422 APPLIED ANATOMY. 



It is these branches which bleed when the gall-bladder is removed. One of the deep 

 arteries may be much larger than the other or altogether lacking. Some very fine 

 branches come directly from the liver. 



Lymphatic nodes are found in the portal fissure and accompanying both the 

 common and cystic ducts. They are especially involved in carcinoma. 



The kidney pouch is a name given to the space in front of the right kidney. 

 The foramen of Winslow opens into it from the left and the abdominal wall is to its 

 right. The liver is above and the duodenum and transverse colon below. Liquids 

 from the lesser peritoneal cavity and bile-passages flow into this hollow, which can be 

 drained by a tube inserted through a "stab-wound" made through the abdominal 

 wall just to the outside of the right kidney. 



Gail-Stones. These and carcinoma are the main affections of the biliary pass- 

 ages. The latter is almost always secondary to pyloric cancer and involves the lymph- 

 atic nodes ; metastatic deposits may also exist in the liver itself. The diagnosis 

 between the two affections is sometimes difficult. Gall-stones are most frequent in 

 the gall-bladder, next in the common duct, and lastly in the hepatic duct. Obstruc- 

 tive symptoms are not often observed from gall-stones in the hepatic duct alone. 

 Obstruction of the common duct causes jaundice, but this is rare in obstruction of the 

 cystic duct ; practically, jaundice is only seen in obstruction of the common duct. 

 Gall-stones usually form in the gall-bladder and, as the cystic duct is smaller than the 

 common duct, if a stone gets out of the former it is frequently passed into the intes- 

 tine. On account of the contracted opening of the common duct into the duodenum, 

 stones are liable to be retained in the ampulla of Vater. This causes a damming back 

 of the bile, and the common duct increases to the size of a finger. Very large gall- 

 stones may cause ulceration into the duodenum or colon or may press on the portal 

 vein and vena cava, and produce ascites. In operating for gall-stones, Mayo Robson 

 incised through the middle of the right rectus muscle and prolonged the upper part 

 along the edge of the ribs to the outer side of the ensiform cartilage. Where more 

 room was desired Bevan added a transverse cut outward from its lower end. Kocher 

 made a curved incision 4 cm. (i}4 in.) below the edge of the ribs (see page 382). 

 In order to make the liver project a hard roll is placed beneath the back. To bring 

 the gall-ducts to the surface the liver is dragged down and its edge turned up over 

 the upper extremity of the wound. The gall-bladder can be drawn out and this 

 straightens the curves in the cystic duct. By placing one or two fingers in the fora- 

 men of Winslow the thumb can palpate the cystic and the common duct until it 

 disappears behind the duodenum. Gall-stones in the second (retroduodenal) portion 

 of the duct or in the ampulla of Vater can often be felt through the walls of the duo- 

 denum. If it is desired to gain access to this portion of the duct, the peritoneum on 

 the outer side of the second portion of the duodenum, binding it to the posterior 

 abdominal wall, must be divided. The duodenum is then turned to the left and the 

 .common duct followed down if necessary through the pancreas to the ampulla of Vater. 

 Stones impacted in the ampulla of Vater can be removed by incising the front of the 

 second portion of the duodenum and then cutting down on the stone through the 

 papilla. In some cases it may be impossible to pass a probe down the cystic duct 

 owing to its being caught by the valve-like folds of the mucous membrane. In 

 removing the gall-bladder, bleeding will be less if the cystic artery be first clamped. 

 If this is not possible, then the bleeding will occur from the branches on one or both 

 sides of the gall-bladder. The peritoneum is to be cut through, not torn. Bleeding 

 from the liver substance is slight and readily stopped by pressure. In incising the 

 common duct for calculi the relation of the portal vein behind and the hepatic 

 artery to the left should be remembered. These can be avoided by cutting down on 

 the calculus. 



THE PANCREAS. 



The pancreas is composed of two portions joined at right angles to each other. 

 Together they measure about 20 cm. (8 in. ). It is divided into a head, neck, body, 

 and tail. The neck is about 2 cm. (^ in.) broad, while the head and body are 

 each about 3 cm. (i^ in.). The head is about 5 to 6.25 cm. (2 to 2^ in.) long 

 and lies parallel to the vertebral column on its right side. The body is about 12.5 



