 
 (i) A wide curve downward, forward and toward the 
 left. 
 
 (2) A sharp curve dispose^ in the same manner. 
 
 (3) A sharp curve directly forward and downward 
 
 along the line of the ascending portion of the 
 duodenum. 
 
 (4) A slight curve, the jejunum passing at once to the 
 
 right. 
 
 In all cases, Harman adds, the position was fixed and 
 not subject to the movements of the intestines (125). 
 But owing to the difificulty of tracing on the fluoroscopic 
 screen a bismuth mixture as it passes through the flexure, 
 it is impossible at present to record the condition during 
 life. Such evidence as we have is distinctly against 
 there being any impediment to the passage of food by a 
 sharp curve or kink at. this site. Moreover, in the 
 cadaver the duodeno-jejunal flexure tends to rise some- 
 what higher in the abdomen than in the standing living 
 individual, and also there is post-mortem contraction 
 and fixation, which tend to exaggerate the sharpness of 
 the normal curve. 
 
 The duodenal-jejunal flexure is not always free, that 
 is, the jejunum may not invariably have a mesentery 
 quite to its commencement. It may be bound down to 
 the dorsal abdominal wall for a short distance beyond 
 the flexure (125). 
 
 In the formalin-hardened cadaver, which has been 
 injected while lying on its back, the first part of the 
 duodenum commences in the middle line, or within three 
 or four cm. to the right of the middle line, opposite the 
 lower part of the first lumbar vertebra, and passes 
 backward to the right and slightly upward to its junction 
 with the second part in the region of the neck of the 
 
THE DUODENUM II5 
 
 gall bladder, and at the level of the first lumbar vertebra. 
 This portion of the duodenum is anchored Ijy a continua- 
 tion of the lesser omentum. Then bending on itself the 
 bowel lies almost vertically on the right side of the 
 bodies of the second, third, and fourth, and it may be 
 the fifth, lumbar vertebrge. This is the second part. 
 The third part then crosses the front of the great vessels 
 upon the vertebral column, and the fourth part ascends 
 toward the left and passes obliquely backward and to the 
 left to terminate at the duodeno-jejunal junction, which 
 lies about three or four cm. to the left of the middle line, 
 at the level of the disc between the first and second 
 lumbar vertebrae. It is to be observed that while 
 Jonnesco, Treves (329) and Hartmann use the terms 
 third and fourth parts of , the duodenum, these are 
 frequently grouped together in English tiext-books as 
 the third portion. 
 
 It has already been mentioned that, in many indi-! 
 viduals, the firmly contracted pylorus can be palpated 
 through the abdominal wall. 
 
 The duodenum, as mapped out on the abdomen of the 
 cadaver, does not altogether correspond to its surface 
 topography in the living. One must remember that in 
 the cadaver all parts of the organ, but more especially 
 the commencement and termination, tend to lie at a 
 higher level than in the normal living adult in the 
 standing posture. The right lateral inguinal, the trans- 
 pyloric and the intertubercular lines are required for the 
 topographic marking. In the cadaver the first part lies 
 on the transpyloric plane, the junction between first and, 
 second portions corresponds to the intersection of 
 transpyloric and right lateral inguinal lines, the second 
 part lies just medial to the lateral inguinal hne, the third 
 
Il6 THE DUODENUM 
 
 .part crosses the median plane at or about the level of the 
 intertuberculax plane (according to certain authors the 
 crossing is somewhat higher than this (2) (100)), and the 
 fourth part passes obliquely upward and to the left to 
 end at the duodeno-jejunal junction about three or foup 
 cm. to the left of the median plane on the transpyloric 
 line. Hence the summit of the iliac crest, if that can be 
 palpated, corresponds roughly, as Addison points out, 
 to the lowest limit of the duodeniyn (2). The foregoing 
 outline indicates for the third part of the ^rgan a lower 
 level than that given by Addison. Addison states that 
 it crosses the middle line about one inch above the 
 umbilicus, a situation rather too high than too low, and 
 one which is indicated by the relation to the umbilicus, 
 which is itself somewhat variable in its position relative 
 to the vertebral column (see p. 2). The differences 
 between the situation of the several parts of the organ 
 in the cadaver and in the living will be obvious by 
 reference to the radiographic appearance (p. 129). , 
 
 Variations in the position of the duodenum may be 
 due to the presence of a mesentery or may be one feature 
 of a general abnormal disposition of the abdominal 
 organs. From time to time such accounts have been 
 published in the Journal of Anatomy and Physiology, 
 and a very marked instance has been recorded by 
 Riechelmann (283). Sometimes, as in Chiene's case, the 
 duodenum passes into the jejunum to the right of the 
 median line (59). This variation must not be confiiged 
 with the appearance noted b}' Jordan in certain cases of 
 so-called Lane's kink (see p. 131). 
 
 The distance of the duodenum from the upper incisor 
 teeth varies according to the individual. Gross has been 
 able to insert a duodenal tube 150 to 200 cm. al^ng the 
 
THE DUODENUM II7 
 
 alimentary canal. By pushing it to the 70 cm. mark and , 
 waiting until the pylorus has allowed it to pass, or rather 
 has carried it into the duodenum, a free flow of yellowish 
 cloudy fluid of acid reaction is obtained. This is soon 
 (eplaced by a clear golden yellow or greenish fluorescent 
 - alkaline fluid, which latter is supposed to be true 
 duodenal juice (119). By the same method, Gross 
 proposes to inhibit bacterial proliferation by insufflation 
 of oxygen (120). Allard recommends Einhorn's test in 
 duodenal ulcef . The somewhat crude technique of this 
 test is carried out by inducing the patient to swallow a 
 string. When drawn up again, brown discolouration 
 from blood on the string at a distance of from 55 to 
 65 cm. from the incisor teeth is said to indicate the 
 presence of a duodenal ulcer (4). Transduodenal lavage 
 is recently recommended by Jutte as treatment for 
 intestinal auto-intoxication (170), but the diagnosis of 
 intoxication is based on the presence of indican in the 
 urine, and as a test of intestinal intoxication, indicanuria 
 is fallacious , (see 271). 
 
 In the accounts given by English text-books the 
 relations of the duodenum to surrounding viscera are 
 frequently incomplete. For this reason the description 
 given by Jonnesco is tabulated below (166): — 
 First Part. 
 
 Above. Liver at right part of hilum. 
 Below. Neck of pancreas. 
 Ventral. Visceral surface of liver. 
 * Body of gall bladder. 
 
 Dorsal. Neck of pancreas. 
 
 Hepatic pedicle (i.e., portal vein, hepatic 
 artery • with its gastro.duodenal branch, 
 union of cystic and hepatic ducts to form 
 ^ common bile duct). 
 
ii8 
 
 THE DUODENUM 
 
 Second Part, 
 
 Ventral, Fundus of gall bladder. 
 
 Right extremity of transverse colon. 
 Right colic vessels. 
 Small intestine. 
 Dorsal. Renal and genital vessels. 
 
 Right kidney, pelvis and ureter. 
 Psoas and quadratus lumborum. 
 Right. Right lobe of liver. 
 Ascending colon. 
 Right kidney. 
 Left. Greater curvature of stomach and pyloric 
 canal. 
 Head of pancreas. 
 Common bile and pancreatic ducts. 
 Inferior vena cava. 
 Vertebral column. 
 Third Part. 
 
 Above. Head of pancreas. 
 
 Ventral. Root of mesentery with superior mesenteric 
 vessels. 
 Small intestine. 
 Pyloric vestibule. 
 Dorsal. Inferior vena cava. 
 
 Abdominal aorta or its bifurcation. 
 Origin of inferior mesenteric artery. 
 Fourth Part. 
 
 Ventral. Small intestine. 
 
 Pyloric vestibule. 
 Dorsal. Left renal and genital vessels. 
 
 Lumbar part of diaiphragm and psoas 
 separated from the duodenum by the 
 ureter. 
 
THE DUODENUM II9 
 
 Pelvis of ureter and hilum of right kidney. 
 (This occasionally in adult, but always in 
 child up to the age of three or foiir.) 
 Right. Aorta. 
 
 Root of mesentery. 
 Hea:d of pancreas. 
 Left. Left kidney. 
 
 Left colic artery. 
 Inferior mesenteric vein. 
 
 In the infant the kidneys fill up the paravertebral 
 hollows, and therefore the loop of the duodenum lies on 
 the hila of the two kidneys arid on the crura of the 
 "diaphragm with the abdominal vessels between them. 
 In the adult, however, the kidnfeys, relatively reduced in 
 size, sink back into the paravertebral hollows, and the 
 duodenum tends to follow them. Hence the more 
 vertical parts of the duodenal loop are recessed in the 
 abdomen to a plane p6sterior to that of the' third or 
 horizontal part. 
 
 The third portion of the duodenum lies in the angle 
 between the aorta dorsally and the superior mesenteric 
 artery ventrally. Besides being bound down by perito- 
 neum, this relation to the vessels makes it the least 
 movable part of the dudderium. Thus in abdominal 
 injuries, if • the organ is ruptured, it is the third part 
 which usually suffers. "Further, this relation may be the 
 cause, in some cases at least, of acute pogt-operative 
 dilatation of the stomach. In patients, who at dperatiori 
 have the small intestine loaded with contents, it iS 
 supposed that the heavy terniinal coils of intestine may 
 drag upon the root of the mesentery, the smooth muscle 
 fibres of which arein ah atonic state. By such action 
 
I20 THE DUODENUM 
 
 the third part of the duodenum suffers mechanical con- 
 striction between the aorta and superior mesenteric 
 vessels. The equally atonic stomach and duodenum are 
 unable to force their contents past the obstruction and 
 rapid dilatation results. Part of the treatment of this 
 condition is directed to the relief of such obstruction by- 
 raising the foot of the bed and so putting an end to the 
 tension on the fnesentery (248). Kelling notes that such 
 a type of obstruction occurs sometimes after a simple 
 cholecystotomy, and he suggests that local peritonitis or 
 perhaps even tight abdoniinal bandaging may be factors 
 in Its causation. He observes also that in certain cases 
 no bile but only food and blood-stained fluid are found 
 in the stomach. In these instances, he believes that the 
 obstruction is produced by the pressure of the distended 
 first part of the duodenum against the ventral wall of 
 the second portion (188). 
 
 Richardson recently had the opportunity of watching 
 a stomach dilate on the operating table before his eyes. 
 It seemed to be obstructed at cardia and pylorus, and as 
 the organ distended, it rolled upward so that the greater 
 curvature came forward. No distension of the duode- 
 num was noted. The stomach wall contracted firmly 
 when the gas was allowed to escape through a stomach 
 tube passed through the mouth (281). 
 
 Acute obstruction of the duodenum is a very fatal 
 condition, the symptoms of which have been studied by 
 several investigators. They have been induced lately 
 by Whipple and his co-workers in dogs, and by Bunting 
 in rabbits, by isolating a loop of duodenum. This is 
 effected by ligaturing the duodenum just beyond the 
 entrance of the common bile duct, and immediately distal 
 to the duodeno-jejunal junction and then performing a 
 
THE DUODENUM 121 
 
 posterior gastro-enterostomy. If the duodenal loop is 
 excised or drained, the symptoms are absent or much 
 less marked. The activity of the mucosa and contained 
 bacteria form some very toxic substance, which is 
 apparently absorbed directly into the blood (342). Hence 
 it would seem that the rapidly fatal character of high 
 intestinal obstruction in man is not due merely to the 
 mechanical occlusion. 
 
 Chronic obstruction with duodenal stasis has been 
 much studied of late by Lane and Jordan. The organ 
 is said to become distended most in the first part, but 
 this bulbus is apparent radiographically in normal cases 
 (see p. 125). There is said to be a kink at the duodeno- 
 jejunal junction, but this has never been fully substan- 
 tiated. The bismuth shadow, in cases of duodenal stasis,- 
 is said by Jordan to lie entirely to the right of the middle 
 line (168). Dwight believed that in many cases the 
 fourth part of the empty duodenum lies to the right of 
 the vertebral column in the adult, and that in such cases 
 it is only displaced to the left by distension. In the 
 infant Dwight said the fourth part is usually to the right 
 of the column (85). Hartmann (Bull. Soc. Anat., Paris, 
 1889), on the other hand, wrote that the terminal part of 
 the duodenum is only exceptionally to the right of the 
 column. Even if Dwight's view be taken, it could not 
 account for the condition observed by Jordan in the 
 obviously distended duodenum. It is plain that Jordan 
 has not considered the possible cessation of the shadow 
 at the point of crossing of the gut by the superior mesen- 
 teric vessels. 
 
 In their relation to the peritoneum, the several parts' 
 of the duodenum differ markedly from each other. The 
 first part is entirely surrounded by peritoneum, as is the 
 
122 THE DUODENUM 
 
 Stomach, Indeed, extensions of both gastro-hepatic and 
 greater omenta are carried along continuously from the 
 stomach on to the first part of the duodenum. Further, 
 in one subject out of four the gastro-hepatic omentum 
 extends to the gall bladder, so that from this organ to 
 the duodenum there is, in such cases, a peritoneal band, 
 which is called the cysto-duodenal ligament (i66). 
 Sometimes this is continuous over the ventral face of the 
 duodenum with the greater omentum, and thus the 
 duodenum is bound also to the transverse colon by 
 the so-called duodeno-colic ligament. Previous to the 
 passage of a gall stone into the duodenum by direct 
 ulceration, many adhesions are formed between gall 
 bladder and duodenum, with the cysto-duodenal ligament 
 as a nucleus. 
 
 The second part of the duodenum is bound down to 
 the dorsal abdominal wall by peritoneum. Indeed, even 
 the ventral aspect of the organ is devoid of a peritoneal 
 coat where the transverse colon crosses it. The perito- 
 neum passes directly from the duodenum on to the 
 ventral aspect of the right kidney. Kocher's method of 
 mobilising the duodenum in cases in which it is desirable 
 to remove a gall stone from the common duct or Vater's 
 ampulla from behind, consists in incising the peritoneum 
 over the right kidney and turning the bowel, freed in 
 this manner, forward and to the left (191). As the first 
 and second parts of the duodenum form part of the dorsal 
 wall of the subhepatic channel (see p. 28), it follows 
 that perforation of the ventral wall of the first part, in 
 duodenal ulcer, will result in the passage of contents to 
 the right or left, but more usually the drainage is to 
 the right into the peritoneal pocket to the lateral side of 
 the right kidney, in other words, into the area known 
 
THE DUODENUM I 2^ 
 
 as the right kidney pouch of Rutherford Morison (p. 
 22) (312). As the appendix may also drain into the 
 pouch, local tenderness may occur over this area either 
 from appendicular abscess or from a perforated duodenal 
 ulcer (248). 
 
 Here one may observe that it is the peritoneal coat 
 which is most important in preventing sutures from 
 tearing out of the bowel wall. Where the gut is not 
 covered by peritoneum, the wall is friable and does not 
 hold sutures. Consequently when it is necessary in cases 
 of extensive resection of the pylorus to mobilise the 
 second part of the duodenum and to divide it rather 
 than the first part, the dorsal wall of the gut which is 
 devoid of peritoneum requires special care in suturing. 
 Krogius advises that after lig'ature or suture that part 
 of the duodenum from which the peritoneal coat is absent 
 should be depressed into the intestinal lumen and buried 
 by a continuous Lembert- suture uniting the adjacent 
 margins of the peritoneal defect (193). 
 
 The third part of the duodenum, like the second, is 
 devoid of a mesentery and, further, it is also uncovered 
 by peritoneum where it is crossed by the root of the 
 mesentery with the included superior mesenteric vessels. 
 Reference has already (p. 119) been made to the connec- 
 tion of this with duodenal stasis and injury. 
 
 Between the fourth part of the duodenum and the 
 hilum of the left kidney in the adult, there is a vertical 
 fold of peritoneum raised by the left colic artery, a 
 branch of the inferior mesenteric artery, and the inferior 
 mesenteric vein, a tributary of the splenic. Together 
 these vessels form the vascular arch of Treitz. The 
 terminal part of the duodenum and the vascular arch, 
 with the splenic vein above and the commencement of 
 
124 
 
 THE DUODENUM 
 
 the left colic artery below, form the ramparts, as it were, 
 of a peritoneal fossa. The peritoneal folds do not, 
 however, always lie over the structure which probably 
 was the original cause of the fold. But any one of these 
 folds may form a poclcet of peritoneum into which an 
 internal hernia may find its way (251). They are 
 superior, inferior, right and left duodenal foss« respec 
 
 tively. , , 
 
 The duodenum has a greater calibre than any succeed- 
 
 Fig. 18. Tracing from radiogram taken of patient suffering from 
 duodenal irritation. Tlie duodenal cap is well shown, but this is apparent 
 also in normal individuals. The open pylorus allowing continuity between 
 the shadows of the pyloric canal and duodenal vestibule is characteristic 
 of the lesion. 
 
THE DUODENUM 1 25 
 
 ing portion of the small intestine. In cases of congenital 
 hypertrophic stenosis of the pylorus, the diameter of the 
 lumen shortly after birth is only about five mm. (half 
 the normal). This must be borne in mind in contem- 
 plating operations for the relief of the condition (70). 
 The first portion of the duodenum is generally con- 
 sidered to be the most capacious. Its lumen is egg- 
 shaped (85), and when filled with bismuth, its radio- 
 graphic shadow has been termed the " bulbus duodeni " 
 by Holzknecht. It is also known as the vestibule or 
 antrum. In congenital stenosis of the duodenum this 
 portion may become so distended that it resembles the 
 second pouch of a bilocular stomach. The dilatation of 
 the stomach and duodenal vestibule which occur in such 
 instances, together with the relative constriction at the 
 pylorus, have given rise in some cases to the mistaken 
 diagnosis of hour-glass stomach (74). On the other 
 hand, Dwight, by taking casts of the lumen of the 
 duodenum found the greatest circumference to occur in 
 the second and third portions. He stated that the second 
 part may be very large and yet not over-distended (85). 
 Congenital duodenal occlusion is a very rare condition. 
 According to Tandler it occurred nine times in 150,000 
 children in Petrograd. It is probably due to the 
 discrepancy in time between the period of epithelial 
 increase and that of growth in size of the lumen of the 
 gut, rather than to the persistence of the omphalomesen- 
 teric duct or artery, or to the presence of amniotic bands 
 (Tandler). Between the thirtieth and the sixtieth day of 
 foetal life there is an increase in the epithelium of the 
 mucosa of the duodenum, which, occurring in advance 
 of a corresponding increase in the calibre, occasions a 
 blocking of the lumen of the gut. There is most perfect 
 
126 THE DUODENUM 
 
 occlusion halfway during this period, after which the 
 lumen is reformed, and at the end of this period the 
 process terminates (322). With greater exactitude F. P. 
 Johnson describes this process as the temporary oblitera- 
 tion of the lumen owing to vacuolation in the mucosa 
 of the gut. The vacuoles extend throughout the entire 
 length of the duodenum in the embryo of 16 mm., but 
 are most numerous just below the opening of the bile 
 and pancreatic ducts, at which site the lumen is com- 
 pletely occluded. While the lumen again became 
 pervious in Johnson's embryo of 19 mm., it was once 
 more blocked at 22'8 mm. But at the 30 mm. stage the 
 vacuoles have completely disappeared from the duode- 
 num (162). 
 
 Hence temporary occlusion of the duodenal lumen is 
 a normal physiological process in early foetal life. We 
 now know that this process of partial occlusion of the 
 lumen is not restricted to the duodenum, but occurs 
 throughout the intestinal tract. As a rule occlusion or 
 stenosis of the duodenum occurs in the neighbourhood 
 of the entrance of the common bile duct (179). Some- 
 times the gut may be actually interrupted at this site, 
 in which case it looks as if there might have been some 
 cause at work external to the gut itself (112). 
 
 Besides congenital defect of the gut, other causes cited 
 as producing duodenal occlusion are a general inversion 
 of the abdominal viscera and a ring-shaped pancreas, 
 which encircles and is supposed to constrict the duode- 
 num (233), 
 
 The mucosa of the first part of the duodenum is smooth 
 and presents neither the plicEE circulares (valvuli conni- 
 ventes), which commence in the second part opposite to 
 the entrance of the common bile duct, nor the irregular 
 
THE DUODENUM 1 27 
 
 folds found in the cadaver, especially on the dorsal wall 
 of the second or third part (85). 
 
 As in the rest' of the small intestine, villi are present 
 throughout, but in addition there are certain glands 
 peculiar to the duodenum known as Brunner's glands. 
 The precise function of their secretion is not understood. 
 They are most numerous in the first part of the organ 
 and in the second part as far as the entrance of the 
 common bile duct. Beyond this point they decrease in 
 number and finally cease at or about the duodeno-jejunal 
 junction (273). Their final distal limit forms, therefore, 
 a very useful indication of the termination of the 
 duodenum. But Villemin does not admit their presence 
 even so far as the duodeno-jejunal flexure (see p. 113). 
 
 So-called pressure diverticula of the mucous membrane 
 occur at what are termed weak points. As a rule these 
 are found at or near the entrance of the common bile 
 duct and the pancreatic ducts (180). They may occur 
 either just distal to the common bile duct or immediately 
 proximal to it (293) (276). Sometimes they consist of 
 miicous membrane only; sometimes they also present 
 muscular tissue in their wall. They may occur in the 
 third part and present no relation to bile or. pancreatic 
 ducts (157). The various cases in the literature and the 
 suggested etiology have been .collected and summarised 
 recently by Baldwin (7). In many cases, if not all, the 
 diverticula are congenital in origin, and have been shown 
 by Lewis and Thyng to be the final result of knob-like 
 extensions from the mucosa (204). 
 
 Duodenal ulcer of the peptic variety occurs as a rule 
 on the ventral .wall within two or three cm. of the pylorus. 
 Certain cases are recorded in which the ulcer is stated 
 to have occurred in the wall of the second part, but in all 
 
128 THE DUODENUM 
 
 probability the misleading appearance in such instances 
 has been due to the adhesion of the ulcerated bowel, to/ 
 surrounding structures with the result that the affected! 
 portion has been brought into close apposition with the 
 right kidney (252). Sometimes the duodenum at the 
 site of ulceration becomes adherent to the liver or gal| 
 bladder. This may cause referred pain in the hepatic 
 area, i.e., the right infrascapular region. If the ulce| 
 occur on the dorsal wall, adhesions to the pancreas may 
 develop. In all cases of ulcer with adhesions, it is saiq 
 that the pain occurs much later after a meal than if nd, 
 adhesions are present (252), and that the pain also occursi 
 later if the ulcer be on the dorsal wall (252). 
 
 Primary carcinoma of the duodenal mucosa is as rare 
 as it is elsewhere in the small intestine. The cases of 
 so-called duodenal carcinoma start in the termination of 
 the common bile duct or in the pancreatic duct or tissue. 
 
 The muscular coat of the duodenum was recently 
 studied by Ochsner, who described special sphincteric 
 bands of circular muscle of varying widths and at 
 varying sites in the organ. One of the most common 
 positions was from three to ten cm. distal to the entry 
 of the common bile duct (261). Very quickly, however, 
 the presence of these special sphincters was denied by 
 Boothby (38), and it is now recognised that they represent 
 mere irregularities in the thickness of the circular 
 muscular coat induced by varying irritability and 
 contraction of the muscle after death. These irregu- 
 larities ai'e numerous throughout the intestine, and are 
 specially obvious in formalin hardened cadavera (339). 
 
 Although Ochsner's findings are not substantiated as 
 actual morphological sphincters, it must be understood 
 that the contraction forms represent the living condition 
 
THE DUODENUM 1 29 
 
 of the duodenum in caricature, just as contraction forms 
 found post-mortem in the stomach present a caricature 
 of the living condition of that organ. Cannon and 
 Blake have shown that after the pyloric sphincter has 
 been cut, rhythmic contractions of the circular muscula- 
 ture of the duodenum prevent too rapid exit of food from 
 the stomach (51). This function of the duodenal muscu- 
 lature replaces that of the pylorus and ensures mixing 
 of the food with the bile and pancreatic juice. Its 
 importance after pyloroplasty is obvious. 
 
 Radiographic examination with the fluoroscope, as 
 already stated (p. 80), shows the pylorus to lie at a 
 lower level than in the cadaver. Whereas in the latter 
 it is at the level of the disc between the first and second 
 lumbar vertebrae (transpyloric plane), in the living it lies 
 normally one vertebra lower (on the infracostal plane). 
 In life the first part of the duodenum is often directed 
 almost vertically upwards from the pylorus to the 
 commencement of the second part. Hence the first part 
 lies even ventral to the second. In normal individuals 
 actual examination of the bismuth shadow in the 
 duodenum is difficult because of the rapidity with which 
 the food passes through this part of the bowel. The 
 entire length of the duodenum is traversed in from 
 twenty-five to sixty seconds (201). In addition, the large 
 quantity of digestive secretions which is mixed with the 
 bismuth and its vehicle so reduces the density of the 
 shadow as to make it almost invisible (141). It has, 
 however, been found possible by the use of a watery 
 suspension of bismuth given on an empty stomach, to 
 fill the duodenum and thus more readily to observe its 
 condition (201). Miiller claims to have observed con- 
 tractions in the first part of the duodenum, and states 
 
130 
 
 THE DUODENUM 
 
 that he has seen antiperistalsis in the descending part in 
 the absence of organic obstruction (254). Cannon and 
 Blake state that food accumulates in the duodenum and 
 there undergoes the process of rhythmic segmentation 
 to mix with the bile and pancreatic juice (51). Joseph 
 
 Fig. 19. Tracing of radiogram showing bismuth food in the duodenum 
 as far as the site of crossing of the transverse colon. The position at 
 which the bismuth terminates is near the site of Lane's second kink. 
 
 and Meltzer (169) have noticed in the rabbit that there 
 is a kind of receptive relaxation of the duodenum when 
 the pyloric portion of the stomach contracts. A similar 
 
THE DUODENUM I3I 
 
 relaxation of the duodenum, in association with a hyper- 
 tonic stomach, is present in cases of duodenal ulcer. 
 
 In normal individuals examined by the ordinary 
 methods, a shadow is seen only in the first part of the 
 duodenum. This is the "duodenal cap" or " bulbus 
 duodeni." No shadow is perceptible in the rest of .the 
 organ. If the rapid radiogram is used, small flecks of 
 bismuth are seen scattered throughout the duodenum 
 (201). In the condition known as gastroptosis, and in 
 organic obstruction of the bowel, true duodenal stasis 
 may occur with consequent appearance of the bismuth 
 shadow oyer more than the first part of the duodenum 
 (140). 
 
