THE SMALL INTESTINE. 911 



sometimes as three inches. The fundus of the stomach reaches, on the left side, as high as the 

 level of the sixth costal cartilage of the left side, being a little below and behind the apex of the 

 heart. The portion of the stomach which is in contact with the abdoniinal walls, and is therefore 

 accessible for opening in the operations of gastrotomy and gastrostomy, is represented by a triangular 

 space, the base of which is formed by a line drawn from the tip of the tenth costal cartilage on 

 the left side to the tip of the ninth costal cartilage on the right, and the sides by two lines drawn 

 from the extremity of the eighth costal cartilage on the left side to the ends of the base line. 



Surgical Anatomy. Operations on the stomach are frequently performed. By 

 "gastrotomy" is meant an incision into the stomach for the removal of a foreign body, the 

 opening being immediately afterward closed in contradistinction to "gastrostomy," the 

 making of a more or less permanent fistulous opening. Gastrotomy is probably best performed 

 by an incision in the linea alba, especially if the foreign body is large, by a cut from the 

 ensiform cartilage to the umbilicus, but may be performed by an incision over the body itself, 

 where this can be felt, or by one of the incisions for gastrostomy, to be mentioned immediately. 

 The peritoneal cavity is opened, and the point at which the stomach is to be incised decided 

 upon. This portion is then brought out of the abdominal wound and sponges carefully 

 packed around. The stomach is now opened by a transverse incision and the foreign body 

 extracted. The wound in the stomach is then closed by Lembert's sutures i. e. by sutures 

 passed through the peritoneal and muscular coats in such a way that the peritoneal surfaces 

 on each side of the wound are brought into apposition, and in this way the wound is closed. 

 (litxtrostnmy was formerly done in two stages by the direct method. The first stage consisted in 

 opening the abdomen, drawing up the stomach into the external wound, and fixing it there : and 

 the second stage, performed from two to four days afterward, consisted in opening the stomach. 

 The operation is now done by a i-<i/ni!nr method. An incision is commenced opposite the eighth 

 intercostal space, two inches from the median line, and carried downward for three inches. By 

 this incision the fibres of the Rectus muscle are exposed and these are separated from each 

 other in the same line with a steel director. The posterior layer of the sheath, the transver- 

 salis fascia and the peritoneum, are then divided, and the peritoneal cavity opened. The ante- 

 rior wall of the stomach is now seized and drawn out of the wound and a silk suture passed 

 through its muscular and serous coats at the point selected for opening the viscus. This is 

 held by an assistant so that a long conical diverticulum of the stomach protrudes from the ex- 

 ternal wound, and the parietal peritoneum and the posterior layer of the sheath of the rectus 

 are sutured to it. A second incision is made through the skin, over the margin of the costal 

 cartilage, above and a little to the outer side of the first incision. With a pair of dressing 

 forceps a track is made under the skin through the subcutaneous tissue from the one open- 

 ing to the other and the diverticulum of the stomach is drawn along this track by means of 

 the suture inserted into it ; so that its apex appears at the second opening. A small perforation 

 is now made into the stomach through this -protruding apex and its margins carefully and 

 accurately sutured to the margin of the external wound. The remainder of this incision and 

 the whole of the first incision are then closed in the ordinary way and the wound dressed. 



In cases of gastric ulcer perforation sometimes takes place, and this was formerly regarded 

 as an almost fatal complication. In the present day, by opening the abdomen and closing 

 the perforation, which is generally situated on the anterior surface of the stoniach, a considera- 

 ble percentage of cases are cured, provided the operation is undertaken within twelve or fifteen 

 hours after the perforation has taken place. The opening is best closed by bringing the peri- 

 toneal surfaces on either side into apposition by means of Lembert's sutures. 



Kxcision of the pylorus has occasionally been performed, but the results of this operation 

 are by no means favorable, and, in cases of cancer of the pylorus, before operative proceedings 

 are undertaken, the tumor lias become so fixed and has so far implicated surrounding parts that 

 removal of the pylorus is impossible and gastro-enterostomy has to be substituted. The object 

 of this operation is to make a fistulous communication between the stomach, on the cardiac side 

 of the disease, and the small intestine, as high up as is possible. 



Digital dilatation of the pylorus for simple stricture was first performed by Loreta. He 

 exposed the stomach and opened it by a transverse incision near the pylorus. He then inserted 

 the i'oreliuiMTs of both hands and passed these through the pylorus and stretched it with some 

 degree of force. The operation has now, however, dropped out of use and been replaced by 

 pyloro-plasty. This consists in making a longitudinal incision from the stomach through the 

 pylorus into the duodenum, and converting this longitudinal incision into a transverse one by 

 traction at the centre of the incision, and retaining it permanently in this position by sutures. 



THE SMALL INTESTINE. 



The small intestine is a convoluted tube, extending from the pylorus to the 

 ileo-csecal valve, where it terminates in the large intestine. It is about twenty 

 feet in length, 1 and gradually diminishes in size from its commencement to its 



1 Treves states that, in one hundred cases, the average length of the small intestine in the adult 

 male was 22 feet 6 inches, and in the adult female 23 feet 4 inches: hut that it varies very much, 

 the extremes in the male heing 31 feet 10 inches in one case, and 15 feet 6 inches in another, a 

 difference of over 15 feet. He states that he has convinced himself that the length of the bowel is 

 independent, in the adult, of age, height, and weight. 



