Peritoneal cavity

“ Some operators of experience completely ignore the absence of peritoneal adhesions, and, even in these circumstances, open the abscess without previous stitching of peritoneal surfaces. The risk and danger of escape of pus into the peritoneal cavity, they hold, is very small if free drainage to the outside is secured. McLeod considers that, in the circumstances, stitches will not hold in the soft and inflamed liver tissue; he also considers that, in the event of the incision having to be made in the thoracic wall, removal of part of a rib is unnecessary. ”

“ Less frequently the edges are ragged. Post-mortem digestion may, however, so change the borders of the opening as to make it difficult or impossible to tell from their post-mortem appearances alone whether perforation has occurred before or after death. The peritoneal cavity after death from perforation is found to contain gas and substances from the stomach. Usually within a few hours after perforation septic peritonitis is excited, but in exceptional cases no inflammation of the peritoneum has occurred even when life has been prolonged twenty-four hours after perforation. ”

“ The cavity created by the removal of the uterus is filled in loosely with iodoform gauze, which extends to the vulva. An exact closing of the peritoneal cavity over this gauze is effected by the sewing up of the anterior and posterior flaps of peritoneum. The final step is the closure of the abdominal incision.
After-treatment. This is relatively simple. The strips of iodoform gauze are removed through the vagina in from five to ten days successively. The patient gets up on the fifteenth day. The bladder requires very careful attention, as it is usually paralysed for some days. ”

“ Collect a further sample of blood or serum for subsequent investigation as to the presence of antibodies.
Peritoneal Cavity.—
16. Sear a broad track in the middle line of the abdominal wall; open the peritoneal cavity by an incision in the centre of the seared line. Observe the condition of the omentum, the mesentery, the viscera and the peritoneal surface of the intestines.
17. Collect a specimen of the peritoneal fluid (or pus, if present) in a capillary pipette. Make cultivations, tube and surface plate, and cover-slip preparations from this situation. ”

“ These two sections of the body cavity, which in Amphibia and Sauropsida remain in free communication with the undivided peritoneal cavity behind, may, from the fact of their containing the lungs, be called the pleural cavities.
In Mammalia a further change takes place, in that, by the formation of a vertical partition across the body cavity, known as the diaphragm, the pleural cavities, containing the lungs, [Pg 632] become isolated from the remainder of the body or peritoneal cavity. ”

“ The objections to these methods are various: the more gentle are uncertain and inefficient; of the more severe, some involve mutilation, by the loss or removal of the testicle; others, as those of Langenbeck and Schmucker, are very dangerous and fatal, by the inflammation spreading to the peritoneal cavity (20 to 30 per cent. died) ; while all of these methods afford at best only temporary relief. And this is only what might have been expected, for the sac was only a result of the protrusion, not a cause ”

“ Once the peritoneal cavity is opened, the incision through the peritoneum must be extended to the full length of the external wound by a probe-pointed bistoury.
The operator's hand must now be passed into the abdomen, and the tumour isolated from its connections as far as possible. When no adhesions exist it is{227} extremely easy to pass the hand quite round the tumour, ascertain its relations to the uterus and Fallopian tubes, and the length and thickness of its pedicle. The presence of adhesions adds very seriously to the danger and duration of the operation. ”

“ The bladder, on account of its close relationship to the cervix, is always involved in the last stages. The disease may extend to the vesical mucous membrane, and symptoms of cystitis will appear. Sometimes the vesico-vaginal septum is destroyed and a urinary fistula results. Extension to the rectum is not so common. As the disease extends upward the peritoneum may be perforated, though this is an unusual accident. In most cases peritoneal involvement is preceded by local inflammation and by adhesions which prevent direct penetration of the peritoneal cavity. ”

“ The cephalic layer, lining the “lesser peritoneal cavity” invests the ventral surface of the pancreas. The caudal layer continues over the caudal surface of the body of the gland and transverse portion of the duodenum into the parietal peritoneum and the free mesentery of the jejuno-ileum. Consequently the returning layers of the great omentum are said to surround the transverse colon and unite along the dorsal border of the intestine to form the transverse mesocolon, which membrane is continued dorsad toward the vertebral column as two layers. ”

