I74C HUMAN ANATOMY. 



abdominal wall. In gastroptosis the normal pancreas may easily be felt above the 

 stomach and might readily be mistaken for a new growth. Usually the swelling is 

 behind the stomach and above or behind the colon. In suppurativc pancreatitis the 

 collection of pus may push the stomach forward, or may become superficial, either 

 above or below it ; it may, starting at the pillar of the diaphragm, and guided by the 

 psoas-sheath or the iliac fascia, reach the iliac region ; it may occupy the areolar 

 tissue of the loin, becoming a perirenal abscess ; it may open into either the stomach 

 or duodenum. When confined to the pancreas, it will usually be recognized during 

 an exploratory operation. It may be drained posteriorly by an incision at the costo- 

 vertebral angle, or anteriorly through a large tube surrounded by gauze packing. 



Cancer of the pancreas usually affects the head of the gland, which accounts for 

 the frequency with which obstruction of the common bile-duct and of the duodenum 

 occurs in such cases. 



The further growth of the tumor may cause compression of the pylorus, of the 

 cardiac end of the stomach, of the whole stomach by forcing it against the anterior 

 abdominal wall, of the colon, the ureter, the portal vein, the vena cava, the aorta, 

 the splenic vessels, and the superior mesenteric vein (Robson and Moynihan). 



If the tumor extends to the right, there are apt to be jaundice and intestinal 

 obstruction ; if upward, in addition to these symptoms, pyloric obstruction and 

 gastric dilatation ; if backward, ascites and oedema of the lower limbs. 



The pancreas may be approached for operation through a median incision, and 

 reached, above the stomach, through the gastro-hepatic omentum ; below the stom- 

 ach, through the gastro-epiploic omentum or the transverse mesocolon, the omentum 

 having been turned upward. It has been exposed (in a case of hydatid cyst) 

 by an incision beginning at the tip of the twelfth rib and passing forward in the 

 direction of the umbilicus. Indirect drainage in chronic pancreatitis by means of 

 cholecystostomy has given excellent results (Robson). 



In cases of nephrectomy the relations of its tail to the left kidney and renal 

 vein should be remembered. The relations of the vena porta, the vena cava, the 

 aorta, the superior mesenteric artery, and the cceliac axis are so close that when 

 complicated by adhesions or infiltration, as in chronic inflammations or new 

 growths, operations for total excision of the pancreas become formidable and have 

 rarely been undertaken. The close relation of the pylorus especially when the 

 stomach is depressed by a new growth to the neck of the pancreas should be 

 remembered in pyloroplasty or pylorectomy, as should the proximity of the spleen 

 to the other extremity of the pancreas in cases of splenectomy. 



THE PERITONEUM. 



The peritoneum is the serous membrane lining the abdominal cavity and reflected 

 over the viscera. Like all serous membranes, it consists of a free mesothelial sur- 

 face and a deeper layer of fibro-elastic tissue, the tunica propria. Beneath the latter a 

 variable amount of subperitoncal tissue connects the peritoneum with the structures 

 which it covers. The quantity of this areolar layer differs in various localities, and 

 it is at times difficult to decide just what is really a part of the serous membrane 

 proper. It is convenient to look upon the peritoneum as having a right side and a 

 wrong side ; the former is the free mesothelial surface, the latter the areolar which 

 is attached to other structures. Thus it may be compared to a wall-paper of a 

 room without door or window, of which the right side is always free and the wrong 

 side adherent to walls or to projections from them. Should a flue traverse the 

 room, it is easy to imagine it invested by a continuation of the paper on the walls. 

 It passes through the room, but is not within the closed sac formed by the right 

 side of the paper. While it is true that during development the mesothelial covering 

 ith the tissue beneath it, the conception that rojections of organs 



s f>nri frtssn with the tissue beneath it, the conception that projections of organs 

 into the peritoneal cavity carry the serous membrane before them is very convenient 

 ami justified. The peritoneum of the female is the only serous membrane that is 

 not a closed BftC, >n a. count of the openings of the Fallopian tubes. The blood- 

 vessels for the viscera, around which the peritoneum is thrown, must pass on its 

 wrong side. To return to the simile of the Hue in the chamber ; if this should need 



