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The choledocho-duodenal junction. A morphologic study in the dog

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THE C~HOLEDOCHO-I)UODEhALJUNCTION
A MORPHOLOGIC STUDY I N THE DOG
BELA HALPERT'
Department of Pathology, T h e University of Chicago, and Department o f
Surgery, Y a l e University School of Medicine2
TEN FIGURES
The mechanism regulating the flow of bile into the
duodenum is not clearly understood. Inf orination about a n
anatomic sphincter at the terminal end of the ductus choledochus is, therefore, of prime importance. In the course of
a morphologic study of the effects of choleeystectorny on the
biliary system, the writer and his collaborators could find
no anatomic sphincter at the choledocho-duodenal junction of
the dog(1). In view of the significance of this observation, it,
seemed desirable to extend the study of the choledochoduodenal junction and to trace the origin of the belief that
such a structure existed in the dog.
HISTORICAL REMARKS
Reference to a sphincteric mechanism regulating the flow
of bile into the duodenurn of man was made as early as 1654
by the London physician Glisson (1597-1677) ( 2 ) . I n 1853,
Tobien noticed in the lower third of the human ductus
choledochus a few thin muscle bundles which finally arranged
themselves into a n inner longitudinal and a n outer circular
layer of which the latter was the stronger(3). Luschka
published, in 1869, a study of the pars intestinalis of the
common bile duct in man. H e contended that the intramural
William Harvey Cushing Fellow in Surgery.
' A part of this work has been conducted under the joint auspices of the
Otho S. A. Sprague Memorial Institute and the Douglas Smith Foundation for
Medical Research of The University of Chicago.
83
THE ANATOMICAL RhCORD, VOL.
53, NO. 1
a4
BELA HALPERT
portion had the same structure as the rest of the ductus
choledochus: nowhere could he find any muscle fibers in the
biliary ducts. According to Luschka, contractions of the
circular muscle layer of the duodenum and its influence upon
the intramural portion of the common bile duct regulated the
flow of bile into the duodenum or gall bladder(4). Gage of
New York was the first, in 1879, to mention the sphincter of
the ductus choledochus in the cat(5).
The Italian Oddi in 1887 described an anatomic sphincter
at the choledocho-duodenal junction in the dog and sheep and
also in man, in the pig, cat, horse, pigeon, chicken, and guineafowl. Oddi made gross and microscopic studies. He placed
the descending portion of the duodenum in a mixture of equal
parts, by volume, of concentrated nitric acid, glycerol, and
water and allowed maceration to take place for three or four
days. His microscopic observations on the course of the
ductus choledochus through the duodenal wall were made
on longitudinal and cross-sections prepared by staining the
tissues in toto with carmin and embedding them in paraffin.
Oddi stated that:
On close observation of the opening of the duct one sees distinctly
that it is surrounded by rings of muscles which one might consider
as almost completely independent structures were it not for some
thin fibers which merge with the fibers proper of the intestine.
No illustrations are attached to Oddi’s publication(6).
Znaniecki (’95) fixed in alcohol the extrahepatic biliary
ducts including the ‘Portio duodenalis’ of five individuals.
Appropriate portions of these were embedded in celloidin
and the ducts studied in cross-sections, the choledochoduodenal junction in serial transverse o r longitudinal sections
stained with Orth’s pikrolithioncarmin or alauncarmin. He
observed in the external layers of the extrahepatic biliary
ducts smooth muscle fibers united into smaller and larger
bundles which, however, did not form a regular ring around
the wall, but were separated from one another by connective
tissue so that no true muscle layer could be distinguished.
There were variations in the amount of the scattered bundles
THE CHOLEDOCHO-DUODENAL J U N C T I O N
85
of longitudinal smooth muscle fibers present. They were
more numerous in the ductus choledochus than in either the
ductus cysticus or the ductus hepaticus. Only occasionally
were there any smooth muscle fibers arranged circularly. In
cross-sections of the lower third of the ductus choledochus
both the longitudinal and circular muscle fibers increased
so that large bundles of circular fibers could be distinguished
external to the longitudinal fibers. These appeared curved
with their concavity toward the lumen of the duct. The
longitudinal and transverse muscle bundles materially increased in strength during the passage of the duct through
the duodenal wall. The muscle bundles lay closer to one
another, but were still separated by connective tissue. This
arrangement of the musculature remained as far as the ostium
of the duct into the duodenum. I n the vicinity of the duct,
Znaniecki noticed an increase of the duodenal musculature to
almost twice its thickness elsewhere. According to this
author, neither the muscularis mucosae nor the rest of the
duodenal musculature is continuous with that of the ductus
choledochus (7).