 The shadow is recognised as being in the duodenal 
 vestibule by the fact that it is unaffected by the peristalsis 
 of the stomach. Such a shadow, which is more persistent 
 than usual, is seen in cases of duodenal ulcer (12). It is 
 not, however, diagnostic of this condition, for it is equally 
 met with in puckering of the duodenum from any cause, 
 as for example, in carcinoma and in cholecystitis (14). 
 In every case the patient must be examined in the 
 horizontal as well as in the upright posture, for the 
 passage of food through the duodenum can be seen with 
 greater ease when the patient is lying down than when 
 he is standing up. Apart from the'"bulbus duodeni " 
 a persistent separate shadow in the duodenum is very- 
 suggestive of the formation of a pocket produced by 
 spasm, cicatrisation, adhesions, growth or diverticulum 
 (14). Duodenal stasis can be induced even in a healthy 
 patient by giving rapidly a large amount of bismuth 
 food. The stomach is thus weighed down, and 
 apparently constricts the duodenum at the crossing of 
 the superior mesenteric vessels. Such a view is in 
 
132 THE DUODENUM 
 
 accordance with that put forward by Mathieu in acute 
 post-operative distension (227), and will explain the 
 appearance found in Jordan's cases (167), and that 
 mentioned on p. 57 of Barclay's book (14). Cole holds 
 that bismuth does not adhere to the crater itself of an 
 ulcer, but that by the use of serial radiography he can 
 diagnose duodenal ulcer from indentations on the contour 
 of the bulbus produced by cicatricial contraction around 
 the crater. He admits, however, that one cannot always 
 eliminate the puckering due to adhesions caused by gall 
 bladder infections (67). Very frequently in cases of 
 duodenal ulcer the bismuth shadow is not interrupted 
 at the pylorus as it is in normal individuals, biit is 
 continuous as a thin streak from stomach to duodenum 
 owing to inefficient contraction of the pyloric sphincter 
 (254). Cole states that by the use of serial radiography 
 if one radiogram out of fifty shows a perfectly symme- 
 trical cap or " bulbus " and a normal pyloric sphincter, 
 a negative diagnosis of duodenal ulcer is justified (68). 
 The arterial supply of the duodenum comes partly 
 from the coeliac axis vessel via the superior pancreatico- 
 duodenal branch of the gastro-duodenal artery, which 
 itself arises from the hepatic trunk, and partly from the 
 superior mesenteric artery through the inferior pancrea- 
 tico-duodenal branch. These two vessels form a loop 
 around the head of the pancreas. According to Wilkie, 
 the first part of the duodenum does not get its blood 
 supply direct from the main trunk of the superior 
 pancreatico-duodenal vessel, but through a branch which 
 arises from the proximal part of the gastro-duodenal 
 artery or more rarely from the hepatic vessel or from one 
 of its branches, the right terminal, left terminal or cystic 
 artery. The special artery for the first portion of the 
 
THE DUODENUM 1 33 
 
 duodenum was called by Wilkie the supra-duodenal 
 vessel, and as usual with the arteries on the intestinal 
 wall, in the majority of cases it .presents no anastomosis 
 with neighbouring arterial channels. Even when com- 
 munication with the right gastric (pyloric) or with the 
 duodenal branch of the right gastro-epiploic artery does 
 take place, it is never very free (345). Hence, as in the 
 appendix, Wilkie believes that interference occurs easily 
 in the blood supply to the first part of the duodenum. 
 In duodenal ulcer, haemorrhage frequently comes from 
 the gastric mucosa (269). But if one of the pancreatico- 
 duodenal arteries be involved, the superior vessel is 
 always the one affected. It is ulcerated in its course 
 along the first part of the duodenum on its way to the 
 adjacent parts of that organ and of the pancreas. Mayo 
 has drawn attention to the anaemic spot which often 
 appears on the ventral wall of the first part of the 
 duodenum if the gut be stretched by traction on the 
 pylorus. Wilkie considers that in such cases the supra- 
 duodenal artery arises at a high level, and running down 
 to the duodenum, has its lumen narrowed when the 
 artery is stretched by the traction. A similar appearance 
 in the peritoneal coat frequently accompanies duodenal 
 ulcer (229). 
 
 The veins of the duodenum call for no special comment. 
 
 The lymphatics drain into the nodes immediately 
 around the head of the pancreas. The so-called 
 " duodenal gland," which lies behind the third portion 
 in the root of the mesentery close to the commencement 
 of the superior mesenteric artery, does not drain the 
 duodenum, but is one of the main nodes as defined by 
 Jamieson and Dobson (161), and derives its vessels ulti- 
 mately from the ileo-caecal region. 
 
134 THE DUODENUM 
 
 The nerve-supply to the duodenum originates in the 
 vagus and splanchnic trunks, the splanchnics ultimately 
 coming from the ninth dorsal segment (133). Hence 
 pain referred from the duodenum is localised in the 
 median line in the umbilical region as in pyloric disease, 
 or may be present to the right of the middle line at the 
 same level (252), especially if adhesions to the gall 
 bladder be present. 
 
CHAPTER VIII. 
 
 The Jejuno-Ileum. 
 
 The major portion of the small intestine, constituted by 
 the jejunum and ileum, remains to be considered. As 
 already mentioned, the jejunum commences at a site 
 marked by the beginning of the mesentery, although in 
 certain cases the first inch or so of the jejunum, like the 
 duodenum, may be bound down by peritoneum to the 
 dorsal abdominal wall. In the majority of cases the 
 commencement of the jejunum lies to the left of the 
 median plane. 
 
 The jejuno-ileum terminates at the ileo-caecal or ileo- 
 colic junction, which normally lies in the right iliac 
 fossa. Following on variations in the site of the caecum, 
 however, the distal end of the ileum may be found else- 
 where in the abdomen. As a rule the ileum ascends, but 
 sometimes it descends to its termination, especially if the 
 coils of intestine are arranged in other than the usual 
 manner. Sometimes the terminal part of the ileum is 
 attached to the right psoas' sheath by a non-inflammatory 
 fold of peritoneum continuous with the under or left 
 layer of the mesentery. Occasionally the last few inches 
 of ileum are adherent to the cascum, though again this is 
 not an inflammatory adhesion (329). 
 
 The subdivision of the jejuno-ileum into its constituent 
 parts, jejunum and ileuni, is ill-defined and of no 
 particular significance. As a rule it is stated that the 
 proximal two-fifths of the small bowel (excepting the 
 duodenum) constitute the jejunum, while the distal three- 
 fifths form the ileum. 
 
 ]35 
 
136 THE JEJUNO-ILEUM 
 
 Bardeen has stated that there arises from the superior 
 mesenteric artery, opposite its ileo-c«cal branch, a vessel 
 which passes to the small bowel near the junction of its 
 upper and middle thirds. This Bardeen calls the jejuno- 
 ileal artery, and he suggests that the region supplied by 
 this vessel represents the junction between that portion 
 of the small intestine, the primitive coils of which 
 develop within the umbilical cord, the ileum, and that 
 whose primitive coils develop within the abdominal 
 cavity, the jejunum (C. R. Bardeen, Am. Journ. Anat., 
 1914, vol. 16, p. 427, and Anat. Rec, 1915, vol. 9, p. 137). 
 
 The position in the abdomen of the several parts of 
 the jejuno-ileum has been the subject of several investi- 
 gations. Of late Monk has stated that usually the upper 
 part of the jejunum lies in the left hypochondrium, the 
 lower jejunum and upper ileum to the right of the 
 median line under the liver, the succeeding portion of 
 ileum to the left of the median line in the lumbar and 
 iliac regions and the, terminal portion in the pelvis and 
 right iliac fossa (242). This is marked out in surface 
 topography in a very simple manner (see p. 141). Unfor- 
 tunately this disposition of the bowel is not invariable. 
 Even in the adult, the gut is in many instances otherwise 
 disposed. The amount of bowel in the pelvis naturally 
 varies with the distension of the bladder and rectum, and 
 in pregnancy with the size of the uterus. But the pelvis 
 may contain even loops of jejunum in addition to the 
 lower ileum (329). In the foetus in many cases the coils, 
 while starting in the left hypochondrium, as in the adult, 
 pass first downward and then upward on the right side 
 of the abdomen to the caecum, which lies just beneath 
 the liver. In the young child the arrangement is rather 
 that of the older foetus than of the adult (329). In 
 
THE JEJUNO-ILEUM 1 37 
 
 embryos of from 7 mm. to 40 mm. in length a part of 
 the intestine is found within the ccelom of the umbilical 
 cord. At the 40 mm. stage it suddenly returns to the 
 peritoneal cavity. The upper part of the portion extruded 
 is the first to return, and the caecum is the last. As the 
 upper part of the small bowel returns, it assumes its 
 position in the left side of the abdomen (226). The 
 existence in certain children of a loop of jejuno-ileum in 
 the coelom of the umbilical cord at birth, thus forming a 
 congenital umbilical hernia, may be a persistence of or 
 a return to the condition found in early foetal life. 
 
 As regards the distance from the mouth to the jejunum, 
 it need only be said that Gross has succeeded in passing 
 a tube 150 — 200 cm. along the alimentary canal, thereby 
 withdrawing a light yellow, cloudy, thick, neutral or 
 weakly acid fluid, which he claims to be typical, jejunal 
 juice (119). 
 
 The length of the intestine in the cadaver is about 7 
 to 8 metres. During fife its elasticity enables it to 
 lengthen somewhat more. After the intravascular injec- 
 tion of formalin, the length of bowel decreases to 4 or 5 
 metres. In the infant the gut is relatively longer than in 
 the adult. 
 
 The jejuno-ileum is provided with a mesentery 
 throughout its whole length save in those instances in 
 which either the commencement or termination is bound 
 down to other structures by peritoneum. 
 
 The successive portions of the jejuno-ileum have 
 certain distinguishing features, some of which are in the 
 gut itself and some in the mesentery, and by these a 
 rough idea may be obtained of the relative distance from 
 the duodenum or csecum, of any given loop of intestine. 
 These have been described by Monk (242), and more 
 
138 THE JEJUNO-ILEUM 
 
 recently investigated by Latarjet and Forgeot (199), who, 
 however, did not describe any material characters beyond 
 those already stated by the former author. On palpation 
 the upper part of the jejuno-ileum seems thick because 
 of the plic£e circulares (valvuli conniventes) in its walls. 
 As these become fewer, the wall of the gut feels thinner 
 on palpation until in the lower ileum, which is practically 
 devoid of plic£e, the wall feels much thinner than near 
 the duodenum. 
 
 The fat in the mesentery increases progressively in 
 amount in the distal direction. But observing this fact 
 one must remember that there is as a rule a much greater 
 proportion of fat throughout the mesentery of the male 
 adult than in that of the female. Latarjet and Forgeot 
 point out that these fatty tufts do not occur in the 
 mesentery of the upper half of the jejuno-ileum of the 
 adult nor anywhere throughout the mesentery of the 
 fcetus or infant. Consequent on the comparative lack 
 of fat in the mesentery of both sexes in the upper jeju- 
 num, this portion of gut exhibits in its mesentery close 
 to the bowel wall semilunar areas known as lunules, 
 which are entirely devoid of fat. Lastly the number of 
 arterial arches in the mesentery progressively increases 
 from one to three or four in the downward direction. 
 This increase in the number of arches also occurs, 
 though in less obvious manner, in the case of veins (81), 
 which are more obvious on the right face of the mesen-' 
 tery, while the arteries attain greater prominence on thf 
 left face (199). 
 
 The mesentery may be the site of development of cysts, 
 frequently of Wolffian origin (259). They are mobile 
 and form tumours palpable through the abdominal wall, 
 though not usually diagnosed as such before operation. 
 
THE JEJUNO-ILEUM 1^9 
 
 Scattered throughout the mesentery are smooth muscle 
 fibres, homologous with the suspensory muscle of Treit^. 
 Reference has already been made to the thickened portion 
 of this muscle which indicates the duodeno-jejunal junc- 
 tion (see p. 112). It is a muscle bilateral in character, 
 suspending the coils of intestine to the dorsal abdominal 
 wall. In man it is especially thickened where it arises 
 from the two crura of the diaphragm (217). Smooth 
 muscle fibres have also beein observed by Rost in the 
 transverse mesocolon near the hepatic flexure (296). 
 Possibly the oesophageal muscular tendrils which con- 
 nect that organ to surrounding structures belong to this 
 same muscular sheet, which has thickened bands in other 
 situations in lower animals (26). The muscle tends to 
 become changed into fibrous tissue as age advances and 
 in visceroptosis. In the foetus much more involuntary 
 muscular tissue is found in the muscle of Treitz, in the 
 adult more elastic tissue (76). The muscle was regarded 
 by Keith as being composed of two parts, the upper 
 derived from the diaphragmatic crura and like them 
 composed of striated muscle, the lower from the sub- 
 peritoneal layer of muscle which also gives rise to the 
 gubernaculum (181). 
 
 The action of the mesentery in entero-colic intussuscep- 
 tion is worthy of note. Barnard described it thus (20) : 
 " It is difficult to understand how the short piece of 
 mesentery to the last three or four inches of the ileum 
 can permit the ileo-cascal valve to traverse the colon from 
 end to end, and even project from the anus. It must, 
 however, be remembered that this portion of the mesen- 
 tery is attached about the promontory at the centre of 
 the abdomen. From this centre the mesentery swings 
 round like the hand of a clock, and sinQe the^ length of 
 
140 
 
 THE JEJUNO-ILEUM 
 
 the entering layer is not increased, no extra length of 
 mesentery is required to reach the intussusception as it 
 passes along the colon around this centre. The meso- 
 
 Fig. 20. Chart to illustrate Monk's statements on the localisation of 
 the intestine in the cadaver. 
 
 The solid black line represents the rough delineation of the attachment 
 of the mesentery to the dorsal abdominal wall. The broken lines A and 
 B are drawn at right angles to the line of mesenteric attachment. 
 Successive portions of jejuno-ileum are lodged in the areas I, II, III 
 and IV. Compare with figs. 19, 21, and 22. 
 
 colon in infants is extraordinarily loose and long. This 
 permits each part of the colon in turn to be drawn 
 towards the promontory around which the intussuscep- 
 
THE JEJUNO-ILEUM 14! 
 
 tion travels in quite a small circle until it passes vertically 
 down the rectum and out of the anus." 
 
 Occasionally holes are found in the mesentery and 
 may be the cause of internal hernia, which sometimes 
 becomes strangulated. Doubtless some of these holes 
 are of traumatic origin, but the majority are not. Treves 
 states that most are found in the mesentery of the 
 terminal part of the ileum between the ileo-colic branch 
 of the superior mesenteric artery and the last of the vasa 
 brevia to the small intestine. Though not constant, this 
 area, which is conspicuous by its thinness and blood- 
 lessness, is found also in the foetus and in children 
 under puberty, in whom its diameter measures about 
 3 cm (329). 
 
 The surface topography of the mesentery and small 
 bowel is comparatively simple. In the cadaver the upper 
 limit of the mesentery lies at the level of the transpyloric 
 plane, 3 cm. to the left of tl}e median line. The termina- 
 tion lies at the intersection of the intertubercular and the 
 right lateral inguinal lines. A straight line drawn from 
 the first to the second of these points indicates roughly 
 the attachment of the mesentery tO the dorsal wall of 
 the abdomen. As a rule, however, the terminal inch or 
 so of the mesentery is attached obliquely to the dorsal 
 wall in an upward and outward direction. Hence it is a 
 little more exact to indicate the attachment of the mesen- 
 tery by a line starting at the same point as before, but 
 terminating midway between the right anterior superior 
 iliac spine and the median plaqe (317)- From this a 
 short line drawn obliquely upward and outward to the 
 intersection of the intertubercdlar .and right lateral 
 inguinal lines indicates the terminal upward^ curve of 
 the mesenteric attachment. The commencement of the 
 
142 THE JEJUNO-ILEUM 
 
 jejunuip and therefore of the mesentery is often lower 
 by the lareadth of a vertebra in the living than it !s in the 
 cadaver. Hence the mesentery in the living may be 
 said to commence on the infracostal plane or just above 
 it. In mapping out, on the_ surface the position of the 
 small intestine, Monk recommends first that the line of 
 the mesentery be drawn in and then at each end of this a 
 line at right angles to it. Thus the abdomen is sub- 
 divided into four areas, one above the mesentery and to 
 the left, one on each side of the mesentery^, of which the 
 right lies obliquely above the left, and one below the 
 mesentery comprising the pelvic cavity and right iliac 
 fossa. , The first portion of jejuno-ileum lies in the 
 uppermost of these areas, the next in the one to the right 
 of the mesentery, succeeding coils in the area to the left 
 of the mesentery, and the terminal portion in the lowest 
 area including pelvis and right iliac fossa (242). 
 
 The mucosa of the jejuno-ileum is about o'5 mm. in 
 thickness, and very loosely attached to the submucosa. 
 It exhibits plicze circulares and villi, the latter through- 
 out its extent, the former most abundantly in the upper 
 jejunum, but fewer in a downward direction until in the 
 terminal part of the ileum none are found. They consist 
 of a fold of mucosa with some submucous tissue, and 
 extend for a variable distance round the wall of the gut. 
 The greater number only pass round one-third of the 
 wall. Some, however, pass round two-thirds, and some 
 form complete rings or may even subdivide. As is to 
 be expected, the contraction in length of the bowel after 
 formalin embalming results in the appearance of more 
 plicae than normally exist in the intestine of the living. 
 F. P. Johnson noticed in his work on the bowel that 
 when the intestine is distended the villi and glands 
 
THE JEJUNO-ILEUM .143 
 
 become shorter and broader, and that they may even 
 disappear on great distension. From this he argues 
 that, with each dilatation and contraction in normal 
 diastalsis and seg^nentation movements, the villi change 
 their sliape ^nd bring about a more thorough mixing of 
 the contents. He also suggests that by the unfolding of 
 the glands, a greater amount of epithelium is exposed to 
 the intestinal contents (163). While not denying that 
 these phenomena may occur experimentally, one would 
 doubt whether they really are of much effect in distension 
 and contraction under normal conditions in the body. 
 
 The lumen of the jejuno-ileum progressively' dimin- 
 ishes towards its termination. While it is 37 rnm. in 
 diameter near the duodeno-jejunal flexure, it is only 
 27 mm. in diameter near the ileo-caecal junction (166). 
 In the jejuno-ileum the same vacuolation of the mucosa 
 which is found in the duodenum occurs during early 
 ■ foetal life (see p. 125), but the lumen of this part of the 
 gut is never completely occluded. Associated with these 
 vacuolations are diverticula or pockets which occur 
 throughout the length of the small intestine (204). They 
 are much rarer in the upper jejunum than elsewhere and 
 are most common in the ileum (162). The difference 
 between these pockets and those of the duodenum is that 
 whereas in the latter portion of the gut they are often 
 on the side of the bowel adjacent to the pancreas, in the 
 former ' they are always on the wall of the intestine 
 furthest from the mesentery and invariably point distally 
 (Elze, see 162). It is suggested by Lewis and Thyng 
 that these diverticula may be one cause of para-intestinal 
 cysts (204). Associated with pockets in the duodenum 
 may be accessory pancreatic tissue, and a small pancreas 
 has been known to develop even at the umbilicus in 
 
144 THE JEJUNO-ILEUM 
 
 connection probably with a diverticulum of the embryonic 
 jejunum (352). 
 
 The best-known pocket in the jejuno-ileum is Meckel s 
 diverticulum, which is of varying size and situation and 
 which represents the^ embryonic connection between the 
 mid-gut and the yolk-sac. It is found in 2 per cent, of 
 autopsies and it opens into the ileum usually between 
 two and three feet from the ileo-caecal junction (34). 
 When the mid-gut is withdrawn into the abdomen from 
 the coelom of the cord, a portion of the intestine may be 
 left to form a congenital umbilical hernia. Or the entire 
 mid-gut may return to the abdomen but leave a patent 
 diverticulum still connecting the bowel to the umbilicus, 
 and thus give rise to one form of umbilical fistula. The 
 obliterated duct may remain to form a band whose free 
 extremity is attached to another coil of gut, and thus 
 predispose the individual to internal strangulation of a 
 loop of bowel. Lastly, a small diverticulum alone may 
 be present. Barnard (22) noted that in connection with 
 Meckel's diverticulum there may be four varieties of 
 cords which cause obstruction to the bowel : — 
 
 1. Cords from the apex of the diverticulum to the 
 
 umbilicus (atrophy of the duct). 
 
 2. Cords from the apex of the diverticulum to an 
 
 adjacent part of the mesentery. 
 
 3. Cords from the mesentery to the umbilicus. 
 
 4. Bands from inflammatory adhesions of the diver- 
 
 ticulum. 
 Among mammals Chalmers Mitchell found no trace 
 of Meckel's diverticulum, but it occurs constantly in 
 certain groups of birds, in which it is provided with a 
 mesentery which is an extension from that of the ileum 
 (182). A similar condition is occasionally found in man. 
 
THE JEJUNO-ILEUM 1.45 
 
 Sometimes the diverticulum is hammer-shaped (113). In 
 certain cases it is difficult to be sure whether the fibrous 
 band present is inflammatory or embryonic in origin 
 
 (265). 
 
 The lumen of the jejuno-ileum may be narrowed or 
 obliterated at any situation. Often, as in Clogg's second - 
 case, the occluded portion is near the distal extremity 
 (61). Sometimes a portion both of the gut and of the 
 corresponding mesentery is absent (341), and the condi- 
 tion may or may not be coexistent with a Meckel's 
 diverticulum. 
 
 The submucosa of the intestine is dealt with elsewhere 
 
 (P- 34)- 
 
 The muscular coat of the jejuno-ileum consists pf a 
 superficial longitudinal layer and of an inner circular 
 layer with coarse elastic fibres between. The muscular 
 coat gradually becomes thinner toward the ileo-caecal 
 junction. Its average thickness is about o"4mm. of 
 which the circular layer forms about two-thirds. The 
 longitudinal layer is fairly firmly attached to the over-, 
 lying peritoneal layer, and is thin at the mesenteric 
 aspect of the gut, where it may even be wanting in 
 places, and thickest in the wall opposite to the attach- 
 ment of the mesentery. The circular layer shows here 
 and there a hiatus for the passage of vessels and nerves 
 to the mucosa and submucosa (166). In the dissecting- 
 room the jejuno-ileum is frequently found irregularly 
 contracted. This has been shown by Waterston to be 
 occasioned by the formalin of the embalming fluid, 
 acting on areas of varying irritability. In cases in 
 which the irritability of the intestine had been dimin- 
 ished, for example, in septic peritonitis, thi? irregular 
 contraction does not occur to such an extent. 
 
146 THE JEJUNO-ILEUM 
 
 The normal movements of the bowel are of the 
 segmentation and diastaltic varieties, with perhaps 
 " pendulum " movements. At times the so-called peris- 
 taltic rush and possibly antiperistalsis occur. For a 
 fwJl discussion of these the reader is referred to Cannon's 
 monograph (48). 
 
 Segmentation movements intimately mix the food with 
 the digestive juices, and expose it to the organs of 
 absorption. They also assist the blood flow from the 
 submucous plexus into the radicles of the superior 
 mesenteric vein and propel the lymph along the lacteals. 
 They only involve about a one centimetre of the gut at 
 one time, and consist of a wave of contraction alone 
 without a preceding wave of inhibition such as occurs 
 in diastalsis. They are stimulated by distension of the 
 gut. When the contraction begins, the ring of muscle 
 becomes refractory and will not respond again to the 
 stimulus of stretching until it is relaxing. Hence a 
 continuous stimulus results in a rhythmic response, and 
 the contraction always occurs in the bulging part midway 
 between the sites of two previous contractions. In man 
 about seven divisions occur in one minute (142), and give 
 rise to characteristic sounds (49). ' 
 
 Another form of slow peristalsis which appears to be 
 allied to the katastaltic movement consists in the onward 
 progression of food in large masses rather than in small 
 divisions. Movements somewhat similar to those of 
 segmentation occur, but instead of merely subdividing 
 the food mass, they reunite it in addition and gradually 
 pass it onward toward the colon (48). 
 
 In diastalsis the wave of contraction is preceded by a 
 wave of inhibition, and it extends for four to eight centi- 
 metres along the intestine in an ab-oral direction at the 
 
THE JEJUNO-ILEUM 1 47 
 
 rate of one or two centimetres a minute. Mere mechani- 
 cal stimulus by .distension is probably not responsible 
 for the normal starting of diastaltic waves. The exciting 
 cause is more probably a chemical one, the degree of 
 digestion, the status of the mucosa or some relation 
 between these two factors, because different foods do not 
 pass along the intestine at the same rate. A like chemical 
 cause also is probably the main factor in bringing a 
 diastaltic wave to a finish. 
 
 The so-called "peristaltic rus'h "is essentially of the 
 same character, as other forms of diastalsis, and is 
 probably a response to chemical rather than to mechanical 
 stimulation. It probably occurs in abnormal conditions 
 of the intestine and may be the characteristic movement 
 when purgatives are given. Cannon has noted its 
 occurrence in the human after the giving of a soapsud 
 enema. It may sweep over the entire length of the small 
 intestine, taking but a minute or so to pass the whole 
 distance, or it may affect a large portion only of the 
 canal. 
 
 There are conflicting opinions regarding the occurrence 
 of antiperistalsis in the small intestine. Cannon, Kelling 
 and others indicate that such a movement may occur in 
 abnormal conditions (48). The clinical evidence that 
 such a movement may occur is quite equivocal, for as 
 pointed out by Barnard, there is no need to postulate 
 this phenomenon in order to account for "faecal" 
 vomiting (2p). 
 
