134 TOPOGRAPHIC AND APPLIED ANATOMY. 



FIG. 63. The liver, seen from below. 



FIG. 64. The position of the structures at the porta hepatis. 



mentum phrenico-colicum, this fixation is not firm enough to hinder the occurrence of "floating 

 spleen," which is accompanied by a stretching of these ligaments. Like the liver, the spleen 

 may be displaced by tympanites, by ascites, or by abdominal tumors, which press the organ 

 upward toward the pleural cavity, or by a left-sided pleural exudate which forces the spleen, 

 together with the diaphragm, downward. An abscess of the spleen may perforate into the 

 left pleural cavity, into the stomach, into the intestine, and even into the pelvis of the left 

 kidney. 



The Pancreas. The pancreas (Plates 15, 17, and 18, and Figs. 61 and 68) may be seen 

 and felt through the gastrohepatic omentum in the posterior wall of the bursa omentalis. It may 

 be exposed in three ways: (i) By dividing the gastrohepatic omentum and displacing the stomach 

 downward; (2) by dividing the ligamentum gastrocolicum (see page 113) and displacing the 

 stomach upward; and (3) by dividing the floor of the bursa omentalis, i. e., the transverse meso- 

 colon, and reflecting upward the transverse colon and the stomach. The long flat organ is 

 transversely situated at the level of the second lumbar vertebra; it is retroperitoneal, only the 

 anterior portion of the viscus being covered by the peritoneum of the bursa omentalis. The 

 "head" lies in the concavity of the duodenum (Fig. 61), but sufficient space is left for the superior 

 mesenteric vessels to pass beneath the inferior pancreatic margin and over the ascending portion 

 of the duodenum to reach the root of the mesentery. The tail lies upon the anterior surface of 

 the left kidney, sometimes higher, sometimes lower, and extends to the [basal surface of the 

 Eo.] spleen. The posterior surface is separated from the vertebral column by the crura of 

 the diaphragm, by the inferior vena cava, and by the abdominal aorta (Fig. 69). There is a 

 groove upon the dorsal surface of the head, which lodges the superior mesenteric artery and 

 vein. The splenic vessels run along the upper border of the organ. 



Owing to the deep position of the pancreas it is difficult to make a positive diagnosis of its 

 diseases, such as cysts, abscesses, or tumors. The extension of such diseases to the stomach is 

 preceded by adhesions to the posterior gastric surface within the bursa omentalis. In spite of 

 all this, clinicians have succeeded in palpating the head of the pancreas through the abdominal 

 walls in spare individuals. It will be readily understood that the intimate relations with the 

 transverse colon, with the duodenum, with the pylorus, and with the transverse fissure of the liver 

 add greatly to the difficulty of making a positive diagnosis of the diseases of the pancreas, par- 

 ticularly of carcinoma of the head of the viscus. 



The Duodenum. The duodenum (Msxdttdxrolov, because twelve inches long) extends 

 from the pylorus to the duodenojejunal flexure and has a length of about thirty centimeters. The 

 commencement of the pylorus is often made visible by a constriction, but it may be more surely 

 determined by palpation of the thickening produced by the muscular tissue, which is 

 plentiful in this situation (sphincter pylori). The pars superior, the shortest portion, 

 lies to the right of the median line at the level of the first lumbar vertebra and is 

 attached to the transverse fissure of the liver by the ligamentum hepatoduodenale [right 

 edge of the gastrohepatic omentum. ED.]. This ligament forms the anterior boundary 