Hendrickson ( '98) reported gross and microscopic studies
of the extrahepatic biliary system of the dog, rabbit, and man,
and reviewed the literature up to that time. For the gross
studies Hendrickson employed first, the method of Illarcacci,
the same which Oddi used; secondly, maceration in Ranvier's
alcohol. The microscopic studies were made on sections
embedded in celloidin or paraffin most of which were then
stained by the method of Van Gieson. Hendrickson described
in detail the choledocho-duodenal junction in the dog and was
the first to illustrate his findings with diagrams. Although
he contended that an anatomic sphincter of the ductus choledochus existed in the dog, his figures 11 to 13 are convincing
evidence to the contrary. Particularly figure 13, which shows
the ductus choledochus entering the wall of the duodenum,
demonstrates that about one-fourth of the circumference of
the duct is devoid of muscle fibers(8).
86
BELA HALPEltT
Letulle and Nattan-Larrier (’98) reported gross and microscopic studies of the ‘ampulla of Vater’ in man. They
illustrated the passage of the ductus choledochus through the
duodenal ~ v a l lwith drawings of microscopic sections. One
of these shows both the common and the pancreatic ducts
situated in the circular muscle layer of the duodenal wall. I n
a second illustration the progress of the duct is traced through
the submucosa, and in a third, its opening into the duodenum
is shown. I n the latter two illustrations tlie muscle bundles
about the duct are scattered and do not completely encircle
the duct (9).
Helly (’99), from Zuckerkandl’s Institute of Vienna, published a study of “the musculature closing the termiiial ends
of the biliary and pancreatic ducts” and illustrated the arrangement of the muscle fibers a t the choledocho-duodenal
junction in man( 10).
StoYaiiofY ( ’00) investigated the biliary passages of tlie dog,
grossly and microscopically. He illustrated the passage of
the ductus choledochus through the dEodenal wall with diagrams of histologic sections. According to Stoi’anoff, muscle
fibers were scarce in the wall of the ductus choledochus and
in its ‘extra-intestinal portion’ did not form a continuous
layer, but r a n in three directions predominantly in the longit udinal. In the ‘intraduodenal portion’ the muscle fibers were
still mostly longitudinal and became continuous with the
circular inuscle layer of the duodenal wall and with the
muscularis mucosae. Stoi’anoff concluded that there was 110
true sphincter at the terminal end of the ductus choledochus
unless the fibers of the circular muscle layer were regarded
as such(l1).
Stracker ( ’09), from Toldt’s Institute of Vienna, reported
extensive gross and microscopic studies of tlie plicu longitudiiialis duodeiii of liuman and animal fetuses and adults.
He observed great similarity regarding the presence and the
microscopic structure of a sphincter of the ductus choledochus
in man and in animals lie examined, namely, in the cat, sheep,
ox, pig, and monkey (bhcacus rhesus). Only a gross description was given by Stracker of conditions in the dog(12).
THE CHOLEDOCHO-DUODENAL J U N C T I O N
87
Broman ( ’13) discovered a peculiar valvular arrangement
in the ‘hepato-pancreatic duct’ of a viable fetus of an antarctic
whale species (Leptonychotes weddelli). He observed a similar arrangement of circular musculature and valves in two
other antarctic whale species, namely, in the Lobodon and the
Ogmorhinus ; the arrangement was less distinct in the Phoca
vitulina and still less well developed in the Otaria. I n the
Zalophis and Lutra the circular musculature was well developed, the valves, however, were absent. Broman contended
that in man the circular muscle layer about the terminal end
of the ‘hepatico-pancreatic duct ’ was weakly developed, had
no intimate relation with the circular muscle layer of the
duodenum, and that it originated here perhaps from the
niuscularis mucosae. His photomicrograph of a transverse
section through the duodenum at the level of the terminal
end of the ductus choledochus is a fine illustration of the
’structure and topographic relations of this region in a human
fetus 30 em. long(13).
