On the Gastric Triangle of the Japanese.

On the Gastric Triangle of the Japanese.

By

Kikuo Okamoto.

(From the Anatomical Institute of Keio University, Tokyo)

Plates IX-XIV.

Contents.

Page. 1. Introduction 45

2. Material and method . 46

3. Gastric triangle of the fetus, suckling and child ..... . . .48

4. Gastric triangle of the adult 50

1. Size of the gastric triangle 50

2. Lower limit of the gastric triangle 52

3. Right and left limits of the gastric triangle 54

5. Effects of the stomach contents on the gastric triangle . . . 54

6. Gastric triangle during pregnancy and puerperium 59

7. Summary 59

I. Introduction.

For clinical examination it is very important to know the exact position

of the stomach. Nowadays its position, like any internal orgadt can

easily be determined by means of the X-rays. Yet it may not be useless to

know the natural position of the organ in the cadaver. So far no complete

morphological study of the stomach of the Japanese has ever been under-

taken. I have done this at the suggestion of the late Professor B. Suzuk

while at the Imperial University of Kyoto. I cannot publish the. entire re-

sults of my research at present. I shall describe in ,this paper only the so-

called gastric triangle (Magendreieck), which seems to have some clinical

interest.

Anatomically the gastric triangle has been considered as being of little

use, but it certainly has much importance in clinical examinations, since it is

46 K. Okamoto,

the part of the stomach that is nearest to the surface. It is, therefore, very

important for percussion and operations of the stomach.

Upon opening the abdominal cavity the stomach is exposed only in the

shape of a triangle in the epigastric region,—touching the liver on the

right, the arch of the ribs on the left, and the transverse colon through the

omentum majus at the lower part. This is the so-called " Magendreieck."

Its apex is situated at or a little left to, the xiphoid process of the sternum, its

left side is covered by the left arch of the ribs, and the right side by the liver ;

its bottom coincides with the curvatura, ventriculi major, i. e., the part to

which the omentum majus is attached, and below it reaches the transverse

colon. It was found that it, in the main, coincides with the front part of the

vestibulum pylori and sometimes also with the canalis pylori. Its position

and size can easily be made out by percussion. If this can be determined

topographically, and from this indirectly the position of the whole stomach

can be found, this triangle will undoubtedly be of no little value for

• clinicians.

2. Material and Method.

-The freshest cadavers I could secure were used for this study. They

were injected with potassium bichromate-formalin (3.5% p. b.-9Q parts

plus 1.40 parts), and hardened so as to keep various organs in natural posi-

tion. But fetuses were fixed with formalin-alcohol.

The study of the forms of internal organs in hardened cadavers was for

the first time undertaken by His and Braune (4). They first used potassium

bichromate, and afterwards came to the freezing method. Although the

latter is better, I used potassium bichromate-formalin for the reason that it

is an excellent fixing fluid, so much so that a part of material besides the pre-

sent purpose could be utilized for histological study. The material used was

as follows :

On the Gastric Triangle of the Japanese. 47

Twenty-four hours after injection the abdominal wall was opened . The position and form of the gastric triangle were drawn by means of an

orthoscope on millimeter paper. Though its surface is somewhat vaulted,

yet for the sake of convenience the area of the sketches made by the above method was taken as that of the gastric triangle .

As to the position it was noted whether it is situated in the region of

48 K. Okamoto,

the epigastrium or that of the lower ribs, or of the mesogastrium ; and further-

more it was recorded that on which side of the median line it is situated. Its dimensions and boundaries were also measured. The lower limit of the gastric

triangle, which is in 'many cases coincides with the bottom of the stomach, were measured along the median line by the distance from the umbilicus.

3, Gastric Triangle of the Fetus, Suckling and Child.

B roman (1), Keith und Jones (6) were the first to study the stomach of sucklings. Schwalbe (12) made a study of morphological evolution of

the form of the stomach from the phylogenic viewpoint. Then Hasse (2) studied the shape of the stomach, especially that of the fetus.