 The relation of normal, movements of the intestine to 
 
 the two varieties of intestinal anastomosis is worth 
 
 consideration. In favour of lateral anastomosis and 
 
 against end-to-end union, it has been urged that in the 
 
 'former a large contact of serous surfaces can be produced 
 
148 THE JEJUNO-ILEUM 
 
 and that not only may the opening be made as large as 
 is desired, but also that this operation can be performed 
 without regard to the relative size of the intestinal parts 
 to be united. But intestinal openings tend to become 
 smaller with the course of time. In end-to-end suture 
 the transverse cutting of the gut destroys the local 
 mechanism which governs diastalsis. In lateral anasto- 
 mosis the circular muscular fibres which force the food 
 onward are cut. Contraction of the circular fibres in 
 either one or other of the overlapping intestinal ends 
 cannot force the food onward but only move it over into 
 the inactive part. Unless a co-ordinated advancing 
 contraction of the circular muscular fibres of the two 
 opposed loops should develop, no forward propulsion of 
 the food can occur. 
 
 Experimental investigation shows that this condition 
 does not develop, and therefore in lateral anastomosis 
 there is stasis of normal food material at the site of the 
 junction. This is not present in end-to-end suture, which 
 must, therefore, in spite of its greater difficulty and other 
 disadvantages, be held to be the more satisfactory 
 operation of the two (48). Should lateral anastomosis be 
 performed, care must be taken to leave no superfiuotis 
 intestine beyond the union, lest food stagnate in and 
 distend the proximal loop or invagination occur in the 
 distal loop, with consequent blocking of the opening. 
 
 The peritoneal or serous coat of the intestine is 
 adherent to the outer or longitudinal layer of the 
 muscular coat. 
 
 It has been pointed out by Latarjet and Forgeot (199) 
 that when the intestine distends, the mesentery does not 
 abut on the intestinal circumference as a radial to the 
 centre of the intestinal circle. The gut curves round to 
 
THE JEJUNO-ILEUM 
 
 149 
 
 lie to a certain extent dorsal to the mesentery, so that 
 the latter meets the intestinal circumference at a tangent, 
 the segment of intestinal lumen lying in front and to 
 the right of the mesentery, being much less when the 
 
 Fig. 21. Tracing of radiogram which shows a bismuth shadow in 
 the upper jejunum. The site was identified at operation as adjacent to 
 the obstruction. The jejunal shadow appears above the left iliac crest. 
 The duodenal bulb is shown together with shadows in the succeeding 
 portion of the duodenum as far as the crossing of the superior mesenteric 
 vessels (the region of Lane's second kink). Compare with fig. 20. 
 
 gut is distended than the segment dorsal and to the left. 
 
 Radiographic examination shows ■ that food passes 
 
 along the intestines very rapidly, the average rate for a 
 
 tnixed meal being about one inch a minute, that is, it 
 
ISO 
 
 THE JEJUNO-ILEUM 
 
 reaches the caecum from three and a half to five hours 
 after the meal (143). If a bolus can be observed in the 
 jejunum, it is seen to be broken up by the segmentation 
 movements and tossed back and forth, but on the whole 
 
 Fig. 22. Tracing from radiogram showing bismuth shadow in the 
 lower part of the small intestine. 
 
 The site of obstruction was identified at operation. Compare with 
 fig. 20. 
 
 passed onward (14). The segmentation movements occur 
 at the rate of about ten in a minute and a half (142). 
 This rate varies in different animals (48). As a rule the 
 movement is too rapid- for observation, and nothing but 
 
THE JEJUNO-ILEUM 151 
 
 a general abdominal opacity is apparent to the eye. If, 
 however, the bismuth contents can be observed, in the 
 upper part of the small intestine they are flocculent in 
 appearance, while in the lower part they present a 
 coagulated character (66). As a rule, the average time 
 before a meal reaches the caecum is four hours for 
 carbohydrates, five for fat and six for pure protein diet 
 (48). 
 
 In tubercular or other forms of adhesive peritonitis, 
 the segmentation contractions are defective, so that 
 shadows may be observed readily in the course of the 
 small intestine. In lesions of the jejunum the symptoms 
 are those of duodenal ulcer (14). 
 
 Sir W. A. Lane (198) has described a kink in the ileum 
 about two inches from the ileo-cascal junction. The kink 
 is said to be produced by the contraction of the mesentery 
 at the point, following, thickening of its left or under 
 layer, the thickening being an;effort on the part of nature 
 to hold up a caecum which is' otherwise slipping down- 
 ward because of its dilatation caused by the stasis of 
 contents within it. The idea has beien greatly elaborated 
 of late years. The thickening is said to be non-inflam- 
 matory, and to have no connection, though there may be 
 association, with appendicitis. It has already been 
 mentioned at the beginning of this chapter. The 
 rationale of postulating the dragging power of the csecum 
 will be discussed later (see p. r6o). There are many 
 facts and considerations which are opposed to the inter- 
 pretation given by Lane. 
 
 As regards the supply of the bowel-wall by blood 
 vessels, it is well to bear in mind that the arteries on the 
 wall itself do not anastomose with' each other very freely 
 if at all. Hence in resection of bowel one must be 
 
152 THE JEJUNO-ILEUM 
 
 careful to cut away rather less mesentery than gut and 
 to cut the bowel itself obli<[uely, thus leaving more of 
 the gut at the mesenteric attachment than at the point 
 diametrically opposite to this, in order that there be no 
 danger of gangrene occurring from loss of blood supply. 
 
 The arterial arcade systems in the mesentery have 
 already been discussed (p. 138). Corsy and Aubert 
 describe a particular artery from the inferior pancreatic 
 vessel to the duodeno-jejunal angle (72). 
 
 In occlusion of the mesenteric arteries, the collateral 
 circulation is rarely established. This is due to the 
 practical absence of anastomosis between the arteries on 
 the wall of the gut. Faber (98) explained that the 
 inferior mesenteric artery does not take up the work of 
 the occluded superior artery because it is smaller than 
 the latter and cannot suddenly assume the function of 
 the larger artery. In addition, when occlusion occurs in 
 the superior mesenteric artery, the pressure in the 
 superior mesenteric vein becomes reduced to nothing. 
 Consequently the pressure in the portal system is 
 lowered. Blood can flow more freely along the inferior 
 mesenteric vein, and thus it is easier for the blood in 
 the inferior mesenteric artery to flow by its natural 
 channel. 
 
 The loss of carbon dioxide from the bowel, especially 
 from its blood vessels, which occurs when the intestine 
 is exposed in abdominal operations is stated by Hender- 
 sort to be the cause of atony of the gut which sometimes 
 occurs as a complication in such cases, and is part of a 
 condition of acapnia, or, as he terms it, carbon dioxide 
 starvation (137). 
 
 The collecting lymphatic trunks of the jejuno-ileum 
 are extremely abundant. The lymphatic nodes are 
 
THE JEJUNO-ILEUM 1 53 
 
 divided into three groups, one close to the intestinal 
 wall, a second on the primary branches of the superior 
 mesenteric artery, and a third around the main trunis of 
 the vessel. The nodes are most numerous in that part 
 of the mesentery corresponding to the jejunum, and 
 again increase in number around the ileo-cjecal artery 
 (272). 
 
 The nerve-supply of the small intestine comes from the 
 vagi and the splanchnics, the former containing the tonic 
 and the latter the tonic inhibitory fibres. For after 
 complete severance of the splanchnics the rate of passage 
 of lean meat along the small bowel was found by Cannon 
 to be greatly accelerated, whereas after total section of 
 the vagi the passage was rendered slower than usual (48). 
 Apparently both sets of fibres are in continuous action. 
 A very full account of the innervation of the intestine 
 was recently given by Miiller (255). 
 
 Gastro-Jejunostomy. 
 
 Having now discussed both stomach and intestine, 
 some reference may with advantage be made to the 
 anatomy of gastro-enterostomy. Much information may 
 be obtained from Cannon's monograph, from which the 
 following account is largely extracted (48). 
 
 In spite of many clinical assertions to the contrary, 
 experimental evidence indicates that gastro-enterostomy 
 is never a " drainage " operation. If a stomach upon 
 which this operation has been performed be filled with 
 water, the liquid does not flow out through the artificial 
 opening even when the patient is standing erect. Gravity 
 has- very little action, and under ordinary circumstances 
 the food is semi-solid and not liquid like water. The 
 stomach is never a passive reservoir, although the 
 
154 THE JEJUNO-ILEUM 
 
 pressure in the pyloric part is greater than that at the 
 cardiac end. Material does not pass along the alimentary 
 canal by gravity or syphon action, but by the muscular 
 action of the wall. As digestion proceeds, the pylorus 
 rather than the greater curvature tends to become the 
 lowest part of the stomach, and therefore it is impossible 
 to perform gastro-enterostomy in the most dependent 
 part of the organ. The operation cannot relieve the 
 pyloric part of the stomach from irritation by food or 
 gastric juice, but as the alkaline juices which enter the 
 organ through the artificial opening neutralise the 
 stomach contents, the pyloric sphincter is relaxed and 
 food passes on more quickly into the duodenum. 
 
 In consequence of the greater fluidity and pressure in 
 the pyloric portion of the stomach, food will tend to pass 
 through the pylorus rather than through the artificial 
 opening which must be made some distance to the left 
 of the pylorus. 
 
 But if the pylorus be much narrowed, food passes more 
 readily through the gastro-enterostomy opening. Hence 
 Moynihan has insisted that the operation should be 
 performed only in the presence of demonstrable organic 
 disease (253). As secretion is produced in the jejunum 
 as well as in the duodenum, gastro-enterostomy does not 
 interfere seriously with its production. It is said by 
 Flynn that the digestion of milk is interfered with owing 
 to the inhibition of the secretion of rennin consequent 
 on the regurgitation of alkaline bile and pancreatic juice 
 into the stomach (102). But it has already been observed 
 that probably it is normal to have regurgitation of bile 
 at least into the pars pylorica of the stomach. Moreover 
 one does not find clinically that the patient is less able 
 to digest milk after gastro-enterostomy. 
 
THE JEJUNO-ILEUM 1 55 
 
 J All the same the . presence of acid chyme in the 
 duodenum is the normal stimulus to the flow of bile and 
 pancreatic -juice, and if the food passes directly from 
 stomach to jejunum these functions are seriously inter- 
 fered with (51). 
 
 Jejunal ulcer may develop after the performance of 
 gastro-enterostomy. Diarrhoea also forms one complica- 
 tion of the surgical treatment. It is possible that both 
 these occurrences result from the leakage of free acid 
 directly through the stoma into the intestine. For this 
 reason the operation should be performed as high in the 
 jejunum as possible where the bowel may be relatively 
 immune to acid contents. 
 
 The posterior operation is usually carried out. The 
 incision in the stomach should be near the pylorus and 
 as large as possible in order to provide against subse- 
 quent contraction of the stoma. It should be parallel to 
 the gastric vessels, that is, at right angles to the greater 
 curvature, and its lower extremity should nearly reach 
 the greater curvature. There is no need to twist the 
 jejunal loop. The incision in the jejunum being longi- 
 tudinal, the circular muscular fibres are paralysed. If 
 the stomach is distended, the margins of the stoma are 
 kept apart and the intestinal wall practically forms part 
 ■of the floor of the stomach. For this reason the opening 
 into the intestine becomes a valvular slit, and kinks are 
 liable to form at the proximal and distal margins of the 
 stoma: Therefore it is well to fix the bowel to the 
 stomach for a few centimetres both proximal and distal 
 to the artificial stoma. A kink in the bowel at the edge 
 of .a stoma is a very different matter from a kink in an 
 intact portion of the gut. In the latter case, the contrac- 
 tion of the circular fibres, proximal to the kink invariably 
 
156 THE JEJUNO-ILEUM" 
 
 forces the contents past the mechanical obstruction. In 
 the former case, there being no intact circular fibres 
 immediately proximal to the kink (owing to the presence 
 of the stoma), there is no muscular force to overcome 
 the resistance of the kinked bowel, and the contents will 
 therefore stagnate at the site of the kink. Lest the 
 necessary opening in the transverse mesocolon should 
 contract and assist in the formation of kinks, its margins 
 should be sutured to the stomach wall. 
 
 After gastro-enterostomy, the following misdirected 
 currents may occur, any one producing a vicious cycle. 
 They are the cause of the regurgitant vomiting which 
 sometimes occurs as a complication of the operation. 
 
 (i) Duodenal contents through the pylorus. 
 (2) Fluid from the stomach into the afferent loop. 
 (3). Fluid from the afferent loop into the stomach. 
 (4) Fluid from the efferent loop into the stomach 
 (248). 
 
CHAPTER IX. 
 
 The C^cum, Appendix and Proximal Colon. 
 
 The proximal colon is that part of the large intestine 
 which is developed from the mid-gut. It comprises the 
 bowel from the ileo-caecal junction to the splenic flexure 
 and is anatomically^ subdivided into the following parts : 
 the cascum with the appendix, the Cceco-colic sphincteric 
 tract (in some animals), the ascending colon, the hepatic 
 flexure and the transverse colon. 
 
 I. The CjBCum. 
 
 The caecum is the commencement of the large bowel, 
 and lies proximal to the orifice of the small into the large 
 intestine. In the majority of autopsies it is found 
 entirely within the limits of the right iliac fossa, but its 
 situation may vary not only in different individuals, but 
 in the same person from time to time. As a rule the 
 terminal part of the ileum passes upward and to the 
 right to open into the large bowel, thus forming acute 
 ileo-caecal and obtuse ileo-colic angles. 
 
 The delimitation of the human cagcum from the colon 
 is, in many cases, not well-marked. Struthers defined it 
 as occurring at the site of the anterior and posterior 
 frsenal furrows (316). Berry observes that these may 
 not be obvious on the external aspect, but he 
 suggests that in such cases the limit is fairly accurately 
 indicated by the mid-point between the upper and lower 
 borders of the ileum at its junction with the large 
 intestine (30). 
 
 157 
 
158 THE CJSCUM, APPENDIX AXU PROXIMAL COLON 
 
 Originally the cscum had a mesentery, but in conse- 
 quence of the distension of the organ in early life its 
 mesentery is frequently so small as to be negligible. 
 In such cases, however, the caecum is almost entirely 
 surrounded by a peritoneal coat. Berry states that the 
 viscus is surrounded by peritoneum' in 94 per cent, of 
 cases, and he goes so far as to deny the presence of a 
 mesocascum altogether (30). Around and about the 
 c^cum are certain pockets of the peritoneum . These 
 vary greatly from individual to individual in their precise 
 limitations and extent. Many were figured by Lockwood 
 and RoUeston (210), but in general terms most may be 
 gathered into one of three groups, ileo-colic, ileo-caecal 
 and retro-colic, which are thus named from^ their positions 
 relative to the gut. 
 
 As previously mentioned (p. 135), the termination of 
 the ileum and the caecum may be closely bound together. 
 This sometimes consists in no more than a peritoneal 
 band uniting the two, such as the one figured by Morley 
 in his recent article on Jackson's pericolic membrane 
 (246). Lockwood has pointed out that in the eighth 
 month of foetal life there is a peritoneal band connecting 
 the caecum to the right genital gland in both sexes, and 
 that if descent of the genital gland is imperfect, descent 
 of the c£ecum may also be partial (208). It is not here 
 suggested that one of these conditions is the cause of the 
 other, but they may be associated, and in a case in which 
 the symptoms are those of appendicitis, but in which the 
 signs point to an involvement of the right hypochon- 
 drium and not the iliac fossa, examination of the scrotum 
 for presence of the right testicle may give some assistance 
 in the differential diagnosis between gall bladder and 
 appendicular disease. Probably this peritoneal fold is 
 
THE C^CUM, APPENDIX AND "PROXIMAL COLON 1 59 
 
 related to the genito-mesenteric fold described by Reid, 
 to which reference will again be made (p. 169). 
 
 The caecum can be distinguished first in embryos of 
 65 mm. (Tarenetzky, quoted by Lewis (203)), some time 
 after the first appearance of what ultimately becomes 
 the appendix. Originally starting as a backwardly 
 directed diverticulum of ' the gut in the region of 
 the left hypochondrium, the caecum reaches the right 
 hypochondrium beneath the liver, and then gradually 
 passes down to attain its adult position in the right iliac 
 fossa, which, according to Keith, it reaches about the 
 time of birth (178). In this course two bends occur, one 
 when the caecum, under cover of the liver, begins to pass 
 downward toward the iliac fossa, and the other when it is 
 in the fossa itself. Lewis (203) states that in a 95 mm. 
 embryo the appendix is still in contact with the liver, 
 and the first U-shaped bend of the diverticulum occurs, 
 which ultimately forms caecum and appendix, while the 
 descent of the caecum to the iliac fossa has already begun. 
 At the 218 mm. stage the appendix has taken up its 
 normal position. The bending of the large bowel on 
 itself is described by Toldt (325) (326), and by Parsons 
 (266). The former of these authors shows that the 
 formation of the ileo-caecal valve is probably brought 
 about by this bending. Later, to\<rard the end of foetal 
 life and in infancy, when expansion of the caecum and 
 colon occurs, they still further bulge over the termination 
 of the ileum, and increase the size and extent of the 
 cusps of the valve. 
 
 In certain cases the caecum may be entirely absent, 
 the colon and ileum being normally constituted and even 
 the appendix represented (93). Again the caecum may 
 .be present, but in consequence of imperfect rotation and 
 
l60 THE C.55CUM, APPENDIX AND PROXIMAL COLON 
 
 descent, the ileo-caecal valve may be imperfect (266). 
 
 It is obvious that the c^cum may never reach its 
 normal position in the iliac fossa. It may be that the 
 organ itself has not descended or it may be but one of 
 the abdominal organs which are in abnormal positions 
 associated with faulty rotation of the mesentery. Of the 
 latter a marked case was recoMed by Riechelmann (283). 
 Not only may the caecum be found at autopsy short of its 
 usual position, but the organ may overshoot its normal 
 site and lie within the true pelvis. G. M. Smith states 
 that in 1,050 autopsies recently performed, the csecum 
 was found in the right iliac fossa in 882, between the 
 liver and the iliac fossa in 63, on the left side of the 
 abdomen in 5, and in the pelvis in 100 cases. Of the 
 pelvic Cceca, 66 occurred in females and 34 in males (311). 
 
 A condition known as caecum mobile or cesspool caecum 
 has received considerable attention during the past few 
 years, and a good historical review of the subject has been 
 published by Sailer (299). This "wander" csecum, which 
 is mobile in view of the possession of a mesentery by it 
 and by the lower part of the ascending colon, is said to 
 cause mechanical obsti'uction in three ways : the forma- 
 tion of a kink near the hepatic flexure; the doubling of 
 the Ccecum on the colon ; volvulus of the caecum. Klose 
 states that the condition is present in 10 per cent, of all 
 persons. On the other hand, Cramer and Bevan have 
 strenuously denied the pathogenicity of ceecum mobile. 
 Of this it is certain that the caecum varies in its precise 
 site even in the same individual from time to time. A 
 czecum which is in the pelvis one day may be shown by 
 radiography to lie in its normal iliac position the 
 following day. It is difficult to understand how mere 
 mobility of the caecum could cause the conditions 
 
THE C.-ECUM, APPENDIX AND PROXIMAL COLON l6l ■ 
 
 attributed to it, or how the "kinks" produced could 
 have much obstructing power. Anatomical variation 
 need not necessarily be pathogenic. In a radiogram the 
 organ sometimes appears subdivided at the brim of the 
 
 Fig. 23. Tracing from radiogram showing bismuth shadows in the 
 terminal portion of the ileum, the caeciim and the appendix. Cothpare 
 with fig. 20.' 
 
 pelvis so that there is an upper iliac part and a lower 
 pelvic portion which may be filled with stagnating food. 
 It may be that there is some, perhaps even a considerable 
 amount of atony in the wall of such a caecum, but if this 
 be so, the cause of the trouble is too deep-seated for one 
 
■ 1 62 THE CXCVM, APPENDIX AND PROXIMAL COLON 
 
 reasonably to expect a cure from plication of the wall 
 itself or from the various metho4s of slinging up the 
 organ. 
 
 Sometimes the Ccecum is to be found in a right 
 inguinal hernial sac. According to its initial peritoneal 
 
 Fig. 24. Tracing from radiogram showing the CEecum dipping over 
 the pelvic brim into the cavity of the true pelvis. 
 
 This may be a variation in position from the situation shown in lig. 23. 
 Such a CEecum as is here figured is not necessarily pathological. 
 
 relations its relation to the sac will vary. Thus a 
 " wander " or floating csecum will be found entirely 
 within the sac, or as an adherent organ incompletely 
 surrounded by the sac (see Cavaillon et Leriche (57)). 
 
THE CiECUM, APPENDIX AND PROXIMAL COLON I&3 
 
 Although volvulus of the caecum naturally falls to be 
 discussed at this stage, it will be better to postpone its 
 full consideration until the fixation of the proximal colon 
 has been described. 
 
 After a bismuth meal the x-ray shadow normally 
 appears in the caecum in about four and a half hours. 
 The organ should be nearly empty in twelve hours, and 
 at the end of twenty-four hours it. should contain only 
 traces of bismuth adhering to its walls (139). In some 
 cases of csecal atony, among wTiich would be included 
 instances of caecum mobile, there may be stagnation of 
 food material for two or three days (299) forming the 
 so-called cess-pool CEecum. The elongated and mobile 
 caecum, becoming twisted on its vertical axis, may give 
 rise to one form of volvulus of the organ (71). 
 
 As already mentioned, the c^cum in the majority of 
 instances occupies the right iliac fossa. Its surface 
 topography is simple. The organ extends from the inter- 
 tubercular line above to the inguinal ligament below, 
 and from the anterior superior spine laterally as far as 
 the intersection of the intertubercular and right lateral 
 inguinal lines in the medial direction. There is said to 
 be some relation between the relative development of the 
 caecum and the position of the appendix, but this can 
 have no direct clinical importance. When empty the 
 caecum is separated from the ventral abdominal wall by 
 small intestine and omentum. When partially distended, 
 it comes into contact with the. deep surface of the 
 abdominal wall and frequently can be palpated. As 
 regards the percentage of cseca which can be palpated, 
 statements vary. Obrastow (260) could distinguish the 
 organ in 51 per cent, of men and in 58 per cent, of 
 women. Haussman claimed to be able to palpate it in 
 
164 THE CECUM, APPI^XDIX AXD PKOXIMAL COLON 
 
 80 per cent, of cases (130). Sailer, however, could 
 distinctly identify the caecum by palpation in 20 per cent, 
 only of his patients. On palpation the cascum varies 
 from a soft indefinite movable mass to a distinctly 
 palpable tympanitic balloon-like body. According to 
 Sailer, palpation reveals it in some cases nearer the 
 anterior superior spine, in others nearer the middle line. 
 Also the lower border varies frorii two inches below to 
 one inch above the intertubercular plane (299). But of 
 course neither palpation nor percussion can do more 
 than give the barest and frequently the most misleading 
 idea concerning the site and size of the organ. Pressure 
 on the caecum may elicit gurgling if the organ contain 
 gas. An hour or two after the arrival of food material 
 as shown by the ac-ray shadow, the resonant note is lost 
 over the caecum when the patient is examined in the 
 vertical position (139). Sailer observes that in the atonic 
 condition the caecum is felt as a somewhat indistinct 
 cylindrical or pear-shaped mass which can be passively 
 displaced. 
 
 The relation between the position of the caecum and 
 the abdominal wall makes the formation of a caecal 
 fistula a simple matter. A large opening can be made 
 which easily closes afterward. 
 
 The position of the ileo-caecal valve is indicated by the 
 intersection of the intertubular and right lateral inguinal 
 lines. Of the two cusps the lower is much the larger. 
 Thompson has shown that in foetal, infantile and adult 
 cffica alike, the orifice between the cusps, is directed 
 downward and outward. In some cases the opening 
 looks much more downward than outward (324). About 
 the same time at which the resonant note is lost with the 
 accession of chyme into the caecum, the caecal sounds 
 
THE CECUM, APPENDIX AND PROXIMAL COLON 165 
 
 reach their maximum. If there be irritation of the:' 
 surrounding- peritoneum, the ileo-C£ecal valve closes and 
 as nothing passes from ileum to caecum the sounds cease. 
 Hertz on this account suggests the value of csecal 
 auscultation in appendicitis of doubtful extent. If no 
 sounds are to be heard over the caecum in a case of 
 appendicitis in which there is absence of vomiting and 
 the patient has not been talcing fluid, peritonitis is likely 
 to be present (139). This necessitates the existence of 
 an efficient ileo-caecal sphincter, which has been shown 
 to be present by Keith (183) and by Elliott (91), there 
 being normally no backflow of food material from colon 
 to ileum. Upon this sphincter neither the vagus nor the 
 sacral nerves exert any influence. Stimulation of the 
 splanchnics, however, causes the sphincter to contract, 
 though at the same time it inhibits the circular muscle 
 in the wall of the ileum and colon adjoining the sphinc- 
 ter (91). The same result may be obtained experi- 
 mentally by exposure of the peritoneum to cold air. 
 This sphincter is competent to prevent regurgitation of 
 food passing from the stomach onward, but does not 
 exclude from the ileum food travelling from the rectum 
 upward. Thus large nutrient enemata have been shown 
 to pass through the ileo-caecal orifice into the lower coils 
 of small intestine. These enemata were not, however, 
 given to human patients, but experimentally to various 
 animals, and were of such an amount as to entirely fill 
 the large intestine (48). The function of the sphincter 
 is to prevent regurgitation of chyme into the ileum when 
 the anastalsis in the proximal colon forces the foodstuff 
 back into the cascum (see note, p. 230). 
 
 In certain cases the ileo-caecal sphincter is inefficient. 
 According to Hertz this results in a tympanitic distension 
 
1 66 THE CiECUM, APPENDIX AND PROXIMAL COLON 
 
 of the central parts of the abdomen (148). Case observes 
 that instances are frequently described as ileal kinks 
 which are no more than overloading of the distal end of 
 the ileum through incompetency of this valve (56). 
 
 The function of the caecum is not yet by any means 
 understood. As early as 1814 Home performed experi- 
 ments which suggest that some substances such as 
 rhubarb and fats may be partially absorbed in the organ 
 (153). In 1904 Macewen observed the secretion of a 
 viscid alkaline fluid, the function of which is apparently 
 to neutralise the acid chyme as it passes through the ileo- 
 cecal orifice (222). It is owing to the absence of this 
 neutralisation that the skin surrounding a caecostomy 
 wound may become corroded and inflamed as it does 
 when a fistula is made between the skin surface and the 
 lower ileum. The digestion of surrounding skin does 
 not occur in colostomy wounds even if they are made as 
 high as the transverse colon. Barnard has suggested 
 that certain cases of ulcerative colitis may also be due 
 to the failure of the ceecal glands to neutralise the 
 corrosive acid chyme (20). Macewen states that the 
 caecum maintains an attenuated culture of bacillus coli 
 to assist in digestion (222). 
 