Rost ( ’13) observed in man a s well as in the dog “ a strong
muscle layer of smooth fibers arranged circularly about the
papilla and connected only by occasional fibers with the
musculature of the intestine which undoubtedly is to be
regarded a s a sphincter.” Rost studied the papilla of Vater
in more or less complete serial sections, noted, however, no
particular diference between conditions in man and in the
dog. H e published no illustrations( 14).
Mann (’20) studied the duodenal end of the ductus choledochus in the horse, deer, rat, and pocket gopher (Geomys
bursarius) species without a gall bladder, and in dog, cat,
rabbit, guinea-pig, ox, goat, pig, sheep, striped gopher
( Spermophilus tridecemlineatus), and mouse, which possess
a gall bladder. Gross and microscopic observations lead
Manri to the following conclusion: “There is a definite arrangement of muscle fibers which might functionate a s a
sphincter i n each species studied; no difference could be
observed in animals that have a gall bladder when compared
with those without one.” The photomicrographs in &Iann’s
88
BELA HALPEBT
paper, one of the pocket gopher and one of the rat, show the
common bile duct as it passes through the circular muscle
layer of the duodenum. It is of interest to note that in his
figure 2, few or no muscle fibers seem t o be present on one
side of the duct (15).
Auster and Crohn ( ’22) investigated the choledochoduodenal junction in microscopic sections of three dogs and
three human specimens. They observed: “that the muscular
fibers of the sphincter are scanty, widely separated and diffuse
and are at no time continuous.” It was their impression
“that there is a fusion of the fibers of the intestinal muscularis
with the corresponding layer of the duct which goes to make
up the muscular apparatus of the papilla.’’ They believed
that there was a ‘distinct sphincteric action’(l6),
Matsuno ( ’23) investigated the ductus choledochus in complete or in sectional serial sections “in a large number of
individuals of all ages with normal biliary ducts and also in
such with cholelithiasis.” He observed in the region of the
papilla beneath the mucosa a muscle layer consisting of strong
smooth muscle fibers mostly arranged circularly. Only in
the external layers were there any longitudinal or oblique
muscle fibers. The circular musculature surrounded the
lumen of the ductus choledochus concentrically in the form
of a continuous band, interrupted only at places by ‘larger
glandular convolutions ’ (Driisenkonvolute) . The circular
musculature was occasionally continuous with the musculature
of the intestine, but differed from it by the smaller width of
its muscle fibers. The relation of the ductus choledochus to
the duodenal wall as illustrated by Matsuno in his figure 1
is not quite clear (17).
Westphal (’23) noticed a peculiar arrangement at the eholedocho-duodenal junction in the guinea-pig( 18). The morphology of this region was studied subsequently by Higgins( 19)
and described in more detail by Burget and Brocklehurst (20).
Nagai and Sawada ( ’25) studied the choledocho-duodenal
junction in the Japanese, using Oddi and Marcacci’s method
for the gross and paraffin serial sections stained by the
THE C H O L E D O C H O - D U O D E N A L J U N C T I O N
89
Van Gieson method for the microscopic investigation. They
concluded that an anatomic sphincter of the ductus choledochus existed and illustrated the course of its muscle fibers
on drawings of gross specimens and microscopic sections (21).
Job (’26) reported gross and microscopic studies of “the
duodenal portion of the bile and pancreatic ducts” in man
and stated that:
The musculature of the duodenal wall does not form a n efficient
sphincter of the ducts. Each duct has a n individual circular and
longitudinal smooth-muscle layer and a common circular and longitudinal layer almost t o the tip of the papilla. J u s t inside the gut
wall the bile duct has a very definite sphincter, and from this point
on the two layers of muscle decrease until the longitudinal layer
disappears 1 or 2 mm. from the tip of the papilla, the circular layer
persisting to the tip, though only a few cells. The common and
individual muscle layers seem to intermingle a t various points (22).
Giordano and Mann ( ’27) reviewed “the evidence f o r and
against the presence of a sphincter.” They studied the intramural portion of the common bile duct “in more than twenty
species of animals.” Giordano and hlann concluded that :
“it is usually possible to find a definite bundle of smooth
muscles surrounding the common bile duct, contractions of
which would tend to close the lumen. The amount of niuscle
tissue and its arrangement differ considerably in the various
species and in individuals of the same species, and in many
instances is very meager. ” They also investigated the intramural portion of the common bile duct in man and observed
that: “As the duct enters the duodenum, it is surrounded
by muscle fibers from the duodenum which are reflected over
the duct and intermingle with those of the common bile duct,
thickening the wall of the intramural portion of the duct
for a variable distance” (23).
