1632 HUMAN ANATOMY. 



from the tip of the tenth rib on the left side, towards the pubes, and then curving 

 upward to the right costal margin (Osier). The dilatation may be of any degree, 

 the lower border of the stomach sometimes reaching to the lev^el of the pubes. 



Displace7nent of the stomach {gastroptosis) is attended by great stretching of 

 the gastro-hepatic, gastro-splenic, and gastro-phrenic folds. It is sometimes a dila- 

 tation with the stomach vertical instead of oblique rather than a true descent of the 

 whole organ. 



Three forms are described : ( i ) a slight descent of the pylorus, and with it of 

 the lesser curvature, so that the latter comes from beneath the liver ; (2) " vertical 

 stomach," already alluded to ; (3) a descent of the lesser curvature, the pylorus 

 remaining fi.xed, making a U-shaped stomach (Riegel). The last is very rare. All 

 forms are favored by the use of corsets or clothing constricting the lower thorax, 

 especially in women with fiaccid abdominal walls. The displacement may be con- 

 genital, or may be due to primary elongation or relaxation of the peritoneal folds 

 which act as ligaments, or to malposition or displacement of other abdominal 

 viscera. 



Hernia of the stomach is usually diaphragmatic and often congenital. The 

 viscus may enter the thorax through a stab wound or rupture, or through weakened 

 or enlarged spaces at (a) the central tendon, ((^) the posterior inferior muscular area, 

 (c) the interval between the sternal and costal fibres, (^) the oesophageal foramen, 

 (^) the fissure between the lumbar and costal portions, or (/") the point of passage 

 of the sympathetic trunk (Sultan). These possible locations have been mentioned 

 in the order of frequency. 



The hernia may carry the peritoneum with it {true hernia), as in cases of 

 partial rupture or non-penetrating wound of the diaphragm, or may avoid or pass 

 through the peritoneum (^ false hernia). The latter are more common. All forms 

 are found most frequently on the left side in consequence of the presence of the 

 liver on the right side. 



OperatioJis on the Stomach. — The stomach is most accessible for operation 

 through a triangular space, ape.x upward, bounded on the left by the eighth and 

 ninth costal cartilages, on the right by the free edge of the liver, and below by a 

 horizontal line joining the tips of the tenth costal cartilages and corresponding 

 approximately to the line of the transverse colon. The tenth cartilage has a dis- 

 tinct tip and plays over the ninth cartilage, producing a peculiar crepitus (Labbe). 



If the incision is median, it passes between the recti muscles ; if lateral and 

 vertical, it is made through the rectus or along its outer edge ; if oblique, through 

 the rectus and the external and internal oblique and transversalis. The terminal 

 branches of either the superior or deep epigastric artery may be divided, or the latter 

 vessel itself if the vertical incision is prolonged downward. As the blood-supply 

 of the stomach comes from three distinct sources — the gastric, hepatic, and splenic 

 arteries — and the anastomoses are very numerous, the nutrition of the flaps, even 

 after extensive resection, is usually maintained, in the absence of infection or of 

 cardio-vascular disease. On the contrary, in operations on the intestines the greatest 

 care must be exercised in dealing with the mesentery to preserve the vitality of 

 the gut. 



Upon exposing the stomach, it is well to bear in mind its oblique position and 

 the facts that the pylorus is the only part that is really transverse, that three- 

 fourths of the stomach are to the left of the middle line, that the upper part of the 

 cardia is an inch above the level of the lower end of the oesophagus, and that the 

 larger part of the greater curvature is directed to the left and of the lesser curvature 

 to the right. According to Meinert, the pylorus lies behind the intersection of a 

 transverse horizontal line drawn through the tip of the .xiphoid cartilage with the 

 right costal border ; while the lower curvature, beginning at the latter point, crosses 

 the mid-line and ascends, describing a half-circle around an antero-posterior hori- 

 zontal line drawn through the xiphoid tip. 



The relations of the stomach in general have been described (page 1619). The 

 transverse colon — especially in cases of oesophageal stricture in which the stomach is 

 contracted and rests far back and well up under the diaphragm — may present itself, 

 and has been mistaken for the stomach. The gut, however, is thinner, not so 