 At birth the calibre of the Ccecum is relatively much 
 less than it is a few years later when the organ has 
 become sacculated from the presence within it of chyme 
 and gas. This distension appears about the age of four 
 to five years. As the individual grows to adult age, the 
 caecum frequently becomes the most capacious portion 
 of the large intestine, and in old age, especially in 
 females, may be very distended (266). Of all the large 
 intestine the czecum has the thinnest wall. It is only 
 one to one and a half millimetres in thickness. This is 
 
THE C^CUM, APPENDIX AND PROXIMAL COLON 167 
 
 made up of serous, muscular, submucous and mucous 
 coats, whiqh on the whole present very few special 
 characteristics. Unlike that of the colon, the serous coat 
 of the c^cum presents no appe,ndices epiploicze. The 
 three taenice or bands of longitudinal muscular fibres 
 extend from the colon on to the caecum, and meet at the 
 orifice of the appendix. Parsons observes that possibly 
 the transverse constrictions on caecum and colon are 
 caused by the passage of blood vessels around the gut 
 (266). Further particulars concerning the caecum can 
 better be stated with the general description of the 
 proximal colon. 
 
 II. The Vermiform Appendix. 
 
 The vermiform appendix, which is originally the 
 continuation of the caecum, has, in view of the eccentric 
 growth of the latter organ, become attached to the dorso- 
 medial aspect of the caecum. Unless bound down by 
 adhesions its closed end is free and wanders within limits 
 in the peritoneal cavity. It is essential to remember this 
 characteristic and to realise that the appendix varies in 
 position, not only in different individuals, but in the 
 same individual from day to day (2). Hence statements 
 with regard to its exact site must be accepted on the 
 understanding that the position is more or less accidental. 
 This view is confirmed by the radiographic studies of 
 Cohn,. who watched the appendix, when filled with 
 bismuth, move of its own accord around the caecum, and 
 in addition follow the peristaltic movements of the latter 
 .organ (63). The position of the appendix also varies 
 •with the attitude of the patient. 
 
 The appendix is said to be found most frequently 
 
l68 THE C^CUM, APPENDIX AND PROXIMAL COLON 
 
 behind the terminal loop of the ileum and the mesentery. 
 This covering of the organ by the mesentery results in 
 restriction of the suppurative process which follows 
 inflammation. If the appendix happen to be lying in 
 front of the mesentery, as it sometimes does, when 
 appendicitis occurs, it is in a very dangerous position, 
 for the abscess from an appendix in this situation cannot 
 easily be shut off from the general peritoneal cavity, and 
 is frequently fulminating in type (23). Other common 
 positions for the appendix are, first, dorsal to the czecum 
 or even the ascending colon, should that organ possess 
 a mesentery, and, secondly, hanging downward into the 
 pelvis, where its tip may become adherent to any of the 
 internal genitalia in the female (225). 
 
 Preileal or precaecal positions for the appendix may 
 be considered exceptional (225). But whatever its site, 
 the appendix is always intraperitoneal. Those cases 
 which are stated to be extraperitoneal are in reality 
 instances of reti'ocsecal appendix surrounded by adher 
 sions. Such an appendix may originally have lain in a 
 retrocaecal pouch or in the angle between the caecum and 
 the lalteral abdominal wall (24). In either case the 
 occurrence of adhesions would lead to the same final 
 condition. This type of abscess will probably drain into 
 the right kidney pouch. It is therefore essential that the 
 pouch should be investigated, and if need be, drained. 
 The appendix, when dorsally placed, may lie on the 
 psoas sheath,, to which adhesions may bind it. Thus, it 
 is stated that some cases of appendicitis of sudden origin 
 may be due to actual rupture of an appendix previously 
 adherent to the psoas sheath, consequent on some 
 exertion involving the violent contraction of this muscle 
 (24). Normally the appendix possesses a mesentery, 
 
THE CMCVU, APPENDIX AND PROXIMAL COLON 169 
 
 which however reaches the tip in 50 per cent, only of 
 cases (243). 
 
 Of various relations of the appendix, certain of those 
 to peritoneal folds may be mentioned here in view of 
 the attention recently drawn to them by Macnaughton- 
 Jones .(225). Occasionally the appendix may bear some 
 more or less intimate, though adventitious, relation to 
 the plica vascularis, the fold of peritoneum covering the 
 genital vessels and nerves which, on the way to their 
 distribution, pass close to the ileo-csecal region behind 
 the terminal part of the ileum. Rolleston repdrted a 
 case in a boy of six in which the plica vascularis had 
 obtained an attachment above to the csecum and appen- 
 dix (292). Again Reid has described, as distinct from 
 the plica vascularis, a genito-mesenteric fold in the foetus 
 on the right side from the mesentery to the genital 
 gland. Later some part of this becomes the duodeno- 
 renal ligament, while the rest disappears. The ileum or 
 appendix may become attached to it secondarily (277). 
 This secondary connection may, as Reid suggests, 
 become a pathway of infection between the appendix 
 and the genital gland (278). The relation of the 
 appendix to radicles of the portal system will be dealt 
 with in the section on veins of the proximal colon. It 
 must not be forgotten, however, that the right common 
 iliac vein and its main tributaries lie close to the 
 appendix, and in certain instances phlebitis has developed 
 in these veins after appendicitis (103). Thrombosis may 
 occur in the femoral veins. The etiology in the last 
 group is obscure and frequently the left vein is involved 
 (236). There is also the possibility of the occurrence of 
 pressure necrosis of the external iliac artery by the 
 rubber tube after drainage of an appendicular abscess 
 
 (53). 
 
1 70 THE C^CUM, APPENDIX AND PROXIMAL COLON 
 
 The appendix is not a vestigial but a specialised 
 portion of the alimentary canal (36). Its length averages 
 9'2 cm., and is not so variable nor so great as is frequently- 
 asserted (31). It attains its greatest length and diameter 
 between the ages of twenty and forty years, and there 
 is no relation between its length and the size of the 
 'c£ecum (31). In children it is proportionately longer 
 than in adults (243). Bryant noted that it is usually 
 about one centimetre longer in the malle than in the 
 female (43). \ 
 
 In view of its varying position, only the ba'^e of the 
 appendix, where it is fixed to the caecum, can be\use.d for 
 topographical purposes. Liertz found that the! base of 
 the appendix lies as a rule under normal bodilvj^erndi- 
 tions about one to two centimetres lateral to tne right 
 trisection of a line joining the two anterior superior iliac 
 spines (205). It is usually identified on the surface by 
 a point on the right lateral inguinal line two to three 
 centimetres vertically below the point of intersection with 
 the intertuberculdr plane. McBurney's point, midway 
 between the anterior superior iliac spine and the umbili- 
 cus, indicates the site of greatest tenderness in the 
 majority of instances, and not the origin of the appendix 
 from the caecum. Ewart has utilised the dorsal topo- 
 graphy of the appendicular region in a new test recently 
 published (97). Over both posterior superior iliac spines 
 and the adjoining region of sacrum and ilium are two 
 areas normally of subresonant dulness. The dulness is 
 largely due to the presence of the common iliac blood 
 vessels. That on the right side is duller than the left 
 patch, presumably because of the presence beneath it of 
 the tissues of the ileo-csecal junction. The right area, 
 or its immediate environment, becomes quite dull in 
 
THE CAECUM, APPENDIX AND PROXIMAL COLON 17I 
 
 certain types of appendicitis, such as retrocascal abscess, 
 in wliich the ventral locaHsing signs are ill-marJied or 
 absent. Or there may be an area of resonance over the 
 patch, probably due to gas in the abscess, accornpariied 
 by dulness in the imrnediate neighbourhood. After 
 operation the right subresonant patch becomes equally 
 resonant with the neighbouring atea or may even be 
 tympanitic. 
 
 Two other tests depend on tenderness localised at 
 McBurney's point and perhaps even on pain in the right 
 iliac fossa on distension of the caecum with gas in 
 patients suffering from appendicitis. The- first of these,- 
 Rovsing's test, is carried out by pressure over the 
 descending and iliac colons. • It is supposed that the 
 forcing of contained gas backward along the large bowel 
 distends the caecum. But this test is not always positive, 
 perhaps as Hertz suggests (146) because there is not 
 enough gas in the descending colon. The other test is 
 that x)i Bastedo. This is performed by purnping air 
 through the anus and thus artificially distending |:he 
 caecum (25). 
 
 The orifice of the appendix into the c^cum is marked 
 by the inconstant valve of Gerlach, of which the function, 
 if any there be, is not known. 
 
 The diameter of the appendix according to Bryant (43) 
 and Berry (31) is about six millimetres at the base and 
 five millimetres at the apex in the adult male, slightly 
 less in the female. The lumen of the appendix filled 
 with bismuth can be seen in some radiograms, but in 
 spite of the assertions of Cohn and others it is not yet 
 agreed by all investigators that bismuth can be traced in 
 the lumen of the normal appendix. Occasionally diver- 
 ticula occur from the -lumen of the organ as in any other 
 
172 THE CMCVMj APPENDIX AND PROXIMAL COLON 
 
 part of the large intestine (135). In many cases the 
 lumen of the appendix is obliterated. This was regarded 
 by Zuckerkandl in 1894 as an involution phenomenon in 
 which inflammation plays no part (355), an opinion to 
 which Berry agreed the following year (31). After or 
 about middle age partial obliteration is the rule, and total 
 obliteration occurs at the age of sixty or seventy years 
 (31). Recently, however, Berry and Lack have reversed 
 the opinion of 1895, and have decided that obliteration 
 of the lumen is invariably pathological, being in every 
 case associated with an interstitial fibrosis, the result of 
 vascular obstruction and possibly part of a general 
 arteriosclerotic condition ; and furthermore, that oblitera- 
 tion may occur at any period of life (32). 
 
 The wall of the appendix averages in the adult about 
 two millimetres in thickness. The mucosa is thicker and 
 better defined in the child than in the adult (166). Like 
 the submucosa it is infiltrated with lymphoid tissue, which 
 is present in all embryos of 170 mm. and upwards. 
 Contrary to the opinion of Berry and Lack (32), both 
 diffuse and nodular forms of lymphoid tissue are present 
 at birth (164). The lymphoid tissue diminishes again 
 after middle life (32). Concerning the relation of the 
 csecal region to the absorption of fat, Owen Williams 
 made some interesting observations (347). Calcium 
 soaps are formed in the intestinal wall. In excess they 
 form sand, and associated with this are colic and some- 
 times mucous colitis. The appendix is no exception to 
 this rule, and a ring of calcium soap may be formed in 
 its submucosa, thus cutting off part of the nourishment 
 of the mucous membrane and rendering it more vulner- 
 able to bacterial attack. Probably the causal factors are 
 the stearic and palmitic acids of animal food, for the 
 
THE C.5;CUM, APPENDIX AND PROXIMAL COLON 1 73 
 
 soaps of these, unlike that of oleic acid from vegetable 
 food, are saturated and hence are absorbed with greater 
 difficulty. It is noteworthy that regeneration of mucous 
 membrane may occur very rapidly in the appendix (332). 
 
 The muscular coat, which is o'6 to 07 mm. thick, 
 consists of outer longitudinal and inner circular fibres, 
 at intervals in which are gaps not less than i mm. wide 
 and usually situated at the attachment of the meso- 
 appendix. Through these the blood and lymph vessels 
 pass to the mucosa, and the subserous and submucous 
 tissues come into contact. Lockwood suggested that 
 these gaps may be important pathways by which infec- 
 tion may travel from the mucosa to the peritoneum (209). 
 
 Although the arterial supply of the appendix will be 
 described with that of the proximal colon, it is convenient 
 here to refer to the fact that, the entire supply arrives by 
 a small vessel, coming in the majority of instances from 
 the posterior csecal artery. The blood supply of the 
 appendix is therefore easily shut off, and in this the 
 appendix differs markedly from the gall bladder. As 
 Mayo Robson pointed out (287), gangrene depends on 
 three factors, thrombosis of nutrient vessels, bacterial 
 infection, absence of drainage and therefore tension. In 
 ponsequence of its small opening into the caecum, the 
 appendix is liable to the third of these; the second is 
 frequently present, and the first readily follows either of 
 the others. Hence the frequency of gangrenous appen?- 
 dicitis. Examination with the x-rays of injected speci- 
 mens reveals a much larger supply of blood vessels than 
 former anatomical studies have led us to believe (104); 
 nevertheless the clinical- fact remains. 
 
 III. The C^co-Colic Sphincteric Tract. 
 
 Immediately beyond the ileo-Ccecal orifice in certain 
 
174 THE CJECUM, APPENDIX AND PROXIMAL COLON 
 
 animals, such as the rat, which possess a well developed 
 cascum, there is a specialised portion of the colon called 
 by Keith the c^co-colic sphincteric tract. This is seen 
 in its most distinctive form in graminivorous and 
 vegetable feeding birds. Keith also presents some 
 evidence of its functional existence in man (184), although 
 it must be admitted that its importance has not yet been 
 fully substantiated. 
 
 IV. The Ascending and Transverse Colons. 
 
 The parts of the proximal colon, which still remain to 
 be described, are the ascending and part of the transverse 
 colons together with the hepatic flexure. The separation 
 of the colon into proximal and distal portions is based 
 upon considerations of physiology rather than those of 
 . anatomy. It is still uncertain at what point in the 
 transverse colon these two portions meet. Nor is it 
 known as yet whether the site is the same in all 
 individuals. Hence for purposes of anatomical conve- 
 nience the whole of the transverse colon will be included 
 in the proximal colon, there being always the reservation 
 that the physiological limit may be overstepped by this 
 Subdivision. It may be observed that in the human 
 subject the blood and nerve supply to the colon proximal 
 and distal to the splenic flexure are distinct, although 
 the gross features of the two portions of the bowel are 
 not in themselves sufficient to indicate any marked 
 difference in function. 
 
 The ascending colon is a short length of bowel extend- 
 ing upward from the right iliac crest to the region of 
 the hilum of the right kidney. At this level it turns to 
 the left under the liver to become the transverse colon, 
 the bend being known as the hepatic flexure. In length 
 
THE C.i:CUM, APPENDIX AND PROXIMAL COLON 1 75 
 
 the ascending colon averages 10-12 cm., though it fre- 
 quently increases to 19 cm., or even more in old people 
 (166). As an anatomical entity it may be wanting, the 
 cascum apparently being continuous with the transverse 
 Colon. In cases of nephroptosis it may be very far from 
 its normal position (3). The surface topography of the 
 ascending colon may be mapped out as extending in a 
 vertical direction lateral to the right lateral inguinal line 
 from the intertubercular plane to the level of intersection 
 of the mid-axillary line and the tenth rib, at which site 
 lies the hepatic flexure (323). 
 
 Rost states that he finds constant a thickening of the 
 circular muscular coat in the transverse colon about three 
 fingers' breadth from the hepatic flexure. This he 
 considers to act as a valve, but he examined only five 
 cases (296). Radiographic examination however appears 
 to confirm this (285). 
 
 The splenic flexure lies higher and deeper in the 
 abdomen. Its level is that of a plane passing through 
 the intersection of the left mid-axillary line with the 
 upper border of the ninth rib (323). Between the two 
 flexures lies the transverse colon, the disposition of which 
 in the abdomen is very variable. In subjefcts preserved 
 with formalin it usually presents a downwardly directed 
 hepatic loop at its right extremity. Radiographic 
 examination shows that this loop is transitory in 
 character ; it is sometimes present and sometimes absent 
 in the same individual. Beyond the hepatic loop the 
 transverse colon proceeds across the abdominal cavity 
 in intimate relation with the greater curvature of the 
 stomach (2), on the state of distension of which its 
 position largely depends. In the adult the transverse 
 coloii is usually about 50 cm. in length (166). The colon 
 
176 THE CiECUM, APPENDIX AND PROXIMAL COLON 
 
 in abnormal cases may have a very different disposition. 
 It may lie entirely to the left of the median line (354)> or 
 form merely ascending and descending limbs (349)) or 
 part only may be displaced (123). 
 
 The method of fixation of the proximal colon to the 
 dorsal abdominal wall is usually the following. The 
 caecum is provided with a mesentery. The ascending 
 colon and hepatic flexure are bound directly to the 
 parietes without the intervention of a mesocolon. Over 
 the head of the pancreas a mesentery again appears for 
 the attachment of the transverse colon, and is lost only 
 at the splenic flexure. Occasionally there is no attempt 
 at direct fixation of the ascending portion, and the whole 
 of the proximal colon, in such cases, possesses a mesen- 
 tery. Usually, however, some part of the ascending 
 colon, especially near the hepatic flexure, is bound down, 
 the lower part alone having a mesentery in common 
 with the caecum. G. M. Smith states that among 982 
 autopsies, the former condition was found 17 times and 
 the latter 304 times (311). Either arrangement renders 
 possible a twisting of the ileo-colic region of the gut 
 round the superior mesenteric artery as an axis, and thus 
 one variety of volvulus of the caecum is produced (71). 
 Certain additional peritoneal bands are found in some 
 subjects. Of these the phrenico-colic ligament is 
 described as constant. It connects the splenic flexure 
 with the abdominal wall at the point where the 
 diaphragm arises from the eleventh rib. Another fold 
 binds the hepatic flexure in similar manner to the 
 abdominal wall. A third is present on an average in 
 one subject among four, and connects the transverse 
 colon and duodenum to the gall bladder. The chief 
 interest of all these bands is that they form centres around 
 
THE C^CUM, APPENDIX AND PROXIMAL COLON 1 77 
 
 which peritoneal adhesions of inflammatory origin may 
 develop. Adhesions of such a nature are especially 
 common around the gall bladder, but are often found in 
 the regions of the hepatic and splenic flexures, which, 
 be it observed, are gentle curves when seen in ^c-ray 
 examinations from the side and not acute flexions (145), 
 rendering these bends in the gut angular and binding 
 the adjacent loops of bowel more closely together. In 
 spite of many assertions to the contrary, there is no 
 conclusive evidence that adhesions in these areas cause 
 any stagnation or obstruction to the passage of contained 
 food material. The two flexures, nevertheless, when 
 surrounded by adhesions have served Lane as sites for 
 two of his so-called kinks. 
 
 The nephro-colic ligament, on which emphasis is laid 
 by Longyear, may be mentioned here. This consists of 
 the fibrous tissue between the right kidney and the colon. 
 Longyear has stated that nephroptosis is really secondary 
 to coloptosis, and that the kidney is dragged out of place 
 by its attachment through this ligament to a prolapsed 
 colon (214). The view has not met with general accept- 
 ance. 
 
 Other adhesions of more obscure origin occur in the 
 region of the proximal colon, but it is well to bear in 
 mind that the large intestine generally, and the proximal 
 colon especially, is the most frequent site for peritoneal 
 adhesions of inflammatory type (240). 
 
 Jackson's membrane is found in children and even in 
 infants as well as in adults. It runs from the right 
 lateral abdominal wall to the ascending colon, and some- 
 times to the cascum, at or in the neighbourhood of the 
 ventral tasnia muscularis. According to Morley it is in 
 some cases the continuation of the great omentum, 
 
178 THE C^CUM, APPENDIX AND PROXIMAL COLON 
 
 although the arrangement of blood vessels in it does not 
 suggest such an origin. The vessels are arranged in 
 parallel from the abdominal wall toward the gut. Flakes 
 of fat are present in its substance. Morley states that 
 his cases showed it to be of congenital origin, although 
 he perhaps underestimates the difficulty of distinguishing 
 congenital from acquired peritoneal membranes. Accord- 
 ing to Morley, the membrane may co-exist with a com- 
 plete mesentery to the ascending colon (246). Such 
 cases as that of Bevan (33) would indicate that sometimes, 
 at any rate, the membrane may be acquired as the result 
 of a pathological condition in adult life, and Jackson 
 himself doubts the uniform, origin of the membrane in 
 all cases (158). At any rate, Eastman claims to have 
 produced the membrane experimentally in rabbits (86), 
 
 Among such bands and membranes should be men- 
 tioned the contracted psoas parvus tendon, the result of 
 a chronic inflammation following on appendicitis or 
 typhlitis. Macdonald has recently drawn attention to 
 this as a cause of stagnation of contents in the csecum, 
 but he produces no radiographic evidence in support of 
 his view (221). 
 
 The sacculated condition of the colon itself is said by 
 Parsons to be due possibly to the constricting influence 
 of blood vessels (266), and to the contraction of its 
 longitudinal muscular coat, which is arranged in three 
 bands, one of which lies on the ventral aspect of the gut, 
 one on the side proximal to the small intestine, and one 
 on the side distal to it. As already pointed out, these 
 three ta^nia^ meet at the orifice of the appendix. 
 
 Along the gut are numerous fatty tags known as 
 appendices epiploicje. They occur especially along the 
 ventral tasnia and frequently contain small diverticula 
 
THE C.15CUM, APPENDIX AND PROXIMAL COLON lyg 
 
 from the mucous lining of the colon. They are not 
 found on the csecum. 
 
 Diverticula of the lumen of the colon are not infre- 
 quent about the ileo-cascal region. In the colon they are 
 present along the mesenteric border and in the appen- 
 dices epiploicae, but are much rarer in the proximal than 
 in the distal colon. When present they are frequently 
 found in stout people beyond middle life, and more 
 frequently in males than in females (316). They are 
 subject to the same complications as is the appendix. 
 
 In the proximal colon the last of the food disappears, 
 cellulose may be so transformed that it can be utilised 
 in the body, and water is absorbed (50). Great thirst is 
 one of the usual complications of a csecal or right 
 inguinal colostomy, and in such cases the patient soon 
 suffers from vomiting, which is relieved by the subcu- 
 taneous infusion of fluid (256). 
 
 The contents of the transverse colon are almost as solid 
 as those of the sigmoid (290). The mere passage of the 
 faeces over the mucosa seems to have some special 
 significance, for in Williams' case, when no faeces were 
 allowed to pass into the colon, purpura hsemorrhagica 
 developed, but disappeared as soon as the fasces pursued 
 their normal course (241). 
 
 The mucosa is thicker than that of the small intestine^ 
 but paler and less well supplied with blood vessels. It 
 shows temporary longitudinal folds, which disappear on 
 distension of the gut, but on it are neither plicag circu- 
 lares (valvulse conniventes) nor villi. The last-mentioned 
 disappear from the mucosa in early foetal life (164). 
 -There are, however, semilunar folds which run trans- 
 versely to the long axis of the bowel, and which separate 
 the interior of the bowel, especially when dried, into 
 
l8o THE CiBCUM, APPENDIX AND PROXIMAL COLON 
 
 haustra or saccules : these are known as plicae semi- 
 lunares. Glands are distributed most thickly in the 
 ascending colon. They are less closely packed in the 
 caecum and still less in the transverse colon (128). 
 Peyer's patches are only exceptionally found in the 
 proximal colon of man (166), though present in many 
 lower animals (83). The intestinal wall is thinnest in 
 the cscum and gradually increases in the distal direction 
 (128). According to Roith, the caecum and ascending 
 colon contain on an average about twice the amount of 
 material present in an equal length of transverse colon, 
 and from three to five times as much as an equal length 
 of descending colon (296). Thus the proximal colon, 
 especially in its higher portion, is very distensible. For 
 the distensibility of the gut depends upon the square or 
 the cube of its calibre. The c^cum, having twice the 
 calibre of the transverse colon, will have a distensibility 
 of between four and nine times that of the latter (5). The 
 termination of the proximal colon has been stated to be 
 provided with a sphincter. Addison remarks that in the 
 neighbourhood of the splenic flexure there is usually to 
 be found a considerable diminution in the lumen of the 
 gut with marked sacculation (2), And Rost notes the 
 occasional occurrence of a thickening of the circular 
 muscular coat near the commencement of the descending 
 colon (296). In his radiographic examinations Boehm 
 noticed a narrowing of the transverse colon usually to 
 the .right of the middle hne (see p. 175). Between this 
 site and the caecum, the colon contained undivided 
 contents. Beyond it the colonic mass was permanently 
 segmented. At this point there probably start the. 
 anastaltic waves soon to be mentioned; indeed it may 
 be at or near the site of physiological subdivision 
 between the proximal and distal colons. 
 
THE CiECUM, APPENDIX AND PROXIMAL COLON l8l 
 
 In lower animals, as in the dog, the external longitu- 
 dinal coat is continuous round the whole wall (117). In 
 human subjects this is not so obvious (166) (296) as the 
 majority of the longitudinal fibres are massed in the 
 three taeniae already described. In the dog the greatest 
 diminution in thickness of the bowel wall on distension 
 occurs in the transverse colon and the least in the 
 ascending colon (128). 
 
 The various movements in the proximal colon may 
 here be noted briefly, but a full description is given in a 
 recent article by Cannon (50). By radiographic methods 
 the contents of the caecum have been seen to pass onward 
 for a short distance towards the hepatic flexure and then 
 to return to the caecum. This may, be due simply to 
 relaxation of the previously contracting caecal and colonic 
 walls, but it may be in part due to anastaltic (antiperis- 
 taltic) contractions of the transverse colon. Certainly 
 the c»cum and adjacent ascending colon retain the 
 bismuth shadows longer than does any other part of the 
 bowel. 
 
 Another movement is that of local contraction in the 
 haustra or segments whereby a small portion of the 
 contents is pressed onward or backward for a very short 
 distance. This is termed haustral churning, and corres- 
 ponds to the segmentation movements of the small 
 intestine. The movement which is characteristic of the 
 proximal colon is that of anastalsis. It is the same 
 movement as that termed peristalsis in the stomach and 
 is really a form of segmentation. The movement has 
 long been noted in cats, and Rieder has observed it to 
 occur in the caecum, ascending and transverse colons in 
 the human subject, and more rarely in the distal colon 
 (285). 
 
l82 THE C^CUM, APPENDIX AND PROXIMAL COLON 
 
 These movements ensure the thorough mixing of food 
 material in the colon and the opportunity for absorption 
 of the last traces of fat, protein and carbohydrate in 
 addition to the water (256). Anastalsis has, however, 
 -the unfortunate effect of returning food material into the 
 proximal colon after the operation of ileo-sigmoidostoray 
 has been performed. 
 