Nuboer (’29) investigated in thirty normal individuals the
choledocho-duodenal junction in serial sections. One to two
centimeters proximal to the entrance of the duct he noticed
small bundles of muscle fibers which increased in number and
reached their greatest thickness at a short distance from the
ampulla of Vater. At this point about two-thirds of the
90
BELA HALPERT
bundles were circular, the rest longitudinal. Near the junction of the common bile and pancreatic ducts the course of the
muscle fibers was a figure of 8. This arrangement of the
musculature about the choledocho-duodenal junction suggested that the sphincter of Oddi was derived from the
duodenal musculature. According to Nuboer, the sphincter
consists of two parts: “1) a sphincter-ring situated in the
region of the intestinal musculature before the union with
the ductus pancreaticus, 2 ) an antrum-musculature situated
proximal to the sphincter-ring consisting chiefly of oblique
and longitudinal muscle bundles ” (24).
Porsio ( ’29) investigated the choledocho-duodenal junction in human infants and adults using serial sections stained
by the method of Van Gieson. He observed that in infancy
an annular muscle surrounded both the common bile and t,he
pancreatic ducts, but was present only in that portion of the
ducts which passed through the musculature of the intestine.
The muscular ring became incomplete and horseshoe-shaped
at the ampulla and in the parts of the duct proximal to the
intramural portion. I n adults the sphincter was more ‘robust,’
more complete, and consisted of a n annular muscle layer
common to both ducts, and in addition each duct had its own
circular muscle throughout its intramural course. The
muscular ring was found completely developed after the age
of ten years. I n the wall of the ductus choledochus of adults,
Porsio noticed, numerous glandular diverticula herniating
through the sphincter. He concluded that the sphincter of
the common bile duct was a n emanation of the circular muscle
layer of the intestine increasing the fibers proper of the duct
which by themselves could hardly be regarded a ‘robust’
sphincter. A schematic gross drawing illustrates his conception( 25).
METHOD
The material for this investigation was identical with that
used by the writer and his collaborators in their study of the
effects of cholecystectomy on the biliary system. This pro-
THE C H O L E D O C H O - D U O D E N A L J U S C T I O N
91
cedure had the obvious advantage that sections of the rest
of the biliary system were a t hand in the event of aiiv uimsual
observation. Thus the choledocho-duodeiial juiictions of
twenty-f our apparently healthy dogs were studied f ollowiiig
the removal of their gall bladders at intervals of oiie to
twenty-three weeks. Sections, fixed in formalin, embedded in
Fig. 1 Cross-section of the ductus choledochus of the dog (‘2-7) a t a level near
the junction with the duodenum. No muscle tissue is seen in or about the wall
of the duct. Pliotomicrograpli, X 12.
celloidin, cut, and stained with haematoxyliii eosin, iron
haematoxylin, and by the method of Van Gieson, were prepared from various levels of the intramural portion of the
ductus choledochus. As mentioned hefore, similarly prepared
sections were available in each case from the rest of the
extrahepatic biliary ducts and from various portions of the
liver arid the gall bladder.
THE ANATOMICATi RECORD, S O L .
5 3 , WO. 1
92
B$LA
HALPEBT
MOltPIIOLOGICAL OBSERVATIONS
The uniformity of findings was a striking feature of this
iiivestigatioii. AIusclc tissue was conspicuously absent in the
F i g . 2 ("ross section of the ductus cholcdochus of thc dog ( C 24) at tlie level
of contart nitli tlie duodenal mall. The inuscle buiidles of the longitudinal coat
of the duodeiiuiii have separated t o admit the duct. The wall of the duet contains no iiiuscle fibers. I'liotoinicrogiaph, x 12
wall of the dnctns cholcdochus in all but one of the t-vrentyf o u r dogs examined. Ti1 this a few irregularly placed longitndiiial muscle bundles were seen in the pei-il)hcry of tlie wall
of tlie duct. Tt miis clearly dcmonstrated in transverse sec-
T H E CHOLEDOCHO-DUODENAL
JUNCTION
93
tions a t various levels of the choledocho-duodenal junction
that the intramural portion of the duct was also devoid of
muscle tissue throughout its course.
