1426 SUKFACE AND SUKGICAL ANATOMY. 



kidney substance to reach the renal pelvis, the incision should be made along the 

 frontier line between the two vascular areas, viz., about half an inch behind and 

 parallel to the lateral border of the kidney. 



The ureters lie behind the peritoneum covering the psoas major muscles ; they 

 descend almost vertically in the umbilical region 1J in. from the median plane. 

 At the level of the intertubercular plane they lie in front of the termination of the 

 common iliac arteries, and then pass down into the pelvis minor, in front of the 

 hypogastric arteries. 



The ureter possesses a well-developed muscular wall so that it is well adapted for 

 suturing, while its rich blood supply favours rapid healing. Its abdominal portion 

 is supplied by the renal and internal spermatic arteries ; its pelvic portion by the 

 superior vesical, the inferior vesical, and the middle hsemorrhoidal arteries. By 

 their anastomosis they form a continuous and somewhat tortuous chain which is 

 generally visible beneath the peritoneum along the whole course of the tube. 



In reading skiagrams with a view of ascertaining the presence or absence of 

 calculi in the abdominal portion, of the urinary tract, Hurry Fen wick makes use 

 of a line projected vertically upwards from the highest part, i.e. the centre, of the 

 iliac crest to the twelfth rib. As this line corresponds to the lateral limit of the 

 kidney, it follows that a " calculus shadow " close to the medial side of this line 

 will generally occupy one of the calyces and be situated, therefore, towards the 

 cortex, while if the shadow be situated close to the tips of the transverse processes 

 of the vertebrae, the calculus will usually be found either in the pelvis of the kidney 

 or in the abdominal portion of the ureter. The other points to be kept in mind 

 in reading the radiogram are that the pelvis of the kidney lies opposite the interval 

 between the transverse process of the first and second lumbar vertebrae, and, 

 secondly, that the abdominal portion of the ureter descends in the line of the tips 

 of the transverse processes of the second, third, fourth, and fifth lumbar vertebrae. 



Pancreas. The head of the pancreas occupies the curve of the duodenum, 

 and lies in the lowest part of the right half of the epigastric region, on a level with 

 the second lumbar vertebra. The neck, which crosses the median plane opposite 

 the fibre-cartilage between the first and second lumbar vertebrae, lies in the trans- 

 pyloric plane, while the body lies immediately above that plane. The tail lies in 

 the left hypochondriac region. The relations of the pancreas to the transverse rneso- 

 colon and to the neighbouring viscera have already been sufficiently referred to. 



After opening the abdomen in the median line, the pancreas is best exposed by 

 passing through the gastro-colic ligament ; access to the organ through either the 

 hepato-gastric ligament or the transverse mesocolon is more limited and therefore 

 less satisfactory. 



A pancreatic cyst gives rise to a tumefaction of the abdomen either in the 

 epigastric or in the umbilical region, depending on whether it pushes the hepato- 

 gastric ligament before it and develops between the liver and stomach, or whether 

 it extends forwards below the stomach. In severe contusions of the abdomen the 

 pancreas may be ruptured against the vertebral column. 



Vessels of the Abdomen. The commencement of the abdominal aorta and the 

 coeliac artery are situated two fingers' breadth above the transpyloric plane. The 

 superior mesenteric artery arises a finger's breadth above the transpyloric plane, the 

 renal arteries a finger's breadth below it. The inferior mesenteric artery arises mid- 

 way between the transpyloric and the intertubercular plane that is to say, about 

 1 in. above the level of the umbilicus. The abdominal aorta bifurcates in, or a little 

 to the left of, the median plane, on a level with the highest part of the iliac crest, 

 and about f in. below the level of the umbilicus. 



The inferior vena cava lies immediately to the right of the aorta; its most 

 important surgical relation is the right ureter, which lies close to its right side. 



The common and external iliac arteries may be mapped out by drawing a line, 

 curved slightly laterally, from a point opposite the bifurcation of the aorta to a 

 point midway between the superior anterior iliac spine and the pubic symphysis : 

 the superior third of this line corresponds to the common iliac, the inferior two- 

 thirds to the external iliac. 



In ligaturing the common iliac artery, or the superior part of the external iliac, 