 If totally occluded the proximal colon- becomes dis- 
 tended with fffical material and will form a fistula or 
 may even burst. Hence a fistula must always be made 
 (256). Anastaltic movements are probably the cause of 
 the acute dilatation of the caecum which suddenly occurs 
 as a complication in certain cases of cancerous stricture 
 of the colon. In some of these cases, as Barnard said, 
 the colon " empties back its accumulated contents and 
 blows up the c^cum like a child's balloon " (20). 
 
 But as yet attention has not been drawn to the 
 movements inducing onward progression of the colonic 
 ■contents. They are less active at night than during the 
 day (139). Of these the first and slower is that already 
 mentioned as haustral segmentation. Another rests for 
 the human .colon on but two observations : those by 
 Holzknecht and Barclay. This is known as the peris- 
 taltic rush movement. Apparently there is contraction 
 in all the circular fibres almost simultaneously, so that 
 the haustra disappear and the colonic contents pass with 
 great rapidity into the distal colon (11). This movement 
 is supposed to take place only a very few times a day. 
 
 Abnormalities in the muscular movement of the 
 proximal colon are seen in both hypokinetic and dys- 
 kinetic types of constipation. In the former, the absence 
 of movement results in the filling of the caecum and 
 ascending colon alone at the end of twenty-four hours. 
 
THE C^CUM, APPENDIX AND PROXIMAL COLON 1 83 
 
 But in such cases there is no actual atony, for the bismuth 
 shadows show these portions of the colon to be no more 
 distended than in normal cases. In the hyper-segmenta- 
 tion variety of dyskinetic constipation, there is well 
 marked haustral segmentation, but apparently no pro- 
 gressive mass movement. More water is absorbed than 
 under normal conditions, as is to be expected when there 
 is retention of contents in this portion of the intestine. 
 In the hyper-repulsion type of diskinetic constipation, 
 there is probably an exaggerated form of anastalsis 
 which prevents the retention in the distal colon of faecal 
 material until defcecation takes place. For a further 
 account of this subject Schwarz's article should be 
 consulted (306). 
 
 •The average time taken by the passage of food material 
 along the proximal colon is given by Hertz as four and 
 a half hours after swallowing to reach the csecum, six 
 and a half the hepatic flexure, and nine the splenic 
 flexure (139). 
 
 As the colon distends to accommodate its contents, it 
 dilates between the layers of its mesentery or separates 
 the peritoneum still more from underlying tissues if it 
 have no mesentery. The arterial arcades are therefore 
 found at some distance from the contracted bowel in 
 order to allow for this expansion. 
 
 Dilatation of the proximal colon may occur acutely 
 in a few hours or may be a chronic condition such as 
 that known as congenital idiopathic dilatation, in which 
 ■disease this portion alone of the bowel may be involved 
 (117). In this last mentioned condition the muscular 
 coat of the bowel is greatly hypertrophied in order to 
 ■carry out the spasmodic efforts at peristalsis (diastalsis) 
 which occasionally empty the gut. Thus the bowel wall 
 anay attain a thickness of 10 mm. 
 
184 THE C^CUM, APPENDIX AND PROXIMAL COLON 
 
 With reference to the serous coat of the proximal coloit- 
 there is little of Clinical importance to observe. 
 
 Coffey has drawn attention to the position of the 
 organs in the abdomen, and has shown that as the 
 
 Fig.25. Tracing fi-om radiogram to sliow bismuth shadows in the 
 proximal colon. 
 
 Individual variations occur in the site of the transverse colon, the 
 position of which varies in the same individual from time to time. 
 This, like corresponding variations in the precise disposition of stomach 
 and caecum, is what one would naturally expect. Compare with fig. 26. 
 
 ascending colon lies on the psoas at a slope of 51°, about 
 30 per cent, of its weight is absorbed leaving only 70 per 
 cent, to be sustained by the tone of the abdominal 
 musculature (62). The position of the transverse colon 
 
THE CiECUM, APPENDIX AND PROXIMAL COLON 1 85 
 
 in the abdomen depends largely upon the tone of its 
 mesocolon. About this nothing is known. Smoler has 
 described what he calls ptosis of the transverse colon 
 with consequent constipation, which was relieved by 
 
 Fig. 26. Tracing from radiogram to show bismuth shadows in the 
 proximal and distal colons. 
 
 For comparison with figs. 25, and 9, 10, ii. Note that in the distal 
 part of the transverse colon the colonic contents are segipented completely 
 into masses, whereas in the ascending colon this subdivision has not 
 progressed so far. , 
 
 ♦• 
 
 suturing up the colon (315), but it is difficult to follow 
 out the reasoning of the argument. As the specific 
 gravity of all the abdominal organs with their contents 
 is the same, and as even the splenic and hepatic flexures 
 
 M 
 
1 86 THE CiECUM, APPENDIX AND PROXIMAL COLON 
 
 surrounded by adhesions, have no delaying effect upon 
 the passage of contents through the bowel, so-called 
 ptosis of the transverse colon must be a condition of 
 very dubious significance. It may be primary or may 
 be secondary to ptosis of the stomach (ii8). At any 
 rate the stomach and the transverse colon are so related 
 that filling of the one organ has a marked influence on 
 the position of the other, and filling of the former reflexly 
 induces emptying of the latter. 
 
 The nervous supply of the proximal colon comes from 
 the splanchnic nerves, which, as elsewhere, are inhibitory 
 in function. . Miiller repeats that the proximal colon, as 
 far as the hepatic flexure, is supplied by the upper 
 splanchnic group, the cell-stations of which are in the 
 coeliac ganglion, while the transverse colon receives 
 splanchnic fibres from the lower splanchnic group like 
 the distal colon (255) (see p. 199). Probably no vagal 
 fibres reach this portion of the gut in man. Elliott and 
 Barclay-Smith deny that the region of the colon which 
 exhibits anastalsis receives any fibres from the sacral 
 nerves (92). Hence the proximal colon receives no motor 
 impulses whatever. It is, however, subject to reflex 
 influences from many parts of the body, the stomach 
 being one of the most important. 
 
 The blood supply of the proximal colon comes from 
 the superior mesenteric artery. This vessel passes along 
 the root of the mesentery to the ileo-csecal region. In 
 its course it gives off the middle colic branch to the 
 transverse colon and th'e right colic vessel to the ascend- 
 ing colon. These form an arch of anastomosis, and the 
 former also completes a second arch in the substance of 
 the transverse mesocolon with the left colic branch of 
 the inferior mesenteric artery, which constitutes the 
 
THE C^CUM, APPENDIX AND PROXIMAL COLON 1 87 
 
 supply to the distal colon. This latter arch has some 
 importance in the performance of gastro-enterostomy (p. 
 155). At the ileo-Coecal region the terminal part of the 
 superior mesenteric vessel divides into branches for the 
 supply of the caecum, the appendix and the last few 
 inches of the ileum. 
 
 As in other parts of the body, the mesenteric arteries 
 are liable to atheroma and to sclerotic processes (196), 
 associated with which may be attacks of what is called 
 abdominal angina. 
 
 The various branches of the artery make anastomotic 
 loops with each other two or three cm. from the wall of 
 /the contracted bowel and in the substance of the meso- 
 colon where it is present. The distance of these loops 
 from the bowel wall provides a free margin of mesocolon, 
 between the layers of which the gut may penetrate as it 
 distends. Beyond these loops there is but little anasto- 
 mosis between the vessels passing to the walls of the gut. 
 This fact must be remembered in the performance of 
 resection of the bowel, in which operation more gut 
 should be cut away at the free than at the attached 
 border in order to provide against possible gangrene 
 (256). Occasionally an embolus enters the main vessel 
 or one of its branches, and then infarct is likely to occur 
 (ill), for, as previously mentioned, the vessels of the 
 intestine are, for practical purposes, end arteries. 
 
 The radicles of the superior mesenteric vein follow the 
 same course as the corresponding arteries, but the main 
 trunk empties directly into the portal vein. Pylephle- 
 bitis and thrombosis , spreading even to the portal 
 junction, may result in cases of appendicitis. Braun 
 suggests that as the ileo-cjecal vein is the one affected, 
 it should be ligated, in view of its distribution, close to 
 
1 88 THE CiECUM, APPENDIX AND PROXIMAL COLON 
 
 the point where it empties into the superior mesenteric 
 trunk, a point situated adjacent to the vertebral column 
 
 (39)- 
 
 The lymphatics of the proximal colon are much more, 
 numerous than those of the upper distal colon. They 
 drain into nodes on the intestinal wall and in the 
 appendices epiploic^e. These are known as the epicolic 
 group. A second set of nodes found alongside the colon 
 is termed the paracolic group. Along the course of the 
 main arterial stems are the intermediate nodes. Lastly 
 at the origin of the superior mesenteric artery lies the 
 main group. One of these lies behind the third part of 
 the duodenum, and is miscalled the " duodenal gland." 
 This is the classification by Jamieson and Dobson. An 
 appendicular abscess may arise around the appendix 
 itself, or it may result from the breaking down of any 
 one of the epicolic or paracolic nodes. Jamieson and 
 Dobson point out that this may also occur in tubercu- 
 losis (i6i). The lymphatics from the appendix may 
 drain into the so-called appendicular node, which, if 
 present, drains varying parts of the appendix, into the 
 nodes along the ileo-csecal artery, or into nodes in front 
 of and behind the caecum. 
 
 Lockwood has frequently noticed in appendicitis the 
 enlargement of the paracolic nodes alongside the ascend- 
 ing colon, a group which has come to be called Lock- 
 wood's Chain (209). This, however, does not indicate 
 the direct route of lymphatic drainage from the appendix, 
 but merely a collateral extension of infection. Also, 
 according to Lockwood, there may be extension along 
 the appendiculo-ovarian ligament if that be present. 
 The collateral extension of inflammation along lymph 
 channels to the pelvis has been discussed by Cohn (64), 
 
THE C^CUM, APPENDIX AND PROXIMAL COLON 1 89 
 
 Quenu has suggested that the presence in fulminating 
 appendicitis of a tender area extending from the right 
 iliac fossa upward and inward toward the middle line 
 may be an indication of nodal enlargement (274). 
 
 For the adequate excision of the area affected in 
 malignant disease of the caecum, Jamieson and Dobson 
 suggest the following order of procedure. The third 
 part of the duodenum is exposed and the " duodenal 
 gland " secured. The ileo-cascal and right colic vessels 
 are ligatured and divided half an inch from the superior 
 mesenteric trunks to devascularise the whole of the 
 ascending colon. Then the terminal part of the ileum, 
 the caecum, the ascending and part of the transverse 
 colons are excised together with a small part of the ileal 
 mesentery, care being taken of the right ureter, which 
 passes behind the last-mentioned. 
 
 Corner and Sargent (71) separated volvulus of the 
 cascum into three varieties, of which two depend on 
 abnormalities of the mesentery, and the third, which 
 may be present with either of the other two^ on congenital 
 malformation of the caecum and its mesentery. 
 
 In the first, jejuno-ileum, Ccecum and a varying amount 
 of colon have one common mesentery, the axis of 
 rotation being practically the pedicle formed by the 
 superior mesenteric vessels. 
 
 In the second, the root of the mesentery is not so 
 limited as in the previous type, but the mesentery of 
 caecum and colon is, like that of the jejuno-ileum, longer 
 than the mesentery of the lower ileum. This variety 
 Corner and Sargent state to be 'the commonest. 
 
 The third type is a rotation of the caecum on its own 
 longitudinal axis, and is the variety already mentioned 
 (see p. 163). 
 
CHAPTER X. 
 
 The Distal Colon, Rectum and Anus. 
 
 The distal colon comprises the descending, iliac and 
 pelvic colons, the rectum and the anal canal. It may be 
 that differences of diet are associated with variations in 
 the limit between the proximal and distal colons. Elliot 
 Smith noted that in ancient Egyptian bodies the contents 
 of the cplon extended uniformly to the iliac portion, and 
 that nodulation was present only in the pelvic segment, 
 a condition of affairs which led Elliott and Barclay-Smith 
 to suggest a possible extension of the proximal colon in 
 these ancient frugivorous people (92). With the excep- 
 tion of the rectum and anal canal, the distal colon closely 
 resembles the proximal colon in its gross features. 
 Tsenije, appendices epiploic^e and diverticula are all 
 present. Indeed diverticula are far more abundant in 
 the pelvic colon than elsewhere in the alimentary tract 
 (316). Differences are found in the nerve, lymph and 
 blood supply from the corresponding features of the 
 proximal colon, and associated with these is a difference 
 in function. The distal colon may be considered a 
 storehouse for ftecal matter until a convenient oppor- 
 tunity occurs for defa;cation. It has practically no 
 absorptive power, and probably its secreting power is 
 limited to the formation of mucus for the lubrication of 
 the faeces. At autopsy it is usual to find the descending 
 and iliac portions contracted and the pelvic segments 
 distended to a variable degree. The length of the pelvic 
 colon varies greatly in different subjects. Even in a 
 
 190 
 
THE DISTAL COLON, RECTUM AND ANUS I9I 
 
 child, it may -be 60 to go cm. long if distended or 
 obstructed. On the other hand, even in an adult it may 
 be less than 30 cm. long. Peritoneum usually binds the 
 descending and iliac portions to the dorsal abdominal 
 wall without the intervention of a mesentery. 
 
 The position occupied by the descending colon is to 
 the lateral side of the left kidney and a little further from 
 the middle line of the body than the ascending colon. 
 The descending colon is mapped out on the surface of 
 the abdomen immediately to the lateral side of the left 
 lateral inguinal line, and extends from the interseiction 
 of the mid-axillary line and the upper border of the ninth 
 rib marking the site of the splenic flexure, to the inter- 
 tubercular plane which indicates the level of the iliac 
 crest. 
 
 From the iliac crest the iliac colon extends to the true 
 pelvic brim at the sacro-iliac synchondrosis, a point 
 indicated by the junction of the upper and middle thirds 
 of a line which joins the umbilicus with the intersection 
 of the inguinal (Poupart's) Hgament and the left lateral 
 inguinal line. The pelvic colon which succeeds the iliac 
 is normally about 50 cm. in length in the adult. It is. 
 equal in length to the transverse colon, and is rather 
 longer in the male than in the female (166). 
 
 Frequently the descending and iliac colons possess no 
 mesentery, but in 364 cases out of 982 in children, Smith 
 noted that some part of this segment of the bowel did 
 actually possess a mesocolon (311). The pelvic colon 
 has a mesentery much more frequently, although where 
 a very short pelvic colon occurs it may be absent (309). 
 The attachment of the pelvic mesocolon to the dorsal 
 wall runs from the left sacro-iliac synchondrosis along 
 the brim of the true pelvis to the neighbourhood of the 
 
192 THE DISTAL COLON, RECTUM AND ANUS 
 
 sacral promontory, and then vertically downward to the 
 third piece of the sacrum or the intervertebral disc 
 immediately caudal to it. At this level the pelvic colon 
 becomes rectum and the mesentery is lost. Very 
 frequently the mesentery is simply attached along a 
 curved line which passes between the sites of its com- 
 mencement and termination, and which presents a 
 concavity downwards. As the distance between the 
 commencement and termination of the mesentery is only 
 about 10 cm., this portion of the colon may be said to 
 have a narrow pedicle. A condition of chronic inflam- 
 mation may be set up and maintained in the mesentery 
 by any source of long continued irritation, and such an 
 inflammation is not uncommon in the pelvic mesocolon, 
 in which case stiffness and contraction are produced, 
 leading in many cases to narrowing of the base of 
 attachment (20). This narrowing of the "pedicle" of 
 the gut assists in predisposing the pelvic colon to 
 volvulus. In three out of twenty-two autopsies Homen 
 and Wallgren found that inflammation had caused great 
 shrinkage in the pelvic mesocolon (154). 
 
 Immediately beneath the commencement of the pelvic 
 mesocolon and intervening between it and the left iliac 
 vessels there is often found a pocket of peritoneum 
 known as the intersigmoid fossa, which may become the 
 sac of an internal hernia. For practical purposes the 
 "sigmoid loop" is now synonymous with the pelvic 
 colon. 
 
 It is the pelvic colon which is utilised in the operation 
 of left inguinal colostomy, for in many cases the iliac 
 colon, not possessing a mesentery, cannot be raised to 
 the level of the wound in the abdominal wall. In order 
 to prevent prolapse of the gut it used to be the custom 
 
THE DISTAL COLON, RECTUM AND ANUS IQS 
 
 to bring into tiie wound the highest possible loop of 
 pelvic colon, but this procedure left only a short length 
 of bowel beyond the splenic flexure for the collection of 
 faeces. Hence it is now customary to fix in the wound 
 the lowest portion possible of the pelvic colon in order 
 to preserve the greatest amount of distal colon to act as 
 a faecal storehouse. Prolapse can be prevented in the 
 low operation by fixing the bowel obliquely in the thick- 
 ness of the aibdominal wall as in Frank's operation for 
 gastrostomy. If the mesocolon is too short for this, the 
 same functional result is obtained by twisting the bowel 
 in a half circle before bringing it into the wound (248). 
 In the adult the pelvic colon, if undistended, lies 
 entirely within the pelvic fossa of the peritoneal cavity, 
 but in the infant and the child, the pelves of whom are 
 comparatively small, it is to a large extent an abdominal 
 organ. In the child it frequently opens into the rectum 
 from the right, the terminal portion of pelvic colon lying 
 in the right half of the pelvic fossa, whereas in the adult 
 in many cases the pelvic colon opens into the rectum 
 from the left. The disposition of the pelvic colon in the 
 pelvis of the adult is first from left to right and thejn 
 from right to left, so that the terminal portion forms an 
 acute angle with the upper part of the rectum. In 
 consequence of this arrangement a valvular fold of the 
 mucosa projects into the lumen of the gut on the ventral 
 and left aspect at the pelvi-rectal junction. The presence 
 of this fold necessitates the turning of the sigmoidoscope 
 to the right before it can slip round into the pelvic colon. 
 This is not invariably the disposition of the bowel even 
 in adults. Sometimes it is necessary to turn the sig- 
 moidoscope to the left to enable it to enter the pelvic 
 colon. It is possible that some sphincteric action may 
 
194 '^HE DISTAL COLON, RECTUM AND ANUS 
 
 take place at the pelvi-rectal junction (256) (268), although 
 the presence of a definite anatomical sphincter is denied 
 by Symington (321). The pelvic colon is distensible to 
 an even greater degree than the transverse colon or the 
 caecum. It is the portion of gut most subject to volvulus. 
 In acute volvulus the increase in size of the pelvic colon 
 may be so great as to cause very considerable distension 
 of the abdomen in a few hours. 
 
 Recently Gysi has collected a number of cases of 
 variation in position and course of the pelvic colon, and 
 to these he has added others which came under his own 
 observation (121). 
 
 Hirschsprung's disease, or chronic distension of the 
 colon, may affect either the proximal or distal segment 
 or both. It is of obscure origin and develops in early 
 life. For a summary of the suggested causes Meyer's 
 paper may be consulted (235). The condition is said to 
 be more obvious radiographically if the bowel is inflated 
 with gas through the anus (105). Children in whom this 
 anomaly is present do not invariably die, and those who 
 live, possess what in later life is termed a megasigmoid 
 (218). Huge dilatation of the colon is seen in some 
 cases of acromegaly. Occasionally Hirschsprung's 
 disease affects part of the distal colon only, as in Bard's 
 (16) and Barclay-Smith's cases (15), in which the anomaly 
 was confined to the rectum and pelvic colon. In some 
 of these cases the hypertrophied longitudinal muscular 
 coat is visible even macroscopically over most of the 
 surface of the bowel (279). According to Geddes some 
 are associated with what he describes as enlargement of 
 the abdominal sympathetic system (108). 
 
 The distal colon is the part of the bowel in which 
 embryonic differentiation and growth is latest and 
 
THE DISTAL COLON, RECTUM AND ANUS 1 95 
 
 slowest. When the foetal duodenum is loo |j, in diameter, 
 the splenic flexure also has a diameter of loo (x (322). 
 In some instances the distal colon never develops, and 
 the gut is permanently occluded from the region of the 
 splenic flexure onwards. 
 
 The wall of the distal colon presents no marked 
 differences in its anatomical features from that of the 
 proximal colon, and the characteristic movements are the 
 same. Cannon describes two methods of emptying of 
 the distal colon, the rapid mass movement and the slow 
 progressive movement of small fragments, both move- 
 ments being similar to the corresponding ones in the 
 proximal colon (50). There is probably also a superficial 
 wave of contraction for the onward propulsion of 
 accumulated gas (28), which is accompanied by small 
 crackling sounds (48). Hertz found that the whole of 
 the distal colon from the splenic flexure onward is 
 emptied in def^ecation (139). But Schwarz has observed 
 even part of the ascending colon to be emptied also. 
 This accounts for the soft nature of the last portion of 
 a large faecal discharge (307). The accumulation of 
 waste material stops at the pelvi-rectal junction. When 
 it becomes distended, the pelvic colon erects itself on the 
 rectum and some of its contents pass into the latter organ 
 thereby stimulating the desire to defaecate. In defaeca- 
 tion there may even be some invagination of the pelvic 
 colon into the rectum (107). Until recently it was said 
 that anastalsis never occurs in the distal colon. Roith 
 now brings forward evidence to show that anastalsis 
 may occur in the pelvic colon, though he denies i'ts 
 occurrence in the descending and the distal part of the 
 transverse colon (291). The observations of Schwarz 
 confirm Roith 's statement of the occurrence of anastalsis 
 
ig6 
 
 THE UlSTAL COLON, RECTUM AND ANUS 
 
 in the distal colon (306), an action also induced by the 
 withholding of a stool (255). The length of time taken 
 by food in passing through the distal colon is compara- 
 tively great. Bismuth reaches the splenic flexure nine 
 
 Fig. 37. Tracing from radiogram to show the course of the colon. 
 
 Obseirve that the "kink" at the splenic flexure is for the greater part 
 an illusion produced by the Rontgen rays passing through the body in the 
 dorsi-ventral direction. Seen from the side both the hepatic and splenic 
 flexures are gentle curves of bowel, not acute bends. 
 
 hours after the meal. It appears in the iliac colon at 
 the end of eleven hours, in the pelvic colon in twelve 
 hours and in the rectum in eighteen hours (139). 
 The arterial supply of the distal colon comes from the 
 
THE DISTAL COLON, RECTUM AND ANUS I97 
 
 inferior mesenteric brancli of the abdominal aorta. This 
 vessel sends the left colic artery upward, medial to the 
 hilum of the left kidney, for the supply of the descending 
 colon. It finally anastomoses with the left branch of the 
 middle colic artery. The main vessel distributes the 
 sigmoid branches, usually two in number (353) to the 
 iliac and pelvic colons, and then continues down the root 
 of the pelvic mesocolon to become the superior hsemor- 
 rhoidal artery for the supply of the rectum. The superior 
 hasmorrhoidal, sigmoid and left colic vessels exhibit a 
 series of anastomotic loops beyond which, as in the 
 proximal colon, there is practically no anastomosis 
 between the arterial branches. In the pelvic mesocolon 
 the anastomotic lobps lie very near the mesenteric root, 
 and are further removed from the contracted bowel wall 
 than the corresponding loops in any other portion of the 
 gut ; a fact which is to be associated with the great disten- 
 sibility of the pelvic colon. The lowest of these loops 
 unites the distal sigmoid vessel with the superior 
 hjemorrhoidal artery, and as a rule the anastomotic 
 branch joins the latter vessel about I'S cm. below the 
 sacral promontory. This is a point of great importance 
 in excision of the recfUm (327), and is known as 
 Hartmann's critical point (127). If, in operation by the 
 perineal route, the superior haemorrhoidal artery is 
 ligatured below the point at which it receives the anasto- 
 motic branch, the whole of the blood supply will be cut 
 off from the area of bowel which is supplied by the 
 superior hEemorrhoidal artery. If the ligature is placed 
 on the superior haemorrhoidal vessel above the entry of 
 the anastomotic branch, there is no danger of gangrene 
 to the bowel since blood flows through the anastomotic 
 vessel to the superior haemorrhoidal and so to the gut,. 
 
igS THE DISTAL COLON, RECTUM AND ANUS 
 
 while, during the operation and until the anastomotic 
 branch enlarges sufficiently, the area of operation is 
 comparatively bloodless. A full discussion of the point 
 together with the best methods of dealing with the 
 problems raised by carcinoma recti will be found in the 
 article just mentioned (327). 
 
 The inferior mesenteric vein receives the venous 
 drainage of the whole of the distal colon except the anal 
 canal. This vessel, which is the continuation of the 
 superior hcemorrhoidal .vein, , passes upward alongside 
 the left colic artery behind the peritoneum and medial 
 to the hilum of the left kidney to reach the splenic vein, 
 which is a tributary of the portal. 
 
 Medial to the kidney the inferior mesenteric vein and 
 the left colic artery form the vascular arch of Treitz, 
 which may be related to retroperitoneal hernia (see p. 
 123). In the adult the inferior mesenteric vein possesses 
 «ither no valves or very incompetent ones (346), a fact 
 which is of importance in relation to haemorrhoids. 
 
 The lymphatics of the descending and iliac colons are 
 less numerous than those from the remainder of the large 
 bowel (272). On the other hand, the pelvic colon is 
 richly supplied with lymphatics. The distribution of 
 lymphatic nodes to the distal colon is on precisely the 
 same plan as in the case of the proximal colon (see p. 
 188). 
 
 The nerves to the distal colon are derived from the 
 splanchnics and the second, third and fourth sacral 
 nerves. The latter do not pass direct to the bowel wall, 
 but have intermediate ganglia on their course. Probably 
 they terminate in the isolated nerve-endings to be found 
 in the distal colon, and do not join the splanchnic plexus 
 in the muscular coat (48). In this respect they resemble 
 
THE DISTAL' COLON, RECTUM AND ANUS 
 
 199 
 
 the vagus nerves in the stomach and small intestine. 
 Their function is similar to that of the vagus in the 
 alimentary tract, namely, to keep up tone and enable 
 diastaltic movements to occur. The splanchnic nerves 
 are, as usual, inhibitory in function, and as suggested 
 
 Fig. 28. Photograph of .dorsi-ventral median section of male pelvis to 
 show the level of the great valve of Houston and the rectal relations. 
 