Fig. 3 Cross-section of the ductus choledochus of tlic dog (C-16) at the level of
entrance into the duodenal wall. The longitudinal layer of the muscular coat
of the duodenum has separated to enibracc the duct. Photoiiiicrogrsph, x 12.
The ductus choledochus approached the duodenum at an
acute angle. At a level near the junction no muscle tissue
appeared in or about the wall of the duct (fig. 1). Adjacent
to the point of contact the muscle fibers of the longitudinal
layer of the duodenal wall changed their course, the muscle
bundles separating to admit (fig. 2 ) and reaching out to
94
BELA HALl’EItT
ciiilnracc (fig. 3) the eiiteying portion of the duct us eholeclochus. At a soniewliat more distal level Tdiere the duct
was leaving the loilgitudinzd aiid ciiteriiig the circular muscle
Fig. 4 Cross sec*tioii through the intramural portion of thc ductus cliolcdoelius
of the dog (P-4). The duct lins passed tlie longitudiiial iiiusrlc layer xvhich is
renrrangiiig itsclf uhile the circular l a j c ~of the diiodeiiuxn is sclmrating to admit
the duet. Pliotoniicrograph, X 1 2 .
layer, a rearrangeiiieiit of the niusclc fibers iii tlie outer layer
aiid a separation in tlie inner layer was noted (fig. 4).
At a level at which the ductus choledochus was passing
through the circnlar coat of the duodenum, oblique and longitudinal muscle bundles were sccii at opposite sides of t,he duct.
T H E C H O L E D O C H O - D V O D E N B L JUNC‘I’IOK
95
Their locatioii was alwa>-s at riglit angles t o the seroiiiucosal
axis and never corresponded t o this axis (figs. 5 and 6). This
arrangement naturally suggested that tlicsc were bundles of
the circular niLisclc layer which changed their course t o permit
the entrance and passage of the cluctus choledochus. It is
olsrions, particularly from IIcl~clrickson’sillustrations, that
these muscle bundles were iiit erpi-ctecl a s a11 anatomic
Pig. 3 Cross scction through the intianiurnl portion of the duetus clioledochus
of the dog (C-8). Tlic duct is situxted in the circular coat of the duodcnum.
Oblique and longjtudinal inusclc hnndles are sccn :it opposite sides of the duct.
Their location is at riglit angles to tllc seroniucosnl axis. I t is nhrious that they
belong to tlic circular coat, the muscle biundlc~sof nliicli changed their course t o
perinit the entra~tcr and passage of the durtus choledochus. T’hotoniicrograph,
x 12.
96
BBLA
HALPERT
sphincter(8). At a slightly more distal level where the duct
has emerged from the circular muscle layer, it mas observed
that these muscle fibers were a part of the circular coat and
Fig. 6 Cross-section tlirough thc intramural portion of the duetus eholedoelius
of the dog ( C 2 ) . The muscular coat of the duodenum is thicker on one side
than on the other. This is also true of the oblique bundles which a r e obviously
a p a r t of the circular coat of the duodenal musculature. Pliotoinicrograph, X 12.
did not constitute a separate anatomic structure (figs. 7
and 8).
Before the lumen of the ductus choledochus merged with
the lumen of the duodenum, the duct, of course, passed
through the submucosa and the muscularis mucosae. This
T H E CHOLEDOCHO-DUODENAL J U N C T I O N
97
latter layer was of variable thickness and thus the muscle
bundles situated about the duct showed considerable individual variations, but at this level never formed a continuous
coat about the lumen. The fact that muscle fibers at the
Fig. 7 Cross-section through the intraiiiural portion of the ductus clloledochus
of the dog (C-16). The duct is leaving the circular coat of the duodenal wall.
The muscularis mucome is me11 developed. Photomicrograph, X 12.
junction of the lumina of the ductus choledochus and the
duodenum (figs. 9 and 10) occurred only occasionally and then
in scanty, scattered bundles, offered further evidence that an
anatomic sphincter of the ductus choledochus does not exist
in the dog.
Fig. 8 Section through the teriiiinal end of the ductus eholedochns o f the dog
(C-19). The rnajor portion of the duct has passed through the circular coat of
tllc duodenal .rr:~11. The obliquc bundles 011 oiie side are ohriously a part of tllc
muscul:ir 1:ij er o f the duodenum. T’hotoiiiicroffratpli, X 1 2 .