It need hardly be mentioned that the stomach of the fetus is different in both its form and position from that of the adult. The liver is much

swollen functioning as the so-called fetus-liver, completely covering the

stomach. No gastric triangle is, therefore, present. From the study of five fetuses I reached the same result as that of pre-

vious authors, having found no gastric triangle. As to the gastric triangle of sucklings about two or three weeks old

Mei n e rt (7) has already written that its form and position were similar to those of the adult one.

Hasse und S t r e c k e r (3) obtained a somewhat different result. My study also showed a slight disagreement with that of Meinert. This dis-

crepancy may 'be due to the different mode of living of sucklings of Europeans and Japanese.

With us the suckling usually takes a lying position. The perpendicular

fetal stomach changes: its position in the period of suckling due to the changes. of i'ts contents and the position of the body. The stomach contents accumu-

late at the fundus ventriculi causing it to swell and to be pressed backwards.

Since the liver becomes smaller and at the same time the stomach swells after

parturition. the liver moves a little to the right with the stomach. The stomach is pressed upwards by the intestine, and besides from the position of

the body it is pressed from both backwards and forwards. The spleen being situated to the right, and the abdominal wall in front, the stomach is naturally

pressed towards the diaphragm and comes in between the liver and the spleen


where the resistance is comparatively weak. And as stated before the fundus ventriculi swells and takes a transverse position due to the position of the body

And gravity. Thus a strong rotation takes place—the curvatura major facing

forwards and upwards, and the curvatura minor backwards and downwards so as to come in contact with the columna vertebralis. The front side of the

stomach now turns upwards. Thus by mechanical changes the stomach is made flat. The fundus ventriculi alone swells. So seen from the front it

looks as though it took a transverse position and • one can barely lOee the

gastric triangle. The transitional changes of the form and position of the fetal stomach to

that of the suckling will be studied in future. Therefore, I only put this for- 'ward as a cause of non-existence of the gastric triangle.

In my material the gastric triangle is seen only in two cases. In No. 8 it was only 2 sq. cm., and in No. 9 14 sq. cm. In both cases they were in the left

region of the epigastrium, and coincided with the vestibulum pylori. When the suckling grows up, the position of the body axis changes and the contents

,come to be in the lower half of the stomach, especially in its lower part and the vestibulum- pylori, so the stomach again takes a perpendicular position. By this time the longitudinal axis of the stomach is nearly parallel with

the median line. The rotation is much diminished. The gastric triangle is considerably enlarged compared with hat of a suckling, and appears typically

in the left part of the epigastrium. Though the specimens at my disposal were but three and not numerous enough for the purpose, yet the result of my

investigation showed that they were in about the middle of the process, viz., between the suckling type and the adult type. The gastric triangle of a child is smaller than that of an adult. It is situated in the left part of the

epigastrium and coincides with the lower partof the vestibulum pylori. Since in No. 11 the position of the stomach is nearly transverse, the

gastric triangle is small, being only about 1 sq. cm. But in the other two cases they are much larger than this. In No. 13 the gastric triangle takes the shape of a half-moon, its concave side being the free margin of the left lobe of the liver. ,One-third of the gastric triangle is in the right epigastric region. The average gastric triangle measured 6 sq. cm., 45.67 mm. transverse diameter and 24.00 mm. in longitudinal diameter. On an average

50 K. Okamoto,

the lower limit is 65.00 mm. above the umbilicus. The left extension is

39.00 mm., while the right only 8.33 mm. from the median line.

Measurements of such cases are as follows :

4. Gastric Triangle of the Adult.

Simonds (9) has already investigated the gastric triangle of Europeans._

22 Japanese subjects (10 males and 12 females) were examined to compare with S i mon d s. results. Although S ugai (10, 11) measured the stomach in 23 cadavers, but he does not seem to have taken any notice of the gastric-

triangle. However, his measurements of the lower limits, etc., are very useful for my investigation.

1) Size of the Gastric Triangle.

The gastric triangle is very useful at the time of abdominal operation, especially that of the stomach. It is needless to say that the size-of the gastric

triangle differs according to the sexes, to the amount of contents and also to-the condition of surrounding organs.

According to S imonds (9) the gastric triangle of Europeans has the average size of 40.00 sq. cm. in its normal condition. My measurement of

the gastric triangle of Japanese are nearly the same, i.e„ 40.63 sq. cm. on an average. In the male it is 53.60 sq. cm. on an average (147.00 sq. cm.

at maximum), and in the female 27.65, sq. cm. (52.50 sq. cm. at maximum),


This shows that the size of the gastric triangle of the male is nearly twice as

large as that of the female.

