THE SMALL INTESTINE. 1633 



pinkish, and the longitudinal band, the sacculations, and the epiploic appendages 

 on its lower aspect may be seen. If any doubt exists, the under surface of the left 

 lobe of the liver should be followed up by the finger to the transverse fissure and 

 then down on the gastro-hepatic omentum to the lesser curvature of the stomach. 

 The dependent greater omentum and the gastro-epiploic artery on the greater cur- 

 vature aid in the recognition of the stomach. 



In gastrotomy as for foreign body, for exploration, or for retrograde dilatation 

 of the oesophagus the incision may be vertical and midway between the two curva- 

 tures to minimize the hemorrhage (vide supra}. 



In gastrostomy the establishment, for purposes of feeding, of a direct com- 

 munication between the surface of the body and the stomach cavity the abdominal 

 incision may be oblique, parallel to the left costal cartilages, and 2.5 cm. (i in.) 

 from them, or vertical down to the left rectus, the fibres of which may be separated 

 without division. In either case a part of the anterior wall of the stomach, made 

 conical by traction, is brought out, carried upward beneath a bridge of skin, and 

 fixed to the margins of a second opening over the costal cartilages. Various mod- 

 ifications are employed, all with the idea of securing a valvular or sphincteric con- 

 dition in or about the orifice so as to prevent leakage of the stomach contents. 



Inpyloroplasty applicable to simple hypertrophic stenosis or cicatricial stric- 

 turean incision is made from the stomach to the duodenum through the pylorus 

 and parallel to the long axis of the tract at that point. Its borders are then 

 separated as widely as possible so that their mid-points become the ends of the 

 opening, the edges of which are then sutured together in this position, materially 

 widening the lumen of the canal. 



In pylorectomy or gastrectomy large portions of the stomach, or the whole organ, 

 are excised for malignant disease ; in the former the omental connections of the 

 pylorus must be severed and the right gastro-epiploic, the pyloric, and the gastro- 

 duodenal arteries divided ; in the latter, in addition, the pneumogastric nerves 

 below the diaphragm and many more vascular trunks. 



Partial gastrectomies, as for the excision of a nodular carcinoma or of a gastric 

 ulcer, are much less serious. Division of the gastro-hepatic omentum, which holds 

 the stomach up under the costal margins, will facilitate the freeing of the pylorus and 

 lesser curvature and permit of ready access to the lesser peritoneal cavity. The 

 gastro-colic omentum attached to the region of disease can then be made tense by 

 the fingers passed behind and beneath the pylorus and can be ligated and divided 

 (Mayo). 



In gastro-enterostomy as a palliative in cancerous pyloric stenosis or for the 

 treatment of gastric ulcer the intestinal canal (usually that of the jejunum, as 

 the highest movable portion of the small intestine) is made directly continuous with 

 the stomach cavity by the establishment of a permanent fistula between the two. The 

 posterior wall of the stomach is now usually selected because of its nearness to the 

 jejunum. It may be reached through the transverse mesocolon, the greater omentum 

 with the transverse colon having been turned upward ; or the gastro-colic omentum 

 may be torn through or divided. 



Gastroplasty (analogous to pyloroplasty) has been done in cases of hour-glass 

 stomach following cicatricial contraction after gastric ulcer. Occasionally in these 

 cases the constricting band has been mistaken for a thickened, contracted pylorus. 

 Adhesions sometimes connect the constrictions with neighboring parts, as with the 

 right rectus muscle (Elder) or the liver (Childe). 



THE SMALL INTESTINE. 



The stomach is followed by the long and complicated tube of the small intestine, 

 divided into the duodenum and the jejuno- ileum. According to Treves, the average 

 length in the male is 6.8 m. (22 ft. 6 in.) and in the female nearly 15 cm. (6 in.) 

 more. This excess, however, would probably not be confirmed by a larger series. 

 In the male the extremes were 9.7 m. (31 ft. 10 in.) and 4.7 m. (15 ft. 6 in.), in 

 the female 8.9 m. (29 ft. 4 in.) and 5.7 m. (18 ft. 10 in.). The outer wall of the 

 tube is regular, without sharp folds or sacculations, beyond the duodenum. The 



103 