Fig. 9 Section through the terminal end of the ductus choledoclius of the
dog (C-14). Muscle bundles are scattered about the r a l l of the duct. Pliotomicrograph, X 12.
98
T H E C€IOLEDOCHO-DUODENAL JUNCTION
99
COMMENT
There is coiisiderable diff ercnce of opinion regarding the
mechanism regulating the flow of bile into the duodenum.
The treatise of Graham and liis collaborators(26) and that
of Babkin(27) present an up t o date coniprehensive review
Fig. 1 0 Section through the papilla of Vster of the dog ( C - 7 ) . The lmiien
of the ductuv cliolrdochus is seen t o merge with the lumen of the duodenum.
The niuscle fibers in the mall of the duct are scanty and irregularly distributed.
(After Halpert, Rewbridge, and Hcaley.) Photomicrograph, X 14.
of the subject. The most recent contributions are those of
I’uestow(28) and of Lueth(29). The experimental data of
Burget (30), Copher and Kodama (31), and Berg and Jobling
(32) on the physiology of the choledocho-duodenal junction
are of particular interest in view of the morphologic observations presented in this paper.
100
BELA HALPERT
SUMMARY AND CONCLUSION
llicroscopic investigation of the ductus choledochus is
reported in twenty-four apparently healthy dogs. The speciniens from these aninials were obtained from one to twentythree weeks following removal of their gall bladders. Particular attention was paid in this study to the intramural
portion of the common bile duct.
Muscle tissue was conspicuously absent in the wall of the
ductus choledoclius as it approached the duodenal wall.
Transverse sections at subsequent levels demonstrated the
course of the muscle fibers of the longitudinal and circular
coats of the duodenal wall, the fibers separating to admit
the duct and rearranging theniselves after the passage of the
duct. At the junction of the lumen of the duct and that of
the duodenum, muscle fibers occurred only occasionally and
then in scanty, scattered bundles.
The observations presented indicate that at the terminal
end of the common bile duct of the dog no muscular structure
exists which could justly be called an anatomic sphincter of
the duetus choledochus, unless the ensheathing duodenal
inusculature, pal-ticularly the circular layer, is regarded as
such.
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G. REWBRIDGE,
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2 GLISSON,FRANCIS
1654 F. Glissonii
Anatoniia hepatis, etc. Londini.
3 TOBIEN,ADELBERTUS
ISIDORUS
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ratione imprimis habita tclae muscularis. 1naug.-Diss., Dorpat.
4 LUSCHKA,v. H. 1869 Die Pars intestinalis des gemcinsamen Gallenganges.
Vierteljahrschrift f . d. Prakt. Heilkunde, Prag., Bd. 103, 8. 86.
5 GAGE, S. H. 1879 The ampulla of Vater and the pancreatic ducts in the
domestic cat (Felis domestica). Am. Quart. Micr. J., vol. 1, p. 126.
6 ODDI, RUGGERO 1887 D 'une disposition 5 sphincter speckle de l'ouvcrtut-e
du canal choledoque. Arch. ital. de biol., T. 8, p. 317.
7 ZNANIECKI, V. MICHAEL 1895 Beitrag zur Kenntnis dcr Wandungen des
Ductus cysticus, Hepaticus nnd Choledoclius, iiarncntlicli der Muskclfasern des letzteren in der Portio duodenalis. Inang.-Diss, Grcifswald.
8 € I E N D E I C ~ - S ~ N ,WILLIAXIF. 1898 A study of the musculatiire of the entire
.ertr~he.~atic..bi~~r~'sy
tiaL&ZnB
s t e ~ ' that of the common bile-duct
';Lad
th6&@~tc?.~
'
$
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Hosp., vol. 9, p. 221.
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THE C H O L E D O C H O - D U O D E N A L J U N C T I O X
3
10
11
12
13
14
1.5
I6
17
18
19
20
21
2:‘
23
24
23
26
27
28
101
LETULLE,MAURICE, A N D 1,. NATTAN-LAREIEE1898 L ’ampoule de Vater.
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D:U.
1900 Recherches sur la structure des voies hiliaires chez
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STRACKER,
OSKAR 1909 Die Plica longitudinalis duodeni beim Menschen
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BROMAX,
IVAR1913 TTcber die Existenz uiid Bedeutung einer kombinierten
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29
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