In No. 23 (male) the gastric triangle does not appear. This is due to

an abnormal dilatation of the intestinal canal and the paucity of the stomachal

contents. Having examined the position of the gastric triangle, I found

that one-third was to the right and the remaining two-thirds to the left of

the median line. It may be mentioned that in the females the whole triangle

is often found on the left of the median line (Nos. 28 and 29). The trans-

verse diameter is usually longer than the longitudinal.

The measurements of the gastric triangle of the adults are as follows :

Male

K. Okamoto,

Female

2) Lower Limit of the Gastric Triangle.

In its normal condition the lower limit of the gastric irian.gle- does not

reach the navel. In abnormal cases it may go below the navel. The result

of investigation made by S ugai (10, 1A) is that on the median line, the lower

limit of the stomach was 59.66 mm. above the navel in the average male, and

43.30 mm. in the average female.

On the Gastric Triangle of the Sapanese. 53

The result of my own investigation is nearly the same as S ugai's, that

is, 59.80 mm. in the average male, and 56.00 mm. in the average female.

In Nos. 19 and 33 the lower limits were below the height of the navel.

These were in an abnormal condition, the stomach having been dilated.

Jossel (5) has written that in the normal stomach the lower limit is not

lower than the navel, and S a hli (8) also wrote that it is not lower than two

fmgerbreadths above the navel. From this it may not be unreasonable to con.-

-elude that it is abnormal when the lower limit comes below the navel.

Though in the following table the lower limit of the gastric triangle is

recorded and not that of the stomach itself, yet these two may be taken as

the same.

Male Female

(Minus sign means 'below the umbilicus'.)

54 K. Okamoto,

3) Right and Left Limits of the Gastric Triangle.

According to S u gai (10, 11) the left limit of the gastric triangle comes very near the mammillary line. In my cases both the right and left limits, especially the right one, are nearer to the median line in the female than in the male. The left limit in the average male measures 60.40 mm. (100.00-

maximum, 24.00 minimum) ; in the female 56.80 mm. (96.00 maxim:am, 42.00 minimum). The right limit in the average male measures 51.50 (92.00

maximum, 20.00 minimum) ; in the average female 38.00 (68.00 maximum,. 0 minimum). In No. 29 the gastric triangle has diminished in size and in No. 28 the right limit does not go beyond the median line.

Male Female

5. Effects of the Contents of the Stomach on

the Gastric Triangle.

The material I examined was classified in two, (A) with contents less than

100 c.c. and (B) more than 100\c.c.


A. Stomachs which contained only a small amount of contents.

In these cases the gastric triangle were small and the average dimension

being 20.43 sq. cm. (44.00 sq. cm. maximum-0 minimum). In the average

male 23.00 sq. cm., in the average female 18.50 sq. cm. Of all No. 21 has

the largest triangle (44.00 sq. cm.), while No. 22 has none at all. In No.

31 it measured only 1 sq. cm. Both the vertical and transverse diameters are•

short in these cases. From this it may be seen that the less the stomachal

contents, the smaller the triangle.

In passing I may mention a curious phenomenon, viz., in the male cases

the contents mostly were found on the right side, .and in the female on the

left side of the median line. In Nos. 29 and 31 more remained on the right

side.

The lower limit of the gastric triangle was on an average one finger- -

breadth higher than in the normal condition, i.e., in the male 80.00 mm., in,

the female 77.50 mm. above the navel.

56 K. Okamoto,

B. Stomachs which contained much contents.

In these stomachs the gastric triangle were large. In No. 19 was

147.00 sq. cm. and its contents amounted to 600 c.c. Though this was

pathological, it is obvious that the gastric triangle has been enlarged due to large amount of contents.

It is noteworthy that the average size of (B) (48.89 sq. cm.) is more than twice as large as that of (A) (20.43 sq. cm.). Sxual difference is interesting.

In the male the size of the triangle is nearly twice as large as that of female. This is also the case with the normal stomach.

