4 o6 APPLIED ANATOMY. 



in what has been called the Hartmann-Mikulicz line (Fig. 416), which will remove 

 most of the lesser curvature and at least a third of the greater curvature. The two 

 cut ends are then closed with sutures and the lowest portion of the remainder of 

 the stomach connected with the ileum either anteriorly or posteriorly. 



In performing a gastro-enterostomy the upper portion of the jejunum is brought 

 up and anastomosed with the anterior or posterior wall of the stomach. If the 

 omentum is not seen at once on opening the peritoneum it will, perhaps, be found 

 lying rolled up along the lower border of the stomach. It is to be brought out 

 of the wound and turned upward. On its lower surface is seen the colon running 

 transversely from right to left. Follow the transverse mesocolon down to the spine 

 and the commencement of the jejunum will immediately be felt and can be seen 

 coming through the mesocolon, with the ligament of Treitz running from its upper 

 border to the parietal peritoneum. Follow the jejunum down for 40 cm. (16 in.) 

 and bring it up in front of the great omentum and colon and anastomose with the 

 lower border of the stomach anteriorly, preferably near the pyloric end. If it is 



Great omentum 



Transverse colon 

 Transverse mesocolon 

 -~ Posterior wall of stomach 



Duodenojejunal flexure 



desired to do a posterior gastro-enterostomy the transverse mesocolon is divided 

 and the stomach pushed forward through the opening (Fig. 418). The commence- 

 ment of the jejunum as it emerges from the transverse mesocolon is then brought up 

 and anastomosed with the posterior wall of the stomach. 



THE SMALL INTESTINE. 



The small intestine begins at the pylorus and ends at the ileocaecal valve. 

 It has an average length of 6.75 metres (22 ft. 6 in.) in the adult, independent of the 

 age, weight, and height of the individual (Treves). Jonnesco gives its length as 

 7.5 metres (24 ft. 7 in.) and Sappey as 8 metres (26 ft. 3 in.). The duodenum is 

 about 25 to 30 cm. (10 to 12 in.) long, and two-fifths of the remainder, or about 8^ 

 ft., is jejunum, and three-fifths, or about 12^ ft., is ileum. 



THE DUODENUM. 



The duodenum is the thickest, widest, and most fixed portion of the small 

 intestine. Its diameter is from 3. 75 cm. to 5 cm. ( i ^ to 2 in. ) and its muscular 

 and mucous coats are thicker than those of the jejunum or ileum. It also possesses 

 in its upper half the glands of Brunner (glandules duodenales} in the submucous 

 coat. It is thus seen that in its structure it resembles more the stomach than the 

 intestine and, like the stomach, is especially prone to ulcer. While carcinoma fre- 

 quently originates at the pylorus and extends to and involves other parts of the 