 For comparison with fig. 29. 
 
 a, ampulla ; b, bladder ; c, pelvic colon ; d, pouch of Douglas ; h, great 
 valve of Houston ; i, ileum ; 1, bulb of penis ; n, levator ani ; p, prostate ; 
 s, pubic symphysis ; v, line of anal valves. 
 
 by Miiller, they probably originate from the lower 
 splanchnic group of cell stations, which are located in 
 the inferior mesenteric ganglion (255). 
 
 The Rectum. 
 The rectum is the terminal dilated portion of the distal 
 colon and communicates with the exterior by means of 
 the anal canal. It possesses no mesentery and is but 
 
200 THE DISTAL COLON, RECTUM AND ANUS 
 
 partially surrounded by peritoneum even in its upper 
 part, which is termed the pelvic chamber. The lower 
 portion lies beneath the level of the peritoneum, but 
 above the levatores ani, and is called the ampulla. The 
 reasons for this nomenclature will be apparent later (see 
 p. 21 1). The anal canal is a constricted passage below 
 the levatores ani, about 3 cm. in length, by which the 
 rectum opens into the anal fissure between the buttocks. 
 It is the portion which grips the finger in a digital 
 examination. 
 
 After passing through the anal canal, the finger enters 
 the dilated ampulla and then reaches a fold of mucosa 
 which partially subdivides the rectum. This fold is the 
 third or great valve of Houston : it involves the ventral 
 wall of the bowel and extends as a rule more to the right 
 than to the left. It marks the subdivision between the 
 pelvic chamber and ampulla, and approximately indicates 
 the lowest level of the peritoneal cavity, namely, the 
 bottom of the pouch of Douglas. With the aid of the 
 sigmoidoscope other transverse folds are to be seen above 
 the one just mentioned. They are variable in number 
 and their presence depends upon distension of the organ. 
 In the foetus the uppermost projects from the right wall 
 because the pelvic colon opens into the rectum from the 
 right (see p. 193). In sigmoidoscopic examination of 
 the adult, the instrument has usually to be passed to the 
 right before the pelvic colon can be entered, as in the 
 adult the pelvic colon enters the rectum from the left and 
 this causes the valvular fold to involve the left wall (89). 
 The pelvi-rectal fold, like the great valve of Houston, 
 involves the ventral wall of the bowel and extends 
 laterally. It may be so pronounced that the opening 
 from colon to rectum is exceedingly difficult to trace. 
 
THE DISTAL COLON, RECTUM AND ANUS 201 
 
 In such a case the pelvi-rectal orifice is found ventrally 
 and low down (257). The method of production of the 
 so-called pelvi-rectal valve has already been indicated. 
 There is no doubt that the presence of the great valve is 
 associated with the fact that the capacious rectum 
 possessing no mesentery is bound directly to the concave 
 sacrum, which disposition is in itself sufficient to produce 
 a kink in the ventral wall. The presence in the adult of 
 the terminal portion of pelvic colon in the left side of 
 the pelvic cavity causes the pelvic chamber of the rectum 
 to lie somewhat to the right of the middle line, and thus 
 the great valve involves a greater extent of the right 
 rectal wall than the left. In the foetus, child and adult 
 female, the sacral concavity is less marked than in the 
 adult male. Hence the rectum follows a straighter 
 course. It is noteworthy that it is in women and 
 children that rectal prolapse most frequently occurs (see 
 p. 211). 
 
 In the normal individual the rectum contains faecal 
 matter only when there is the desire to defascate, but the 
 pelvic chamber and even the ampulla ■ may be found 
 choked with faeces in constipated persons. Frequently 
 the ampulla contains gas. On distension of the rectum 
 the folds already mentioned become more pronounced, 
 and others, believed to be compensatory in nature, appear 
 on the opposite wall. When distended with gas the 
 rectum is said to be ballooned, a condition dependent for 
 its production upon spasm of the sphincters, which 
 normally alternate in rhythmic manner between contrac- 
 tion and relaxation. The spasm is caused by irritation 
 in the distal colon, and is not characteristic of malignant 
 ■growth. Any catarrhal state of the rectum or pelvic 
 colon will produce ballooning, and it is especially 
 
202 THE DISTAL COLON, RECTUM AND ANUS 
 
 common in atrophic catarrhal proctitis or sigmoiditis 
 (257). On the other hand, relaxation of the sphincters 
 becomes a chronic condition in old age. Therefore in 
 elderly people an anal canal can hardly be said to exist. 
 But in the young healthy adult man, it is about 3 cm. 
 in length; in women its length is about 2 cm. (9). The 
 anus is an indefinite site, but maybe said to represent 
 the junction of skin with mucous membrane. The 
 distance from the anus to the great valve of Houston is 
 about 8 cm. and to the pelvi-rectal valve about 13 cm. 
 The junction of rectum and anal canal lies about 2*5 cm. 
 below and in front of the tip of the coccyx. While the 
 axis of the rectal ampulla is directed ventrally and 
 downward, that of the anal canal passes downward and 
 dorsally, almost at a right angle with the former. 
 
 The mucosa of the rectum proper is red and vascular ; 
 that of the anal canal is paler. Scattered over the surface 
 of the rectum are numerous little depressions known as 
 rectal pits, at the bottom of each of which lies a sub- 
 merged nodule of lymphoid tissue. Far more numerous 
 than these, so plentiful indeed that they give the mucosa 
 a sieve-like appearance when examined with a hand-lens, 
 are the Lieberk-uhn's follicles, which secrete mucus for 
 the lubrication of the fasces. In proctitis and sigmoiditis 
 the mucosa is covered with an exuberant and sticky 
 secretion of white granular mucus, excess of which 
 occasionally gives rise to an intractable form of pruritus 
 (257). In the pelvic chamber, the rugae of the mucosa 
 are transverse like those of the pelvic colon. In the 
 ampulla the rugae are vertical, and are produced by 
 vessels lying in the bowel wall (351). These vertical 
 rugae are continued down to the muco-cutaneous junc- 
 tion, which lies about half the distance along the anal 
 
THE DISTAL COLON, RECTUM AND ANUS 203 
 
 canal, and are called the columns of Morgagni. They 
 are about five in number (89), and their distal extremities 
 are united by folds of mucosa, the remnants of a 
 proctodbeal hyrnen, known as anal valves. Frequently 
 small tags of tissue are found on these valves or on the 
 columns near the valves. Such tags are known as 
 papillae of Morgagni. Between the columns and above 
 the valves are the lacunae of Morgagni, little pouches 
 where faecal matter may lodge and form the starting 
 point of a fistula or a fissure. The muco-cutaneous 
 junction exhibits a white band known as the white line 
 of Hilton. To this band is also given the name of the 
 pectinate line, for the anal valves with the distal extremi- 
 ties of the columns present the appearance of a series of 
 fans. On the cutaneous surface of the anal valves are 
 numerous puckers of skin produced by the action of the 
 external sphincter. If these become inflamed and 
 oedematous, they form one variety of external piles, 
 which later will subside into tags of skin around the 
 anus (89). Sometimes the mucosa of the ampulla 
 presents a diverticulum in the middle line dorsally (9) or 
 ventrally. In aiiy case, in women especially, a pocket 
 of the entire thickness of the rectal wall is liable to 
 develop in the mid-ventral line at the lowest part of the 
 ampulla immediately above the levatores ani. 
 
 The muscular coat of the rectum consists of external 
 longitudinal and internal circular layers, of which the 
 former is distributed evenly around the rectal wall and 
 not massed into taeniae as in the colon. The circular 
 coat is thickened in the region of the great valve of 
 Houston, and again in the upper half of the anal canal 
 to form the internal sphincter, and through it at various 
 levels pass the vessels of supply. It is possible that the 
 
204 THE DISTAL COLON, RECTUM AND ANUS 
 
 effect upon the veins of contraction of muscular fibres 
 may assist in the production of haemorrhoids. The 
 fibres of the levatores ani mingle with those of the 
 musculature of the anal canal. Certain of the longitu- 
 dinal fibres from the ventral aspect of the ampulla and 
 the anal canal pass to the membranous urethra and the 
 dorsal aspect of the prostate gland. These represent 
 the wall of the original communication between the 
 rectum and the urogenital sinus. The ventral median 
 pocket of mucosa already mentioned also represents this 
 communication, which is complete in cases of congenital 
 recto-urethral fistula. 
 
 The external sphincter is situated around the distal 
 half of the anal canal, which is lined with cutaneous 
 epithelium. A common form of fistula passes between 
 the external and internal sphincters. It has its internal 
 opening in the region of the lacunae of Morgagni, and 
 it opens externally on the skin of the buttock wide of the 
 external sphincters. 
 
 In the adult male the peritoneal coat extends on the 
 ventral aspect of the rectum to the neighbourhood of the 
 great valve of Houston (351), about 8 cm. from the anus. 
 It only partially covers the lateral walls of the pelvic 
 chamber, and does not cover the dorsal wall at all. Thus 
 the line of peritoneal reflexion passes downward and 
 ventrally on the wall of the pelvic chamber from the 
 pelvi-rectal junction to its distal limit at the level of the 
 great valve of Houston. Along this line of reflexion 
 runs the main branch of bifurcation of the superior 
 hsemorrhoidal artery. Distension of the rectum raises 
 the level of the lowest limit of the peritoneum. In the 
 woman and the child the peritoneum reaches a somewhat 
 lower level than in the adult man, and covers the front 
 
THE DISTAL COLON, RECTUM AND ANUS 20$ 
 
 of the proximal portion of the ampulla. In the earlier 
 months of foetal life the peritoneum ensheathes the 
 ventral aspect of the whole of the rectum to the upper 
 surface of the levatores ani and the perineal body (93). 
 As the peritoneum in front of the pelvic chamber forms 
 the dorsal wall of the pouch of Douglas, an inflammatory 
 deposit occurring there in such a disease as appendicitis 
 can readily be palpated by rectal examination. Some- 
 times cancerous deposits secondary to carcinoma in other 
 regions of the abdomen (e.g., the stomach) (see p. 23 ) 
 occur in the pouch of Douglas. Frequently they are 
 surrounded by a mass of inflammatory tissue. 
 
 The arterial supply of the rectum and anal canal arises 
 from the hjemorrhoidal vessels. Of these the inferior 
 hasmorrhoidal branch of the internal pudic artery 
 supplies the anal canal distal to the white line, the 
 middle hsemorrhoidal branch of the internal iliac trunk 
 runs to the region of the white line and anal valves, 
 while the superior hiemorrhoidal artery, which is the 
 continuation of the inferior mesenteric, distributes 
 branches to the pelvic chamber and ampulla. The last 
 mentioned vessel reaches the dorsal aspect of the pelvi- 
 rectal junction by passing downward in the root of the 
 pelvic mesocolon. It then subdivides and its two 
 branches of bifurcation pass as already indicated along 
 the lines of peritoneal reflexion, distributing many 
 vascular twigs as they proceed. Its relation to the 
 operation of excision of the rectum by the perineal route 
 has already been discussed (see p. 197). There is a free 
 anastomosis between the several arteries of supply to the 
 rectum and anal canal. 
 
 The veins of the rectum and anal canal have a similar 
 distribution to that of the arteries, and free anastomosis 
 
206 THE DISTAL COLON, RECTUM AND ANUS 
 
 exists also among the veins. The superior b£emorrhoidal 
 vein continued upward becomes the inferior mesenteric, 
 which joins the splenic vein, a tributary of the portal. 
 The middle haemorrhoidal vein throws its blood into the 
 internal iliac, and the inferior hemorrhoidal is a tributary 
 of the internal pudic, which joins the internal iliac. The 
 inferior and middle haemorrhoidal veins form part of the 
 systemic circulation, and the superior haemorrhoidal 
 drains into the portal system. The free anastomosis 
 between the veins of the rectum and anal canal results 
 therefore in the communication between these two great 
 venous systems, and a condition is produced similar to 
 that at the cardiac orifice of the stomach. In portal back 
 pressure, either general or local, the venous anastomosis 
 of the anal canal is engorged owing to the increased 
 drainage into the systemic circulation, and there results 
 a condition of varix or internal haemorrhoids, which is 
 intensified by the passage of the veins through the 
 muscular coat. Besides an arterial twig, each column 
 of Morgagni contains a moniliform venous channel, 
 which on engorgement projects as a pile. When such 
 a condition develops, one haemorrhoid, known as the 
 perineal pile, is frequently found on the ventral aspect of 
 the anal canal, and two others are placed laterally one 
 to the right and one to the left. Smaller haemorrhoids 
 may exist bgtween these larger ones (89). In White- 
 head's operation the mucosa of the proximal portion of 
 the anal canal, above the white line, is removed along 
 with its contained venous plexus, but the muscular coat 
 and skin must not be interfered with lest incontinence or 
 stricture follow. 
 
 Like the blood vessels, the lymphatics of the rectum 
 and anal canal may be divided into three areas. Those 
 
THE DISTAL COLON, RECTUM AND ANUS 207 
 
 of the pelvic chamber and ampulla pass to. nodes placed 
 on the lateral walls of the rectum and in the substance 
 of the pelvic mesocolon alongside the superior h£emor- 
 rhoidal artery. They have no clinical association with 
 the lymphatics of the pelvic colon itself (313). The 
 lymphatics of the anal canal pass to the nodes along the 
 internal iliac vessels. Some run alongside the middle 
 hsemorrhoidal artery while others drain through the fatty 
 tissue of the ischio-rectal fossa to reach the same destina- 
 tion. These travel in the direction taken by the inferior 
 haemorrhoidal artery, but do not slavishly follow the 
 vessel. 
 
 The lymphatics of the skin around the anus drain into 
 the inguinal group of nodes in common with the rest of 
 the perineal vessels (272). All these vessels communicate 
 in the wall of the gut. But there is no clinical commu- 
 nication between the rectal lymphatics and the sacral 
 nodes, between which and the pararectal nodes oii the 
 wall of the rectum lies the fascia propria of Waldeyer 
 
 (327)- 
 
 The nerve supply of the rectum and anal canal comes 
 from the splanchnics and from the nervi erigentes of the 
 third and fourth sacral nerves. The latter pass in a 
 leash from the sacral foramina to the lateral aspect of 
 the ampulla where they penetrate the rectal wall. These, 
 together with the middle hagmorrhoidal vessels and the 
 surrounding connective tissue, constitute the rectal stalks 
 (les ailerons) and form a considerable support to the 
 viscus. Secondary nodules occurring in the sacrum as 
 metastases in carcinoma recti have found their way to 
 the bone along the rectal stalks. It is only when these 
 are severed that the organ can be drawn down and the 
 pelvic colon sutured into the anus without tension (314). 
 
208 
 
 THE DISTAL COLON, RECTUM AND ANUS 
 
 Cutaneous sensation can be perceived for about 3 cm. 
 above the line of the anal valves. Should an abrasion 
 or fissure occur in this situation, intense pain is the 
 result. After perineal excision of the rectum, as after 
 the operation of colostomy, cutaneous sensation is 
 ultimately developed in the two or three cm. of bowel 
 adjacent to the skin surface to which the bowel has been 
 sutured. 
 
 Fig. 29. Photograph of the pelvis represented in fig. 28 with the 
 rectum drawn aside to. to expose the combined rectal fascia and stalk 
 (a), the levator ani (b), and the nerve to the levator ani (c). 
 
 On each side of the anal canal below the level of the 
 levatores ani is the fatty tissue of the ischio-rectal fossa, 
 which IS subdivided into upper and lower compartments 
 by a fascial sheet passing from Alcock's canal (fascia 
 lunata) medially to the wall of the gut (93). It is in the 
 lower of these subdivisions that ischio-rectal abscess 
 
THE DISTAL COLON, RECTUM AND ANUS 209 
 
 occurs. The passage of lymphatics from the anal canal 
 through the tissue of the ischio-rectal fossa determines 
 a worse prognosis for carcinoma recti starting in the 
 anal canal than in any other part of the viscus. Above 
 the levator ani and between it and the peritoneum is an 
 interval called by Richet the superior pelvi-rectal space 
 {89) in which lies the rectal stalk already mentioned (p. 
 207), one of the main and indeed ultimate supports of 
 the rectum. 
 
 As already mentioned, the rectal stalks consist of the 
 perineural tissue surrounding the branches of the nervi 
 erigentes which enter the rectum at the lower part of the 
 ampulla and the perivascular tissue which envelopes the 
 middle hasmorrhoidal artery. In excision of the rectum, 
 after the levatores ani have been severed, these stalks 
 must be dealt with before the gut can be drawn down 
 
 (327)- 
 
 In the hollow of the sacrum and forming for the rectum 
 a dorsal sheath whose lateral extremities are constituted 
 by the rectal stalks is the fascia propria of Waldeyer 
 (337)) or the rectar fascia of. J. W. Smith (313) (314)- 
 This is merely the connective tissue filling the interval 
 between the rectum and pararectal nodes and the sacrum 
 and sacral nodes, but clinically it forms a barrier effective 
 in most cases against the transmission of carcinomatous 
 metastases from the viscus to the sacral nodes. As a 
 rule it can be torn through easily with the finger at 
 operation, and thus differs from the powerful rectal stalks. 
 It is loosely attached to the ventral aspect of the sacrum 
 at the level of the third piece. The rectal stalks may be 
 severed at operation without interference with the 
 branches of the nervi erigentes which pass to the urino- 
 genital tract (327). 
 
2IO 
 
 THE DISTAL COLON, RECTUM AND ANUS 
 
 Fig. 30. Drawing of dorsi-ventral median section of male pelvis. 
 
 The individual from whom this drawing was made died from carcinoma 
 recti. The figure illustrates the function of rectal fascia in making the 
 rectum a "self-contained" organ, in other words, in effectively separating 
 the rectum and pararectal lymphatic nodes from the sacrum and sacral 
 nodes. 
 
 a, site of carcinoma in rectum ; b, pouch of Douglas ; c, bladder ; d, 
 seminal vesicle ; e, prostate ; f, bulb of penis ; g, fistulous ulcer ; h, 
 levator ani ; i, rectosacral aponeurosis ; j, carcinomatous pararectal gland. 
 It is to be noted that though the infected gland shown in the figure lies 
 just above the levator ani, it is separated from the latter by the recto- 
 sacral aponeurosis. This fascial sheath for the rectum and pararectal 
 glands is very well marked in the specimen from which the drawing was 
 made and shows clearly its attachment to the sacrum. The only suc- 
 cessful manner of taking out rectum and pararectal glands in one piece 
 is to dissect from below, passing the hand between levator ani and 
 rectosacral aponeurosis and next between the latter and the sacrum. 
 The numerous sacral attachments of the aponeurosis render it impossible 
 satisfactorily to perform this manoeuvre from above. The muscle and 
 aponeurosis lie in immediate relation with each other in the present case, 
 but could easily be separated. 
 
THE DISTAL COLON, RECTUM AND ANUS 2 1 1 
 
 It will be observed that the rectum bears a very 
 iatimate relation to surrounding fascial tissue. Cripps 
 thus explains the liability to pelvic cellulitis and the 
 subsequent contraction which produces so inveterate a 
 type of rectal stricture. The basis of Mummery's 
 operation for rectal prolapse in adults is the replacement 
 of the cellular tissue in the rectosacral interval by cica- 
 tricial scar tissue (258). 
 
 Most of the types of rectal prolapse or procidentia are 
 really cases of rectal intussusception. The only true 
 prolapse is that variety which starts at the anal margin. 
 In connection with the occurrence of this condition in 
 young children it is worth noting that in infants at birth 
 the rectal stalks are approximately the same in propor- 
 tionate length and extensibility as in the adult, that there 
 is none of the so-called laxity of the stalks, but that the 
 rectum is already a pelvic Morgan, and in view of its low 
 position relative to the bladder and in females to the 
 uterus, and the fact that it is not shielded by an over- 
 hanging sacral promontory, it is, in early life, in a 
 position of mechanical- disadvantage (328). 
 
 The similarity in many ways between the pelvic 
 chamber of the rectum and the pelvic colon has led Wood 
 Jones to include it with the latter in the hindgut. In 
 some cases of imperforate rectum, this is the only portion 
 developed. It is the old rectum so to speak which 
 originally opened into the urino-genital siniis. Accord- 
 ing to Wood Jones, the portion here termed the ampulla 
 and the upper part of the anal canal as far as the white 
 line, are developed from the post-allantoic gut, and form 
 a new development which serves to carry the hind gut 
 from its original cloacal opening to a new perineal outlet. 
 He points out that morphologically the part of the anal 
 
212 THE DISTAL COLON, RECTUM AND ANUS 
 
 canal which lies above the anal valves belongs to the 
 ampulla and therefore he adheres to the alternative 
 nomenclature which includes ampulla and upper anal 
 canal as the perineal chamber (351). As this term is 
 not a good one for clinical purposes, the subdivision into 
 ampulla and anal canal has been retained in the present 
 description. The lower portion of the anal canal forms 
 what Wood Jones defines as the anus proper. It corres- 
 ponds to the original proctodceal ingrowth and extends 
 as high as the level of the anal valves (351), which, 
 originally a kind of rectal hymen, are best marked in 
 the foetus and child. According to Wood Jones' 
 description, if the post-allantoic gut does not develop, 
 the rectum ends blindly comparatively high up in the 
 pelvis, or may terminate by joining the urethra in the 
 male, or the vagina in the female to form a congenital 
 recto-urethral or recto-vaginal fistula. The proctodceal 
 dimple may or may not develop in these cases. If it does 
 develop, the septum between the post-allantoic gut and 
 the proctodoeum may not break down. Or the lower end 
 of the pelvic chamber may be connected with the 
 proctodceal ingrowth by a solid cord of tissue. Lastly 
 the post-allantoic gut may develop too far, and in such 
 cases the ampulla exhibits an appendix-like diverticulum 
 in the median line of its dorsal wall (351) (p. 203). 
 Rarely in cases of imperforate rectum, this backward 
 growth forms a fistula on the buttock through an aper- 
 ture in the sacrum. On the other hand it must be 
 remembered that Frank held strongly that congenital 
 occlusion of the rectum is not to be considered as a 
 malformation due to arrested development, but to an 
 abnormal fusion caused by excessive overgrowth of 
 bowel tissues during the third or fourth month of foetal 
 life (106). 
 
CHAPTER XI. 
 
 Liver, Gall Bladder, Pancreas. 
 I. The Liver. 
 
 The liver lies beneath the right cupola and part of the 
 left cupola of the diaphragm. 
 
 Of its two lobes the right is much larger than the 
 left. 
 
 It is said that a septum occurs between the two lobes, 
 and that the branches of the portal vein, which supply 
 the right and left lobes, do not communicate across this 
 septum (215). In any case cirrhosis of the organ usually 
 causes enlargement of the right lobe only, while in 
 Hanot's cirrhosis the left lobe is also enlarged. S6r6g6 
 suggested that the right lobe is more intimately associated 
 with the venous return from the alimentary canal, while 
 the left lobe has more definite association with the spleen 
 (308), but this interpretation has been shown by Looten 
 to be erroneous (215). 
 
 The position of the liver differs somewhat in the erect 
 and the horizontal positions. In either case the upper 
 limit of the organ is indicated by the level of the 
 diaphragm, and therefore corresponds in surface-marking 
 to the limits already given for that structure (see p. 9). 
 In the horizontal position the upper limit of the liver 
 is sufficiently accurately given by the following points : 
 
 Intersection of the right lateral inguinal line with the 
 fourth intercostal space. 
 
 Intersection of the middle line with the xiphi-sternal 
 line. 
 
 213 
 
214 LIVER, GALL BLADDER, PANCREAS 
 
 Intersection of the left lateral inguinal line with the 
 fifth intercostal space. 
 
 Frequently the liver does not reach quite so far to the 
 left as the lateral inguinal line but terminates in the 
 region of the apex of the heart. The lower margin of 
 the left lobe of the liver is indicated by a line joining 
 the left lateral inguinal line to the middle Hne at its 
 intersection with Addison's plane. The lower border 
 of the right lobe passes from this point along Addison's 
 plane to the right costal margin, where it curves down- 
 ward to reach its limit 2'5 cm. below the lowest point of 
 the tenth costal cartilage, which lies in the neighbour- 
 hood of the mid-axillary line. The right lobe sometimes 
 extends lower than the limit indicated. It may have 
 projecting downward even into the right iliac fossa a 
 tongue-shaped process, which is known as Riedel's lobe, 
 and which is frequently associated with the presence of 
 gall stones (287). 
 
 Sometimes Riedel's lobe does not project downward 
 into the iliac fossa, but takes the same direction as an 
 enlarging gall bladder (136). In such a case it is held 
 up by the transverse colon and mesocolon (see p. 219). 
 
 The blood supply of the liver comes from the portal 
 vein and the hepatic artery, which enter the organ at the 
 hilum on fts visceral or inferior aspect. Together with 
 the bile passages, these vessels form the hepatic pedicle, 
 the influence of which in supporting the duodenum at 
 the junction of its first and second portions is 
 referred to elsewhere. Sometimes two hepatic vessels 
 are present, the additional one arising at the same point 
 as the normal one from the cceliac axis and sometimes 
 from the same trunk at a higher level (96). 
 
 Although there is no direct anastomosis between the 
 
LIVER, GALL BLADDER, PANCREAS 21 5 
 
 portal systems of the right and left lobes, yet according 
 to Looten (215) there does not exist in the portal vein 
 a double blood current as S^reg^ suggested (308). 
 
 Presence of ascites in the later stages of cirrhosis of 
 the liver has led to an attempt to divert part of the blood 
 stream from the portal area to the systemic circulation. 
 To this end the omentum has been implanted into the 
 abdominal wall (Schiassi), or the peritoneal surfaces of 
 liver and spleen have been rubbed with gauze to excite 
 traumatic inflammation with consequent adhesions to the 
 adjacent abdominal wall (Talma, Lens, Morison). 
 
 In one of these ways it is hoped to produce anastomosis 
 between the portal circulation in the omentum or liver 
 and the systemic circulation in the abdominal wall. It 
 is probable, however, that the portal blood is not diverted 
 to any great extent. Moreover, it is most likely that the 
 ascites is due to a toxsemic condition. The good results 
 obtained by the Talma-Morison method have been 
 explained in the following manner : — 
 
 (i) As the blood passing through the liver is some- 
 what diminished, the organ is enabled to deal more 
 satisfactorily with that which does pass through it and 
 so to reduce the toxsemic condition of the blood, which 
 is probably the important' factor in producing ascites. 
 