It should be mentioned that one-third of the triangle was on the right

side, and the remaining two-thirds on the left side of the median line. Average transverse diameter was 104.57 mm. and average longitudinal 84.00 mm. In the male triangle the longitudinal diameter is about 30 mm. and

transverse diameter 15 mm. longer than those of the female one. The lower limit was a little lower t an it should be in its normal condi-

-tion, being 56.64 mm. above the navel on an average. In the male it is lower


than in the female. In Nos. 19 and 23 they were lower than the navel and

showed obviously an abnormal condition.

Measurements of stomachs which contained small amounts of contents.

Male

Female

Measurements of stomachs which contained much contents.

(Minus sign means the lower limit lower than navel'.)

58 K. Okamoto,

Male

Female

Oa the Gastric Triangle of the Japanese. 59

Average measurements :

6. Gastric Triangle during Pregnancy and Puerperium.

Since I came across to the material of two female cadavers, one in pre-

gnancy and the other in puerperium, I may add my findings from them. They were fixed with potassium bichromate-formalin. No. 34 is a 25 year

old female cadaver, who died on the 20th day after delvery . No. 35 is a 32

year old female cadaver, who had been pregnant for about four months. In No. 34 the gastric triangle is in the left epigastric region , and has the

size of 15 sq. cm. Its longitudinal diameter is 44 mm. and its transverse .diameter 56 mm . From this it will be seen that has been reduced to two-

thirds the normal size. The lower limit is 115 mm . above the navel, that is,

59 mm. higher than in the normal condition.

In No. 35 the gastric triangle has been reduced as is No. 34. It measures 24 sq. cm. (15 sq. cm. in the right and 9 sq. cm . in the left epigastric region).

Its longitudinal diameter is 72 mm. and it transverse diameter 92 mrn . The lower limit is situated 100 mm. above the navel , that is, 40 mm. higher than in the normal condition. It need hardly be mentioned that the triangle is

higher ; for the stomach has been pushed up by the large uterus during

pregnacy and pueriperium.

7. Summary.

The important points of my study may be summarized as follows :

1. In the fetus of the Japanese the gastric triangle does not make its ap-perance. In the period of suckling its appears and gradually enlarges as the

child grows.

60 K. Okamoto,

2. In the adult Japanese the gastric triangle is always in the epigastric

region. Its average size is 40.63 sq. cm. and is the same as that of Europeans.

In the male 53.60 sq. cm., in the female 27.65 sq. cm. on an average. The

triangle of the male is nearly twice as large as that of the female. And in the

normal condition nearly one-third of it is in the right to the median line.

' 3 . The lower limit of the gastric triangle is 59.80 mm. in the adult male

and 56.00 mm. in the adult female above the navel, nearly four fingerbreadths

above the navel.

4. The amount of the stomachal contents affects the size of the gastric

triangle. The larger the amount of contents, the larger the triangle. In my

material there was one case in which no gastric triangle was present owing to

the paucity of the contents. The largest one measured 147 sq. cm. The

lower limit goes down as the stomachal contents increases.

5. During pregnancy and pueriperium the gastric triangle is made

smaller as the stomach is pressed to the upper region of the abdominal

cavity.

I dedicate this little work in memory of the late Professor B. Suzuk ip

who kindly supervised the present investigation.


Literature.

1. Broman, I., Normale u. abnorrne Entwicklung der Menschen. Wiesbaden 1911.

2. Hasse, C., Per menschliche Magen. Verb. Gee. deutsch. Naturfor. u. Arzt,e. 76 Vers. Breslau. 1904. T. 2. Halfte 2, p. 478-80. Leipzig 1905.

3. Hasse, C. u. Strecker, F., Per menschliche Magen. Arch. f. Anat. u. Phys. Anat. Abt. 1905.

4. His, W., Studien an geharteten Leichen fiber Form u. Lagerung des mensch - lichen Magens. Magens. Arch. f. Anat. u. Phys. Anat. Abt. 1903.

