DUODENAL ULCER. 363 



already described. The two horizontal portions of these liga- 

 ments are easily demonstrated by opening the lesser sac below 

 the stomach and turning that viscus upwards. The folds can 

 then be seen to spring from the posterior abdominal wall in the 

 neighbourhood of the cceliac axis, and skirting the orifice of 

 the Spigelian recess of the lesser sac of the peritoneum, pass 

 forwards, just above the pancreas, to the cardiac end of the 

 stomach and to the duodenum about an inch beyond the pylorus. 

 The coronary and the hepatic arteries can be felt in the substance 

 of the folds. 



The sharp V-shaped bend which develops in the lesser curva- 

 ture of a prolapsed stomach is due to its being slung up by its 

 two ends. The lesser curvature in such cases, instead of lying 

 under cover of the liver, may be distinctly visible, and sometimes 

 a part of the pancreas can be felt above it, simulating a malig- 

 nant tumour. In extreme prolapse the stomach may form a 

 prominence below the level of the umbilicus. 



DISEASES OF THE INTESTINE. 



Duodenal Ulcer. The first part of the duodenum is the 

 commonest site for ulcers. This part of the bowel begins at the 

 pylorus, opposite the first lumbar vertebra. With the stomach 

 empty, the duodenum is directed first to the right and then back- 

 wards beneath the liver, but with the stomach full it passes 

 directly backwards. It is therefore very movable. Its relations 

 have important bearings on the complications which may arise. 

 The quadrate lobe of the liver lies above and in front of it. The 

 head and neck of the pancreas support it. Behind it the portal 

 vein passes upwards to the liver, and the gastro-duodenal artery 

 and bile duct pass downwards, the artery lying about an inch to 

 the right of the pylorus. The termination of this part of the 

 duodenum lies immediately to the right of the inferior vena 

 cava. The relations to the peritoneum are exactly like those of 

 the stomach. A diverticulum of the lesser sac passes to the 

 right behind the bowel, whilst the remainder of its circumference 