 (2) The presence of vascular adhesions allows a freer 
 supply of arterial blood to reach the liver. The nutrition 
 of the liver cells is thus improved and they are placed 
 under better conditions for undergoing compensatory 
 hypertrophy (Rolleston and Turner) (294). 
 
 Macleod and Pea;rce (224) have shown experimentally 
 that there is a reciprocity between the blood flow in the 
 portal vein and the hepatic artery. Thus if the hepatic 
 flow be diminished, an increased amount of blood passes 
 
2l6 LIVER, GALL BLADDER, PANCREAS 
 
 along the portal channels. Probably this is due to 
 relaxation of the portal branches in the liver. Similarly 
 Burton-Opitz stated that diminished flow through the 
 portal channels results in passage of an increased amount 
 of blood through the hepatic artery. Even if this be 
 true in normal cases, it would not necessarily hold good 
 in cirrhosis, because the interlobular connective tissue 
 may not be loose enough to permit dilatation of the 
 capillaries of the hepatic artery. 
 
 The disposition of the peritoneum in relation to the 
 liver is described in Chapter III. Very little need be 
 added at this juncture. 
 
 It is convenient to notice that the liver is fixed to the 
 ventral abdominal wall by the falciform ligament whose 
 position is mapped out on the surface by a straight line 
 extending from the xiphi-sternal junction to the umbilicus. 
 
 This ligament may be bulged to one or other side by 
 the presence of an abscess in the right or left subphrenic 
 pouch of peritoneum. 
 
 The peritoneum leaves uncovered and in apposition 
 with the diaphragm a portion of the liver known as the 
 bare area, which lies to the right of the vena cava on the 
 dorsal aspect of the organ. Pus from the substance of 
 the liver itself, as in hepatic abscess, may form a sub- 
 phrenic collection in the bare area. Hence in addition 
 to the intra-peritoneal subdiaphragmatic areas already 
 mentioned (see Ch. Ill), there must be added a fifth. It 
 is known as the right extra-peritoneal subphrenic area 
 (i8). 
 
 II. The Gall Bladder. 
 
 The gall bladder is situated on the visceral aspect of 
 the liver to the right of the quadrate lobe and between 
 the ventral border of the liver and the transverse fissure. 
 
LIVER, GALL BLADDER, PANCREAS 
 
 217 
 
 Occasionally it is embedded in the substance of the 
 organ (175), or it may be absent (239). Of pyriform or 
 cylindrical shape, it is divided into a fundus or rounded 
 
 Fig. 31. Approximate surface topography of the gall bladder and bile 
 ducts in the cadaver. 
 
 The positiorj of the duodenum has been indicated by broken outlines. 
 Note that the junction of the cystic and hepatic ducts lies behind and' not 
 above the first part of tlie duodenum. The transverse colon is inserted 
 to show how that organ with its mesentery directs the enlarging gall 
 bladder toward the neighbourhood of the umbilicus. 
 
 extremity, a body or main part with upper and lower 
 aspects, and a neck, which is continuous with the cystic 
 duct. Its direction is from before backward, upward and 
 
2l8 LIVER, GALL BLADDER, PANCREAS 
 
 to the left, so that while the fundus lies 10-12 cm. from 
 the middle line, the neck is only 3-5 cm. therefrom. 
 
 The gall bladder is 8-10 cm. in length, 3 cm. in breadth, 
 and its capacity equals 30 cc. (58). 
 
 As a puncture in the wall of the gall-bladder tends to 
 remain open, it is not advisable to pass an exploratory 
 needle through the abdominal wall into the organ for 
 diagnostic purposes. 
 
 In the child the fundus of the gall bladder lies entirely 
 beneath the liver in the margin of which there is no 
 cystic notch. As the child grows, the fundus extends 
 beyond the liver margin and the cystic notch appears. 
 In the adult the fundus passes beyond the liver margin 
 for a distance of 2-4 cm. according to the state of disten- 
 sion of the gall bladder (58). The fundus is entirely 
 covered by- peritoneum. 
 
 The body of the gall bladder is bound down to the 
 liver by intervening cellular tissue, through which pass 
 the lesser cystic vessels from the liver. Hence peri- 
 toneum covers its lower surface only. Sometimes, 
 however, the body is suspended from the liver by a 
 mesentery (109). The cystocolic ligament, an outlying 
 part of the lesser omentum (see p. 122), is present in one 
 subject out of four, and passes from the under surface 
 of the gall bladder to the second part of the duodenum 
 and the adjacent transverse colon. 
 
 The clinical importance of this ligament lies in the 
 fact that it forms a focus for adhesions binding gall 
 bladder to duodenum or transverse colon, and thus 
 permitting gall stones to ulcerate through into one or 
 other of these viscera. 
 
 The relation of the gall bladder to the transverse colon 
 is again important in that cholecystitis may be associated 
 
LIVER, GALL BLADDER, PANCREAS 2I9 
 
 with obstinate constipation, owing to paralysis oi the 
 large bowel through its contact with the inflamed organ 
 (287). 
 
 The green discolouration of the pyloric canal, some- 
 times seen at autopsy, is due to the fact that the gall 
 bladder not infrequently lies in close relation with it. 
 Adhesions may develop between the gall bladder and the 
 pyloric canal and gall stones may ulcerate through into 
 the stomach and be vomited. 
 
 In marking out the gall bladder on the abdominal 
 surface, the following facts are of importance. Car- 
 michael observed that the position of the fundus of the 
 gall bladder varies much more in the vertical than in the 
 horizontal direction (54), but usually it lies immediately 
 below and to the left of the intersection of Addison's 
 plane with the right lateral inguinal line. This corres- 
 ponds to the angle between the right costal, margin and 
 the lateral border of the right rectus muscle. The neck 
 of the gall bladder lies just above Addison's plane, 
 3-5 cm. to the right of the middle line. 
 
 When chronically enlarged, the gall bladder forms a 
 tumour whose line of extension is downward and toward 
 the middle line about the umbilicus. This direction is 
 taken because the gall bladder rests upon the upper 
 surface of the transverse colon and mesocolon, which 
 form a shelf for the organ. On the other hand, the 
 acutely distended gall bladder usually enlarges upward 
 and inward in the region of the neck (263). 
 
 In cases of gall stones, the associated inflammatory 
 condition produces adhesions to surrounding- organs and 
 fibrosis of the gall bladder wall with consequent contrac- 
 tion. Chronic enlargement of the gall bladder is far 
 more characteristic of malignant disease, especially if 
 
220 LIVER, GALL BLADDER, PANCREAS 
 
 jaundice also be present, than of the presence of gall 
 stones (287). 
 
 Distension of the gall-bladder associated with jaundice 
 may, however, occur as a result of the presence of a stone 
 in the common duct (287). 
 
 The gall bladder is normally situated deeply in the 
 abdomen, but may be brought two or three inches nearer 
 the surface by placing a sand pillow under the patient's 
 dorso-lumbar region (Mayo Robson). More room may 
 also be gained by tilting up the head, of the operating- 
 table (248). 
 
 The neck of the gall bladder forms an acute angle 
 with the body of the organ and lies immediately to the 
 left of the latter. Its direction is upward and forward. 
 It has a second acute angle with the cystic duct, whose 
 direction is parallel with that of the body of the gall 
 bladder. These three portions of the bile system form a 
 Z-shaped figure. At each bend is a reduplication of 
 mucous membrane to form a valve-like structure. 
 Besides these folds there are several partial foldings of 
 mucous membrane in the neck of the gall bladder. The 
 presence of these folds renders very difficult the passage 
 of a probe from the gall bladder into the cystic duct. The 
 length of the neck of the gall bladder is 15-30 mm., and 
 its diameter 7-8 mm. (58). Diverticula are frequent at the 
 junction of the body and neck of the gall bladder. One 
 which is often present is called Hartmann's pouch. This is 
 a frequent starting-place for the formation of a gall stone. 
 
 The cystic duct is the narrowest portion of the bile 
 passages. Its length is 3-4 cm., and its diameter 2-3 mm. 
 (58). It passes upward and to the left, but turns down- 
 ward when it meets the hepatic duct. The two ducts 
 run together in a common fascia for one or two cm. before 
 
LIVER, GALL BLADDER, PANCREAS 221 
 
 they finally join to form the common duct. Hence a 
 stone in the terminal part of the cystic duct will obliterate 
 the hepatic duct also, and thus give rise to symptoms of 
 obstruction in the common duct. The cystic and hepatic 
 ducts lie in the right free margin of the lesser omentum 
 in front of the foramen of Winslow. They finally join 
 to form the common duct behind the first part of the 
 duodenum (58). 
 
 The hepatic duct is formed in the hilum of the liver 
 by the union of the right and left hepatic ducts. Of 
 these the left duct is the longer. The right and left 
 ducts do not accurately represent the drainage vessels 
 for the right and left lobes respectively. The length of 
 the hepatic duct is about 3 cm., and its average diameter 
 is 5-6 mm. It lies in the ventral boundary of the foramen 
 of Winslow and gradually increases in calibre as it 
 passes from its commencement to its termination. 
 
 The common bile duct is formed by the junction of 
 the cystic and hepatic ducts behind the first part of the 
 duodenum. It passes dorsal to this portion of the bowel, 
 and then lies between the second pail of the duodenum 
 and the head of the pancreas. Lastly it passes through 
 the medial and dorsal portion of the duodenal wall to 
 open on Vater's tubercle about midway between the 
 commencement and termination of the second part of the 
 organ. It is Embedded in the duodenal wall for about 
 two cm. The duct is thus conveniently divided into 
 duodenal (or retroduodenal), pancreatic and intramural 
 portions. Its length is 6-7 cm. (58), and its calibre 
 diminishes from its commencement to its termination. 
 The duodenal part is 8 mm., the pancreatic part 5 mm., 
 and the intramural part 3"5 mm. in diameter (248). The 
 duodenal part of the common duct is closely related to 
 
222 LIVER, GALL BLADDER, PANCREAS 
 
 the inferior vena cava, the portal vein (loi) and the 
 gastro-duodenal trunk of the hepatic artery, whose 
 branches are twined around the duct itself (275). The 
 pancreatic part of the common bile duct is entirely 
 surrounded by pancreatic tissue in 80 per cent, of cases. 
 In 20 per cent, it is either partially surrounded or merely 
 grooves the gland (8). 
 
 Vater's tubercle may present one or two openings 
 according to whether the common bile duct and pan- 
 creatic duct join to form an ampulla or remain separate. 
 They open separately in 22 per cent, of cases (8). If one 
 opening only is present, it is never more than 3 mm. in 
 diameter (58). No fluid can be forced into the ducts by 
 distension of the duodenum, but fluid can easily be 
 driven into the duodenum by distending the gall bladder 
 (Cruveilhier). 
 
 Rost claims that if the gall bladder be removed in 
 persons whose Vater's ampulla is surrounded by a long 
 sphincteric muscle, this sphincter acts so as to occasion 
 a dilatation of the bile passages in a few weeks, thus 
 producing an adventitious gall bladder, but he states 
 that if only a short sphincter exists, no such action 
 occurs (295). 
 
 The diminishing calibre of the common duct as it 
 passes to its termination explains the comparative 
 frequency of stones in the terminal portion of the duct. 
 Mayo Robson states that stones in the bile ducts occurred 
 in 39'4 per cent, of his operations for gall stones. Stone 
 in the hepatic duct is almost invariably secondary to 
 stone in the common duct. Pigment calculi alone occur 
 as a primary condition in the hepatic duct (338). 
 
 The variations in the bile system were recently 
 reviewed by Milne (239), who gives a good table. 
 
LIVER, GALL BLADDER, PANCREAS 223 
 
 Lewis and Thyng have pointed out that diverticula 
 are to be found throughout the bile system in embryonic 
 life. They may give rise to glandular tissue (hepatic 
 and pancreatic), they may degenerate and disappear^ 
 they may form detached cysts, or may possibly give rise 
 to permanent diverticula of the gall bladder (204). 
 
 Fenger has shown that the portions of the bile ducts 
 which are most convenient for choledochotomy because 
 of their freedom from surrounding vessels are the upper 
 two-thirds of the cystic duct and the middle portion of 
 the common duct (loi). For stone in the ampulla of 
 Vater it is better to operate by the transduodenal route 
 than by mobilisation of the duodenum and opening of 
 the pancreatic portion of the duct. In the latter operation 
 one has to remember the likelihood of adhesions to 
 surrounding tissues, the proximity of the inferior vena 
 cava and the possibility of a fistula following the 
 operation. 
 
 A nodule of malignant disease in the head of the 
 pancreas may closely simulate a stone in the pancreatic 
 portion of the common duct. 
 
 An enlarged lymphatic node in the right free margin 
 of the lesser omentum may resemble a stone in the 
 terminal part of the cystic duct or in the commencement 
 of the common duct. 
 
 The gall bladder is supplied by the cystic branch of 
 the hepatic artery and by the deep or lesser cystic 
 arteries. The latter vessels pass from the substance of 
 the liver through the intervening areolar tissue to the 
 upper aspect of the gall bladder. 
 
 The cystic artery is given off by the hepatic trunk near 
 the hilum of the liver. It passes above and to the left 
 of the cystic duct to the neighbourhood of the neck of 
 
224 LIVER, GALL BLADDER, PANCREAS 
 
 the gall bladder, where it divides into two branches. 
 These run along the left and right sides of the gall 
 bladder as far as the fundus. On the other hand the 
 cystic artery may arise from the right branch of the 
 hepatic trunk, and its parent artery may come from the 
 superior mesenteric vessel (a point to be remembered in 
 tying it for haemorrhage), or it may arise from the gastro- 
 duodenal artery (175). 
 
 Brewer states that a branch of the hepatic artery lies 
 to the right of the cystic duct in 30 per cent, of cases (40). 
 In cholecystectomy the cystic vessels may be found and 
 ligatured above and to the left of the cystic duet or neck 
 of the gall bladder. The free arterial supply of blood 
 to the gall bladder is probably the reason for the com- 
 parative rarity of gangrene of this organ in contra- 
 distinction to the frequency of gangrene in inflammation 
 of the appendix. 
 
 The cystic duct receives its vascular supply from the 
 cystic artery. The hepatic ducts and the upper part of 
 the common duct are supplied directly from the hepatic 
 trunk. The lower part of the common duct derives its 
 blood from the superior (right) pancreatico-duodenal 
 artery. 
 
 Fenger has pointed out that the portal vein is closely 
 related to the common duct. It lies to the lateral side 
 of the upper third of the duct and may even overlap it 
 in front (loi). 
 
 The lymphatics from the bile passages run to the 
 hilum of the liver, where they join the efferent vessels 
 of that organ. The lymphatics from the lower part of 
 the common duct form an exception to this generalisa- 
 tion. They pass to join the lymphatic plexus on the 
 duodenum. The lymphatic nodes along the hepatic 
 
LIVER, GALL BLADDER, PANCREAS 225 
 
 pedicle form a continuous series from the hilum of the 
 liver to the lesser curvature of the stomach, and are 
 frequently involved in carcinoma of the pyloric region. 
 
 The peritoneal drainage area of the bile system is the 
 right kidney pouch (see p. 22). 
 
 The nerves of the bile passages come from the eighth 
 and ninth dorsal segments of the spinal cord (133). 
 They reach their destination by way of the solar plexus. 
 Referred pain from the bile passages is frequently found, 
 in consequence, in the right infrascapular region. The 
 presence of this pain constitutes Boas' sign. Direct 
 pain is due to local peritonitis over the fundus of the 
 gall bladder. This is most apparent on pressure over 
 Mayo Robson's spot, a point at the junction of the 
 middle and inner thirds of a line joining the ninth right 
 costal extremity with the umbilicus (287). Murphy's' 
 sign is also dependent for its occurrence on local 
 peritonitis, and is elicited by deep pressure under the 
 right costal margin. There is some experimental 
 evidence in favour of the derivation from the vagus of 
 some of the nerves to the gall bladder (73). 
 
 III. The Pancreas. 
 The pancreas is deeply situated in the abdomen. Its 
 head is surrounded by the duodenum, while its body 
 and tail lie dorsal to the stomach. It is not surrounded 
 by a "capsule," but when irritated, a fibrous sheath is 
 formed around it from the peritoneum and subperitoneal 
 cellular tissue (230). On the abdominal wall the general 
 situation of the head may be outlined by mapping out 
 the duodenum (see p. 115, and fig. 19). The body and 
 tail lie along Addison's plane, and the latter reaches the 
 left hypochondrium and can be approached through an 
 
226 LIVER, GALL BLADDER, PANCREAS 
 
 incision in the left loin. Crane has shown that the 
 general shape of the head of the pancreas may be out- 
 lined by radiographic examination of the duodenum if 
 it be carried out in a modified manner. 
 
 Fig. 32. Surface topography of the pancreas as observed in the 
 cadaver. 
 
 Note that by taking the necessary precautions for the radiography of 
 the duodenum, the outline of this portion of the gut indicates in a general 
 manner the site of the head of the pancreas. Compare this with the out- 
 line indicated for the pancreas by the position of the duodenum in figs. 
 16, 19, 21, 31. > 
 
 Cole has been able to demonstrate the shadow of 
 bismuth in the duct of Wirsung (75). The main duct 
 (of Wirsung) of the pancreas opens on Vater's tubercle 
 
LIVER, GALL BLADDER, PANCREAS 227 
 
 with the common bile duct. In 22 per cent, of cases 
 they open separately into the duodenum. In 78 per 
 cent, they open together into Vater's ampulla (8). In 
 the latter instances, obstruction of the duodenal opening 
 of Vater's ampulla may cause regurgitation of bile along 
 the pancreatic duct and set up pancreatitis. Pancreatic 
 calculi contain 50 per cent, of calcium carbonate, and are 
 therefore visible in radiographic examinations (288). 
 
 The accessory pancreatic duct (of Santorini) is of the 
 same calibre as the main duct until the seventh to the 
 ninth month of foetal life, when its relative size 
 diminishes. It is patent and joins the main duct in the 
 substance of the gland in about 80 per cent, of cases (8). 
 Its opening into the duodenum is on the medial wall at 
 the apex of a small papilla two or three cm. above the 
 opening of the common bile duct. Its patency and 
 communication with the main duct provide an outlet for 
 pancreatic juice in certain cases where the main duct 
 is obstructed. 
 
 Hess has pointed out that there are two clinical types 
 of congenital obliteration of the common bile and 
 pancreatic ducts. In one type, although both are 
 obliterated, the accessory pancreatic duct remains patent 
 and functional. In the other type the accessory duct 
 is also absent (149). 
 
 The pancreas lies entirely dorsal to the peritoneum, 
 and hence pus will travel from the gland upward into 
 the subphrenic region or downward into the left iliac 
 fossa (288). 
 
 In operations on the gland particular care must be 
 taken of the middle colic artery which courses upward 
 in front of the head (288). Injury to this vessel results 
 in gangrene of the transverse colon, because of the lack 
 
228 LIVER, GALL BLADDER, PAN'CREAS 
 
 of anastomosis between vessels on the wall of the bowel 
 itself. 
 
 The blood supply of the pancreas comes from the 
 superior and inferior pancreatico-duodenal arteries and 
 from branches of the splenic artery as it runs along the 
 cephalic border of the gland. Its blood supply is then 
 for the most part the same as that of the duodenum. 
 
 The lymphatic vessels do not fall into one or two 
 groups, but follow the vascular supply. They emerge 
 at various points along the course of the gland and pass 
 through the retroperitoneal cellular tissue to join the 
 lymphatic nodes around the pancreas itself and the juxta- 
 aortic nodes, as do those of the duodenum (272). The 
 importance of the widespread lymphatic drainage in 
 infections of the gland is emphasised by Deaver and 
 Pfeiffer (79). 
 
 The nerves come from the solar plexus. Disease of 
 the gland results in pain which is present between the 
 scapulae rather than below the right scapula as in the 
 case of the gall bladder (288). In acute inflammation of 
 the gland local tenderness due to peritonitis may occur 
 above and to the right of the umbilicus (288). 
 
 Acute lesions of the pancreas are accompanied by 
 much shock and cyanosis, which are said to result from 
 stimulation of sympathetic nerves; the pancreas, from 
 its position in the abdomen, being intimately associated 
 with the solar plexus. 
 
 Cysts of the pancreas may be palpated above or below 
 the stomach. They are especially dilE&cult to diagnose 
 from mesenteric or omental cysts, and from pseudo-cysts 
 of the pancreas. The last-named are in reality effusions 
 into the lesser sac of the peritoneum (206). 
 
 Sometimes a ring-shaped portion of the pancreas 
 
LIVER, GALL BLADDER, PANCREAS 229 
 
 encircles the duodenum, most frequently the second or 
 descending part (6), and may cause constriction of the 
 gut (233). 
 
 An accessory pancreas, usually in the form of a mere 
 nodule, is sometimes found in the wall of the stomach 
 or the intestine, and the former variety may account for 
 some cases of congenital hour-glass stomach (see p. 68) 
 (202). Carwardine and Short state that such a nodule is 
 usually situated in the wall of the stomach near the 
 pylorus or the greater or lesser curvatures, in the wall 
 of the duodenum but detached from the true pancreas, 
 in the first eight inches of the jejunum, which is the 
 commonest site, or in the lower jejunum or ileum even 
 near the ileo-caecal valve. Very occasionally it has been 
 found in the abdominal wall at the umbilicus. It is 
 subject to the same diseases as; is" the true pancreas (55). 
 
Note on the Ileo-Pyloric Reflex. 
 
 Since this book went to Press, I have received the 
 second edition of Dr. A. E. Barclay's monograph (" The 
 Alimentary Tract," London and Manchester, 1915), and 
 therefore take this opportunity of drawing attention to 
 what Dr. Barclay has termed the ileo-pyloric reflex. 
 
 In cases of duodenal irritation the stomach commences 
 to empty rapidly, but in some instances this continues 
 only a short time (half to three-quarters of an hour), 
 and then ceases, so that the stomach presents radio- 
 graphically a retention of contents similar to that 
 observed in pyloric obstruction. In such cases the 
 cessation of the passage of food through the pylorus 
 and of general activity in the stomach coincides with the 
 appearance of heavy shadows in the terminal portion of 
 the ileum. There is no doubt, therefore, that in this 
 comparatively short time contents have passed along the 
 whole length of the small intestine. As pressure, 
 externally applied, will no longer cause food to pass 
 through the pylorus, Barclay suggests that reflex closure 
 of the stomach exit has taken place in consequence of a 
 stimulus originated from the mucosa of the distal portion 
 of the ileum, and that this phenomenon affords yet 
 another instance of the intra-alimentary system of 
 reflexes. 
 
 If, after a time, more food is given, the ileo-caecal 
 sphincter relaxes and permits the passage of ileal contents 
 into the large bowel. This is Simply a specific instance 
 of the general truth that the giving or even the smelling 
 of food induces emptying of the ileum into the 
 colon. The spasmodic closure of the pylorus, however, 
 reflexly originated from the ileum, would seem to be a 
 protective against the excessive overloading of the small 
 bowel with chyme which has not yet fully undergone the 
 changes natural to its exposure to the jejunal-ileal 
 mucosa. 
 
INDEX OF AUTHORS QUOTED. 
 
 A. 
 
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 and circular musculature at the upper end of the oesopha- 
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 Berlin, 1913, Bd. 9, p. 523. 
 
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 B. 
 
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 Rec, Phila., 1911, Vol. 5,- p. 197. 
 
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 11. Barclay, A. E. " A note on the movements of the large 
 
 intestine." Arch. Roentg. Ray., London, 1912, Vol. 16, 
 p. 422. 
 
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 London, 1910, Vol. 15, p. 167. 
 
 13. Barclay, A. E. Private communication. 
 
 14. Barclay, A. E. The stomach and oesophagus. London, 
 
 1913- 
 
 231 
 
232 BIBLIOGRAPHY 
 
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BIBLIOGRAPHY 233 
 
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SUBJECT. INDEX. 
 