5. Jossel-Waldeyer., Lehrbuch d. topographisch-chirurgischen Anatomic . Bd. II. 1892.

6. Keith, A. and Jones, F. W., A note on development of the fundus of the human stomach. Proc. of the Anat. Soc. of Great Britain and Ireland , Journ.

of Anatomy. and Physiology. 1902. 7. Meinert, E., Uber normale u. pathologische Lage des menschlichen Magens _

u. ihren Nachweis. Zentlb. f. inn. Mediz. Jahrg . 17. No. 12 u. No. 13. 1896_ 8. S a hli, Lehrbuch der klinischen Untersuchungsmethode .

9. Simonds, M., 'Ober die Form u. Lage des Magens unter normalen u . ab- normalen Bedingungen. Jena 1907.

AO. Sugai, T., -Ober die Lage u. Kapazitat des Magens bei Japanern . Zentralbl.. allgemein. Path. u. path. Anat. Bd. 20, Nr. 9. 1909.

11. Sugai, T. Uber Lage u. Kapazitat des Magens bei der Japanern nebst Bemer- kungen fiber die Verwertbarkeit der Perkussion u. Auskultation . Mittel med.

Gee. Tokyo. Bd. XVIII, H. 7. 1904. 12. Schwalbe, G., Beitriige zur Kentinis des menschlichen Magens . Zeitschr. f_

Morph, u. Authr. 1912.

132 K. Okamoto,

Explanation of Figures.

All the figures were drawn one-fourth the natural size with an orthoscope. The

gastric triangles are hatched. x position of the spina Waca ant sup e position of the navel. U. uterus. Fig. 1. 7 year old male, No. 11. Stomach has been rotated, reducing gastric triangle

to only 1 sq. cm. Fig. 2. 7 year old female, No. 12. Fig. 3. 10 year old female, No. 13. Gastric triangle assumes the shape of a half-

moon. Fig. 4. 20 year old male, No. 14. Fig. 5. 22 year old male, No. 15. Gastric triangle is fairly large. Fig. 6. 32 year old male, No. 16. Gastric triangle in normal condition. Fig. 7. 33 year old male, No. 17. Fig. 8. 45 year old male, No. 18. Fig. 9. 48 year old male, No. 19. Gastric triangle largest (147 sq. cm.) lower limit

is below umbilicus, pathological. Fig. 10. 49 year old male, No. 20. Fig. 11. 51 year old male, No. 21. Gastric triangle extends mainly in the righthand

side of the median line. Fig. 12. 52 year old male, No. 22. No gastric triangle. Fig. 13. 59 year old male, No. 23. Fig. 14. 19 year old female, No. 24. Fig. 15. 20 year old female, No. 25. Fig. 16. 22 year old female, No. 26.

Fig. 17. 25 year old female, No. 27. Fig. 18. 31 year old female, No. 28. Gastric triangle is very small. Fig. 19. 52 year old female, No. 29. Gastric triangle does not appear. Fig. 20. 56 year old female, No. 30. Fig. 21. 59 year old female, No. 31. Fig. 22. 77 year old female, No. 32. Fig. 23. 81 year old female, No. 33. Gastric triangle has enlarged pathologically,

lower limit being below navel. Fig. 24. 25 year old female, No. 34. In puerperium. Fig. 25. 32 year old female, No. 35. In pregnancy.

FOLIA ANATOMICA JAPONICA, BD. i. TAP. IX.

Fig. 1. Fig. 4.

Fig. 2.

Fig. 5.

Fig. 3.

K. Okamoto.

FOLIA ANATOMICA JAPONICA, RDA TAP. X.

Fig. 6. Fig. 7.

Fig. 8. Fig. 9.

K. Okamoto,

FOLIA ANATOMICA JAPONICA, BD. I. TAF. XI.

Fig. 10. Fig. 11.

Fig. 12. Fig. 13.

K. Okamoto.

FOLIA ANATOMICA JAPONICA, BD. I. .TAF.XII.

Pia 14_ Fig. 15.

Fig. 16. Fig. 17.

K. Okainioto.

FOLIA ANATO MICA JAPONICA, BD. I. TAP. XIII.

Fig. 18. Fig. 19.

Fig. 20. Fig. 21.

K. Okatifoto.

FOLIA ANATOMICA JAPONICA, 131).1. TAP. XIV.

Fig. 22. Fig. 23.

Fig. 24. Fig. 25.

K. Okamoto.

On the Gastric Triangle of the Japanese.

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