 Abdominal rings, 17 
 
 Abdominal wall, reflex contraction and 
 
 relaxation, 11, 30, 39 
 Absorption from alimentary canal, 32 
 Absorption of food, 37 
 Acapnia, 152 
 Acromegaly, 194 
 Addison's transpyloric plane, 5 
 Adhesions of stomach to neighbouring 
 
 organs, 77 
 Alcohol, effect on sensation of stomach, 
 
 no 
 Amylolytic action in oesophagus, 53 
 Anal canal, arteries to, 205 
 
 junction of, with rectum, 202 
 
 lyniphatics of, 206 
 
 nerves of, 207 
 
 valves of, 203 
 
 veins of, 205 
 Anastalsis, 38 
 
 in colon, 182, 195 
 Anastomosis between portal and systemic 
 
 veins, 11, 102 
 Aneurysm, relation to oesophagus, 45 
 Angina, abdominal, 187 
 Anomalies of abdominal wall, 12 
 Antiperistalsis in jejuno-ileum, 147 
 
 in stomach, 88 
 Anus, site of, 202 
 Aorta, relation of, to oasophagus, 45 
 Appendices epiploicae, 178, 188 
 Appendix, age and sex differences, 170 
 
 arteries of, 173, 187 
 
 diverticula of, 171 
 
 in hernia, 18 
 
 lymphoid tissue of, 172 
 
 muscular coats of, 173 
 
 occlusion of, 172 
 
 relation of position of, to develop- 
 ment of caecum, 163 
 
 site of, in abdomen, 168 
 
 surface topography of, 170 
 Arteries of abdominal wall, 12 
 Artery to appendix, 173, 187 
 
 Arteries to bile passages, 222 
 
 to distal colon, 196 
 
 to duodenum, 132 
 
 to jejuno-ileum, 152 
 
 to omentum, 30 
 
 to pancreas, 228 
 
 to peritoneum, 30 
 
 to proximal colon, 186 
 
 to rectum and anal canal, 205 
 
 to stomach, gg 
 
 to yolk-sac, 13 
 Arterio-sclerosis and appendicular occlu- 
 sion, 172 
 
 of mesenteric vessels, 186 
 Axone reflex in stomach and intestine, 
 108 
 
 B. 
 Ballooning of the rectum, 201 
 Bare area of liver, 216 
 Bastedo's sign in appendicitis, 171 
 Bile passages, 220 
 Bilocular stomach, 67 
 Bladder in hernia, 18 
 Borborygmi in stomach, 77 
 Bronchi and oesophageal disease, 44, 45 
 Brunner's glands, 127 
 Bulbus duodeni, 125, 131 
 Bulging abdominal wall, causes of, 7 
 Burning sensations, 39 
 
 C. 
 Caecal fistula, 164, 182, i8g 
 
 sounds, 164 
 Cseco-colic sphincteric tract, 173 
 Caecum, absence of, isg 
 
 anomalies in the disposition of, 160 
 
 carcinoma of, 188, 189 ■ 
 
 connection of, to genital gland by 
 peritoneal band, 158 
 
 delimitation of, 157 
 
 development of, 159 
 
 function of, 166 
 
 hernia of, 18 
 
 lumen of, 166 
 
 mesentery of, 158 
 
 257 
 
258 
 
 INDEX 
 
 Csecum — 
 
 mobile, i6o 
 
 palpation of, 163 
 
 radiography of, 160, 161 
 
 rupture of, 1S2 
 
 surface topography of, 163 
 
 volvulus of, i60| 163, 176, 189 , 
 Carcinoma of CEecum, 188, 189 
 
 of pylorus, 104 
 
 spread of, in stomach, 95, 104 
 and note. 
 Cardia, physiology of, 57, no 
 
 site of; 43, 75, 76 
 Cardiac sphincter, 53 
 Cess-pool caecum, 163. 
 Chbledocdtomy, 223 ' 
 Circulatory reflex, 40 
 Coeliotomy, i 
 Colon, ascending, site and length of, 
 
 174 
 capacity of, 180 
 dilatation of, 183 
 distal, arteries to, 196 
 distal, development of, 195 
 distal, lymphatics of, 198 
 distal, mesentery of, 191 
 distal, movements of, 195 
 distal, nerves of, 198 
 distal, rate of passage of food 
 
 through, 196 
 distal, site and length of, 190, 191 
 distal, veins of, 198 
 diverticula of, 179, igo 
 method of holding up, in abdomen, 
 
 184 
 mucosa of, 179 
 muscular coat of, 181 
 pelvic, distensibility, 193, 194 
 pelvic, variations of, 193, 194 
 proximal arteries of, 186, 187 
 proximal, function of, 179 
 proximal, lymphatics of, 188 
 proxim'al, movements of, 181 
 proximal, nerve supply of, 186 
 proximal, rate of passage of food 
 
 through, 183 
 - proximal, veins of, 187 
 sacculations, cause of, 178 
 subdivision into proximal and distal, 
 
 174, 180, 188 
 
 Colon — 
 
 transverse, relation to stomach, 184, 
 
 Coloptosis, relation to nephroptosis, 177 
 
 Colostomy, inguinal,. 192 
 
 Common bile duct, 221 
 
 Constipation, movements in, 182, 183 
 
 Constriction, sites of, 33 
 
 Cooper's ligameait, 15 
 
 Crampi 39 
 
 Cyanosis in pancreatic lesions, 228 
 
 Cystic arteries, 223 
 
 duct, 220. 
 Cysto-colic ligament, 122, 176, 177, 218 
 Cysto-duodenal ligament, 122 
 Cysts of mesentery, 138 
 
 of pancreas, 228 
 
 D. 
 
 Defaecation, 195 
 Descending colon, site of, 191 
 Desmoid tumour, 8 
 Diastalsis, 38 
 
 Diaphragm, action on subcostal angle, 
 I, 2 
 
 site of, 9 
 Diet, relation of, to gastric glands, 97 
 Distension of alimentary canal, effect of 
 
 on abdominal wall, 11, 29, 39 
 Distension in stomach, sensation of, no 
 Diverticula of appendix, 171 
 
 of colon, 179, 190 
 
 of duodenum, 127 
 
 of gall bladder, 220 
 
 of jejuno-ileum, 143 
 
 of oesophagus, 51 
 
 of rectum, 203 
 Drainage areas of peritoneum, 22 
 Ductus venosus supplying blood to 
 
 stomach, 102 
 Duodenal bulb or cap, 125, 131 
 " Duodenal gland," 133 
 Duodenal juice, 117 
 Duodenal vestibule, 125 
 Duodeno-colic ligament, 122 
 Duodeno-jejunal flexure, varieties of, 114 
 Duodeno-renal ligament, 169 
 Duodenum, 31, 112 
 
 blood supply of, 132 
 
 calibre of, 124 
 
INDEX 
 
 259 
 
 Duodenum — 
 
 carcinoma of, 128 
 
 contractions of, after pyloroplasty, 
 
 129 
 distance of, from incisor teeth, 116 
 diverticula of, 127 
 form of, 113 
 fossae near, 124 
 kinks of, 121 
 lymphatics of, 133 
 mobilisation of, 122 
 mucosa of, 126 
 musculature of, 128 
 nerve supply of, 134 
 obstruction of, 120, 121 
 occlusion of, 125, 126 
 position in abdomen, n6, 129 
 rate of passage of food through, 
 
 129 
 relations of, in adult, 117, 121, 129 
 relations of, in infant, 119, 121 
 surface^ topography of, 115 . 
 termination of, 112 
 ulcer of, 127, 128 
 
 symptoms caused by lesion of 
 I", jejunum, 151 
 variations in position of, 116 
 
 Ectopia vesicse, 12, 13 
 
 Einhorn's test, 117 
 
 Emptying of stomach, 86, 87 
 
 Eructation, 57 
 
 Ewart's test in appendicitis, 170 
 
 Faecal vomiting, 32 
 Fat in abdominal wall, 7 
 Femoral canal, 16 
 Femoral hernia, 16 
 Fistula, recto-urinary, 14 
 
 recto-vaginal, 14 
 
 umbilical, 12, 13 
 Fold of groin, 6 
 Foregut, 31 
 Fowler's position, 22 
 Friability of wall of bowel, 123 
 Fulness, sensation of, 39, no 
 Fundus proper of stomach, 64 
 Funicular process, 18 
 
 G. 
 
 Gall bladder, arteries of, 223 
 
 dimensions of, 218 
 
 distension of, 219 
 
 diverticula of, 220 
 
 lymphatics of, 224 
 
 neck of, 220 
 
 nerves of, 225 
 
 relations of, 218. 
 
 relations of, to peritoneum, 218 
 
 site of^ 216 
 
 surface topography of, 219 
 Gall stones, vomiting in> association 
 
 with, 33 
 Gastrectomy, partial, effect of, on func- 
 tion of stomach, 108 
 Gastric exclusion,, effect of, on function 
 
 of stomach, 10& 
 Gastric tube, 64 , , 
 Gastro-enterostomy, 153 sqq. 
 Gastroptosis, 75, 81 
 Genito-mesenteric fold, 159, 169 
 Gerlach, valve of, 171 
 " Girdle " pains, 10 
 " Globus hystericus," 51 
 Glossopharyngeal nerve, 54. 
 Gullet, lower, 50 
 
 H. 
 Haemorrhage from stomach, 100, loi, 
 
 102 
 Haemorrhoids, 203, 204, 205, 206^ 
 Hartmann's critical point, 197 
 Hartriiann's pouch, 220 
 Hartmann-Mikulicz line and point, 105 
 Hepatic ducts, 220, 221 
 Hepatic flexure, possibility of valve at, 
 
 ■75 
 Hernia of bladder, 18 
 ; of caecum, 162 
 diaphragmatic, 12 
 obturator, 12 
 sciatic, 12 
 umbilical, 137 
 Hesselbach's triangle, 18' 
 Hilton, white line of, 203 
 Hindgut, 31 
 
 Hour-glass stomach, intermittent, 94 
 permanent, 68 
 spasmodic, 94 
 
26o 
 
 INDEX 
 
 Houston, valve of, 200 
 Hufeisenschlinge, 89 
 Hunger pain, 91 
 sensation, 39 
 Hypertonus of stomach, 75, go 
 Hypertrophic stenosis of pylorus, .''6 
 Hypotonus of stomach, 89 
 
 I. 
 Ileo-csecal sphincter, 165 
 
 valve, formation of, 159, 160 
 
 valve, surface topography of, 164 
 Ileo-pyloric reflex, 230 
 Ileum, distension of, 148 
 
 diverticula of, 143 
 
 kinks of, 151, 166 
 
 lumen of, 143, 145 
 
 lymphatics of, 152 
 
 movements of, 146, 147, ijo 
 
 mucosa of, 142 
 
 muscular coat of, 14S 
 
 nerves of, 153 
 
 occlusion of, 144, 145 
 
 peritoneal relations of, 135, 137 
 
 radiographic appearance of, 149 
 
 rate of passage of food through, 
 149 
 
 site of, in abddmen, 136 
 
 subdivisions of, 137 
 
 surface topography of, 141 
 Iliac colon, site of, 191 
 Iliac crest, 3 
 Iliac spines, 3 
 Iliac veins, relation of, to appendicitis, 
 
 169 I 
 
 Imperforate anus and rectum, 211 
 Incisura angularis, 69 
 Inferior thyroid artery in cesophagotomy, 
 
 44 
 Infra-colic portion of peritoneum", 23 
 Infra-costal plane, 5 
 Infra-sternal fossa or angle, i 
 Inguinal canal, 17 
 Inguinal crease or fold, 6 
 Inguinal hernia, 18 
 Inguinal line, 3 
 Injuries to duodenum, ng 
 Intestinal anastomosis, 147 
 Intussusception, action of mesentery in, 
 
 139 
 
 " Isolated area " of stomach, 105 
 Interstitial hernia, 18 
 Inter-tubercular plane, 5 
 Ischio-rectal abscess, 208, 209 
 Ischio-rectal space, 209 
 
 J. 
 Jackson's membrane, 177 
 Jaundice, 220 
 Jejunal ulcer, 155 
 Jejuno-ileum, diverticula of, 143 
 
 kinks of, 151, iSS 
 
 lumen of, 143, 14S 
 
 lymphatics of, 152 
 
 method of distension of, 148 
 
 movements of, 146, 147 
 
 mucosa of, 142 
 
 muscular coat of, 145 
 
 nerves of, iS3 
 
 occlusion of, 144, 14S 
 
 rate of passage of food through, 
 149 
 
 subdivisions of, 135, 137 
 
 surface topography of, 141 
 Jejunum, lesions of, giving symptoms 
 of duodenal ulcer, 151 
 
 radiographic appearances in, 149 
 
 relation of, to peritoneum, 135, i37 
 
 site of, in abdomen, .-36 
 
 K. 
 
 Katastalsis, 38 
 
 Kidney, left, relation of, to stomach, 77 
 Kidney pouch, right, 22, 123 
 Kidneys, varying relation of, to duode- 
 num, 119 
 Kinks, Lane's, 34, 121, 151, 177 
 
 L. 
 
 Ladder coils of intestine, 36 
 
 Laparotomy, i 
 
 Linea alba, 7 
 
 Linese albicantes or atrophicae, 7 
 
 Linea fusca, 8, 13 
 
 Linea semilunaris, 8 
 
 Linitis plastica, 95 
 
INDEX 
 
 261 
 
 Liver, arteries to, 214 
 
 necrosis of, after ligature of left 
 gastric (coronary) artery, 99 
 
 position of, 213 
 
 relation of, to peritoneum, 216 
 
 subdivisions of, 213 
 Localising sensations, 39 
 Lockwood's chain of lynjph nodes, 188 
 Lockwood's hiatus, 173 
 Lung disease simulating an abdominal 
 
 lesion, 30 
 Lunules, 138 
 Lymphatics of abdominal wall, 12 
 
 of bile passages, 224 
 
 of distal colon, 198 
 
 of jejuno-ileum, 152 
 
 of oesophagus, 54 
 
 of pancreas, 228 
 
 of proximal colon, 188 
 
 of rectum and anal canal, 206 
 
 of stomach, 103 
 Lymphoid tissue, 34 of appendix, 172 
 
 M. 
 Magenblase, 64, 72 
 Magensac, 64 
 Magenstrasse, 65, 85 
 Mammary line, 3 
 Meckel's diverticulum, 14, 31, 144 
 Mesenteric arterial arches, 138 
 Mesenteric arteries, 152 
 
 occlusion ^of, 152 
 Mesentery, action of, in intussusception, 
 
 139 . 
 of appendix, 168 
 of cascum, 158 
 cysts of, 138 
 holes in, 141 
 of descending colon, 191 
 of proximal colon, 176 
 surface topography of, 141 
 Mesocolon, pelvic, 192 
 Mesocolon, transverse, 20, 174, 17s 
 
 transverse, relation to gastro-enter- 
 ostomy, 83 
 Middle sphincter, so-called, of stomach, 
 
 84, 87 
 Midgut, 31 
 Mid-Poupart line, 3 
 
 Morgagni, columns, lacunae an(i papillse 
 of, 203, 206 
 
 Movements of stomach, 86 
 Myenteric reflex, 36, 37, 106 
 
 N. 
 Necrosis of liver following ligature of 
 
 left gastric artery, 99 
 Nephrocolic ligament, 177 
 Nephroptosis, 177 
 Nerve-endings of vagus, 38 
 Nerves, damage to, 10 
 Nerves to abdominal wall, 40 
 
 to alimentary canal, 38 
 
 to bile passages, 225 
 
 to distal colon, 198 
 
 to duodenum, 134 
 
 to jejuno-ileum, 153 
 
 to oesophagus, .55 
 
 to pancreas, 228 
 
 to peritoneum, 29 
 
 to proximal colon, 186 
 
 to rectum and anal canal, 207 
 
 to stomach, 103 
 Nischen' symptom, 94 
 
 O. 
 
 Obliqui abdominis, 8 
 Obstipation, movements in, 183 
 jQbstruction of the colon, 182 
 
 of the duodenum, 121 
 Obturator artery, 16 
 Occlusion of the colon, 182 
 
 of the duodenum, 125, 126 
 " Ochsner " muscle of duodenum, 128 
 CEsophageal groove of ruminants, 66- 
 CEsophageal landmarks, distance of, 
 
 from incisor teeth, 47, 48 
 CEsophageal orifice in diaphragm, level 
 
 of, 47 
 CEsophageal sounds, 55,, 56 
 CEsophagus, age and sex differences, 42 
 
 course and relations, 44 
 
 division into upper and lower, 48, 
 
 52 
 glands of, 53 
 lower, 49 
 
 lumen and calibre, 48 
 mucosa of, 53 
 musculature of, 50 
 nerves of, S^ 
 operations on, 46 
 pouches of, 51 
 
262 
 
 INDEX 
 
 (Esophagus — 
 
 rate of passage of food through, 55 
 
 rupture of healthy, 50 
 
 sites of commencement and ter- 
 mination of, 42 
 
 surface marlcings of, ,43 
 Omenta, relation of gastric vessels to, 
 
 99, 100 
 Omentum, 24 
 
 Omentum in herpias, ,16, 18 
 Ovary in herniae, 18 
 
 Pancreas, anomalies of, 228 
 
 arteries to, 228 
 
 capsule of, 225 
 
 cysts of, 225 
 
 ducts of, 226 
 
 lymphatics of, 228 
 
 nerves of, 228 
 
 peritoneal relations of, 227 
 
 relation of, to niiddle colic artery, 
 227 
 
 ring-shaped, 126, 228 
 
 site of, 225 
 Pain in gastric ulcer, 106, 11 1 
 Pain, referred, 29 ' 
 
 Palpitation, relation of, to lower gullet, 
 
 SO 
 Parietal cells of fundictype of gland in 
 
 stomach and duodenum, 96, 97 
 Pelvic colon, 190, 191 
 Pelvi-rectal junction, 192, 194 
 Pelvi-rectal space, 209 
 Peptic ulcer, relation of, to mucosa, 97 
 Perigastric abscess, 77 
 Peristalsis, 36, 38 
 
 in colon, 182, 195 
 
 in jejuno-ileum, 146 
 
 in oesophagus, 57 
 
 in stomach, 87, 106 
 Peristaltic rush, 147 
 Peritoneal adhesions, non-inflammatory, 
 
 13s. 151. 177 
 Peritoneal_ cavity, subdivisions of, 20, 
 
 22, '23 
 Peyer's patches, 34 
 Phrenico-coiic ligament, 176 
 Plaque of Retzius, 86 
 Plicae circulares of bowel, 142 
 
 Portal thrombosis, 187 
 
 Portal vein, relations of, 224 
 
 Portal veins in liver, 214, 215, 216 
 
 Post mortem changes in stomach, 59, 60 
 
 Post operative dilatation of stomach, 119 
 
 Poupart line, 3 
 
 Procidentia of rectum, 211 
 
 Prolapse of rectum, 211 
 
 Pruritus, 202 
 
 Puckering in duodenal shadow, 131 
 
 Purpura haemorrhagica, 179 
 
 Pylephlebitis, 187 
 
 Pyloric canal, situation as shown by 
 
 «-ray, 61 
 Pyloric vein, 103 
 Pyloric vestibule, 65 
 Pyloroplasty in relation to duodenal 
 
 contractions, 129 
 Pylorus, hypertrophic stenosis of, 86 
 site of, 6 
 
 R. 
 
 Radiography of appendix, 171, 173 
 
 of caecum, 161 
 
 of colon, 181, 194 
 
 of duodenum, 129 
 
 of jejuno41eum, 149 
 
 of oesophagus, 55 
 
 of stomach, 60, 62, 67, 6g, 70 
 Rectal fascia, 209 
 Rectal pits, 202 
 Rectal stalks, 207 
 Recti abdominis, 8 
 Recto-sacral aponeurosis, 210 
 Rectum, arteries to, 205 
 
 contents of, 201 
 
 diverticula of, 203 
 
 Junction of, with anal canal, 202 
 
 limits of, 200 
 
 lymphatics of, 206 
 
 mucosa of, 202 
 
 muscular coats of, 203 
 
 nerves of, 207 
 
 occlusion of, 212 
 
 peritoneal relations of, 204 
 
 prolapse of, 211 
 
 subdivisions of, 200 
 
 supports of, 209 
 
 veins of, 205 
 
INDEX 
 
 261 
 
 Referred pain, ag 
 
 Referred pain in gastric ulcer, m 
 Reflexes in alimentary canal, 39, 40 
 Respiratory reflex, 40 
 Retraction of abdominal wall, 7 
 .Retro-csEgal appendix, 168 
 Retro-peritoneal appendix, so-called, 168 
 Retro-peritoneal hernia, 124,, 198 
 Rickets, 8 
 
 Rhythmic contractions of duodenal mus- 
 culature, 129, 130 
 Riedel's lobe, 214 
 Roy sing's, test in appendicitis, 171 
 
 S. 
 
 Secretion in alimentary canal, 32 
 Semilunar space of Traube, 81 
 Sensation in. alimentary canal, 39 
 
 in anal canal, 208 
 
 in oesophagus, 58 
 
 in stomach, no 
 Sigmoidoscope, 193, 200 
 Soaps, calcium, in appendix, 172 
 Solitary follicles, 34 
 Sounds, oesophageal, 55, 56 
 
 over caecum, 164, 165 
 Sphinctores ani, 201 to 204 
 Splenic flexure, possibility of sphincter 
 
 at, 180 
 Stomach, 36, 59 sqq. 
 
 .age and sex differences, 68, 78 
 
 arteries of, 99 
 
 capacity of, 78 
 
 effect on, of gas in bowel, 71 
 
 hBemorrhage from, 100, loi, 102 
 
 Hartmann-Mikulicz line, loj 
 
 hypertonus irt, 75, 90 
 
 influence of mucosa in primitive 
 subdivision, 67, 68 
 
 " isolated area" of, 105 
 
 lymphatics of, 103 
 
 method of expansion of, 83 
 
 movements of, 86 
 
 mucosa of, 95 
 
 muscular coat of, 83 
 
 nerves of, 105 
 
 partial excision of, 108 
 
 passage of food along, 72, 73 
 
 peristaltic waves in, 74 
 
 post mortem changes in, 59, 60 
 
 Stomach- 
 progression from normal to patho- 
 logical, 62 
 properties of musculature, 88 
 rate of passage of food through, 94 
 relation, of, to transverse colon, 82', 
 
 186 
 relations of, 76, 82 
 sensation in, no , 
 serous coat of, 82 
 shape in life, .66, 68 
 situation of, in abdomen,. 75 ~ 
 spasm of, 90, 92 , 
 subdivisions of, 63 
 submucosa of,, 94 
 Surface topography of, 78 
 tone and peristalsis, 107 
 veins of, ioi ■ , 
 : ;;i:-ray pictures in new-born child, 67 
 
 Subclavian artery, abnormal, relation to 
 ' oesophagus, 46 ■ 
 
 Subcostal angle, i 
 
 Submucosa, 34 
 
 Supra-colic portion of peritoneum, 26 
 
 Supra-duodenal artery, 133 
 
 T. 
 
 Talma-Morison operation, 215 
 Tenderness, local, 29, 30 
 Testicle, imperfectly descended, 18 
 Thoracic disease simulating an abdo- 
 minal lesion, 30 
 Thyroid gland, enlargement of, relation 
 
 to swallowing, 44 
 Thyroid glands, accessory, relation to 
 
 oesophagus, 46 
 Time occupied by passage of food 
 
 through the distal colon, 1,96 
 Time occupied by passage of food 
 
 through duodenum, 129 
 Time occupied by passage of food 
 
 through jejuno-ileum, 149 
 Time occupied by passage of food 
 
 through oesophagus, 55 
 Time occupied by passage of food 
 
 through proximal colon, 183 
 Time occupied by passage of food 
 
 through stomach, 94 
 Tracheo-oesophageal septum, 51 
 Transpyloric plane, 3 
 
264 
 
 INDEX 
 
 Transverse band, so-called, of stomach, 
 
 ^ *7 
 
 Transversus abdojminis, 8 
 Traube, semilunar space of, 81 
 Treitz, muscle of, 112, 139 
 Tone of stomach walls, 107 
 
 U. 
 Umbilical fistula, 12, 13 
 Umbilical hernia, congenital, 137 
 Umbilicus, formation of, 13 
 
 pancreatic node at, 229. 
 
 position of, 20 
 
 Vagus, extent and function of, 38 
 Valve of Gerlach, 171 
 
 of Houston, 200 
 Valves in veins of portal system, 41 
 Valvulae conniventes, 142 
 Vascular arch of Treitz, 123, 198 
 Vater's ampulla, 222, 227 
 Vater's ampulla, sphincter of, 222 
 Vater's tubercle, 221, 222 
 
 Veins of abdominal wall, 11, 12 
 
 of distal colon, 198 
 
 of omentum, 30 
 
 of peritoneum, 30 
 
 of proximal colon, 187 
 
 of rectum and anal canal, 204, 205, 
 206 
 
 of stomach, loi 
 Vessels of alimentary canal, 40, 41 
 Vestibule, duodenal, 32 
 Vicious cycles after gastro-jejunostomy, 
 
 156 
 Volvulus of caecum, 160, 163, 176, 189 
 Volvulus of pelvic colon, 194 
 Vomit, faecal, 32, 33 
 Vomit, gall-stone, 33 
 
 W. 
 " Wander " caecum, 160, 162 
 White line of Hilton, 203 
 Whitehead's operation, 206 
 
 Y. 
 Yolk-sac, arteries of, 13. 
 
A CATALOGUE 
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 The Principal Divisions of Coleoptera, in labels 4 
 
 inches long, red or black [29] 3d. 
 
 The Principal Divisions of Lepidoptera, in similar 
 
 style [35] 3d. 
 
 The Families of Worms, in similar style [32] 6d. 
 
 The Principal Divisions of the Ccelenterata [61] is. 
 
 The Principal Divisions of Amphibians and Reptiles 
 
 Notes from the Manchester Museum 
 
 I— T. H. Huxi,5Y. Suggestions for a Natural History 
 
 Museum in Manchester [17] 6d. 
 
 2 — Thomas Hick. On Rachiopteris cylindrica Will. [18] 6d. 
 
 3 — S. J. HiCKSON. On the Ampullae of Millepora [19] ... 6d, 
 
 4 — H. Bolton. Descriptions of Brachiopoda and Mol- 
 
 lusca from the Millstone Grit, etc. [20] is. 
 
 5 — H. BoWoN. Palaeontology of the Manx Slates [27] ... is. 
 
 6 — A. C. Seward. Notes on some Jurassic Plants in 
 the Manchester Museum [30] {out of print) 
 
 7 — W. Boyd Daweins. On the Cairn and Sepulchral 
 
 Cave at Gop, near Prestatyn [36] {out of print) ... 6d, 
 
 8^F. E. Weiss. On Xenoph3^on radiculosum (Hick) [37] is. 
 
 9 — W. E. HoYLE. British Cephalopoda [39] {out of print) 6d 
 
 10 — W. Boyd Dawkins. The Red Sandstone Rocks of 
 
 Peel (Isle of Man) [41] is. 
 
 II — W. Boyd Dawkins. Carboniferous^ Permian and 
 
 Triassic Rocks of the Isle of Man [42] 6d. 
 
 12 — W. Boyd Dawkins. On Bigbury Camp and the Pil- 
 grim's Way [43] ... IS. 
 
24 MANCHESTER UNIYBRSITY PRESS 
 
 13 — w. E. HoYLE. The Use of Museums in Teaching 
 [44] (out of print) •• 
 
 14 — w. E. HoYLE. The Type Specimen of Loligo 
 
 eblanas [45] 6d. 
 
 15 — J. R. Hardy. The Macro-Lepidoptera of Sherwood 
 Forest [46] {out of print) 
 
 16 — w. BoYb Dawkins. Discovery of an Ossiferous 
 
 Pliocene Cavern at Doveholes [47] is. 
 
 17 — w. Boyd Dawkins. On the Discovery of Elephas 
 
 antiquus at Blackpool [51] 6d. 
 
 18 — W. E. HoYLE. A Diagnostic Key to the Genera of 
 
 Recent Dibranchiate Cephalopoda [52] is. 6d. 
 
 19— ThEophilus D. Pinches. The Hjrmns to Tammuz [55] 3s. 6d. 
 
 20— W. E. A. Axon. Votive Rag-Branches and Prayer- 
 Stick [58] IS. 
 
 21— W. E. HoYi,E. The Education of a Curator [60] ... 6d. 
 
 22— R. Standen. Glue and Turpentine Cement for Alco- 
 holic Mounts [65] 6d. 
 
 Reports on the Progress of the Museum 
 
 1889-1914 {Published Yearly) (each) 6d.