“ Even if no fixation of the duodenum and mesoduodenum takes place this course of the hepatic artery will produce a constricted passage between the liver (caudate lobe) cephalad, abdominal parietes and aorta dorsad, lesser omentum and pyloric duodenum ventrad, and hepatic artery caudad. This passage leading from the general peritoneal cavity into the retrogastric space is the primitive foramen of Winslow. This condition is well represented in the abdominal cavity of some of the lower mammalia, in which duodenum and mesoduodenum remain permanently free. ”

“ Chronic peritonitis may occur as a result of the acute attack, or as a tuberculous disease. In the former case, the gravest symptoms having subsided, some abdominal pain continues, and there is considerable swelling of the abdomen, corresponding to a thickening of the peritoneum, and to the presence of fluid in the peritoneal cavity. This kind of peritonitis may also develop slowly without there having been any preceding acute attack. There is a gradual loss of strength and flesh. The disease is essentially a chronic one; it is not usually fatal. ”

“ If the impaction is not overcome, death by collapse or from peritonitis follows. Post-mortem examination shows enormous fecal accumulation, peritonitis as a consequence of the obstruction, perforating ulcer in some part of the large bowel, more often the sigmoid flexure, or, in some cases, absolute rupture of the cæcum itself, and escape of its contents into the peritoneal cavity. ”

“ Its hemostatic power is also observed in bone cavities. Care should be taken never to use it unless there is a free [Pg 25] exit, as it increases rapidly in volume after coming in contact with dead tissue or pus, and serious accidents have happened from its improper use; for instance, if it is injected into an abdominal sinus where free escape is not provided for, the distention will result in ruptures of the sinus and infiltration of the surrounding tissues; possibly of the peritoneal cavity. ”

“ Differences in the rate of growth between the length of the body wall and the length of the mesocolon may play an important part in the production of peritoneal fossæ, small pouches which in some regions of the abdomen may assume considerable proportions. Such fossæ are found around the duodeno-jejuneal angle, the cæcum and appendix, and the sigmoid flexure. They will be considered more in detail with these respective regions, especially in reference to their relation to retro-peritoneal hernia. ”

“ Their true significance and their influence on the adult anatomical arrangement of the abdomen is, however, only appreciated when the changes in the arrangement of the peritoneal membrane which they involve, are taken into account.
The dorsal mesogastrium changes more than any other portion of the peritoneum in the course of development. It not only becomes displaced and altered in direction by the rotation of the stomach, but in addition it grows so extensively that it finally hangs down like an apron over the entire mass of small intestines, forming the great omentum. ”

“ In the so-called peritonitis lymphatica the inflammatory symptoms are at the outset lacking. The abdominal cavity is found filled with a thin, stinking, greenish or brownish fluid composed of serum and micrococci. The intestines are lax and oedematous, and the muscular structures are paralyzed, with resulting tympanitic distension. The peritoneal covering of the intestines is devoid of lustre, and covered with injected patches, or is stained of a dark-brown color. Death often ensues before the occurrence of exudation. ”

“ At the junction of the median with the intermediate portion, and therefore at the neck of the Malpighian body, a canal grows out in a ventral direction, which meets the [Pg 709] peritoneal epithelium, and then develops a funnel-shaped opening into the body cavity, which subsequently becomes ciliated. In this way the peritoneal funnels which are present in the adult are established. ”

“ The assumption of peritoneal adhesion, and consequent obliteration of serous areas, offers many advantages in considering the adult human abdominal cavity, especially from the standpoint of comparative anatomy. ”

“ These penetrate the gland, and with it the mucous membrane, of which it forms a part, and next, the cellular tissue of the intestine. In numerous instances they perforate the muscular coat, leaving nothing but peritoneum at the bottom; and frequently, passing this, they induce inflammation of the cavity of the belly, and death.
The cases of simple resolution terminate in three weeks: those in which sloughs are formed, in from 30 to 40 days, if not fatal. If death be from peritonitis, it is of course soon after the 15th and 16th days ”

“ By this means any blood oozing from broken adhesions, or any fluid escaping from the cyst into the abdominal cavity, being diluted, is less likely to irritate the peritoneum, the cavity of which can also be more readily cleansed.
When a patient seems in danger of dying on the table from shock or from exhaustion the anæsthetic should be withheld while hypodermic injections of ether and enemata of brandy are given. Warmth should also be applied to the body by bottles of hot water, or, what is better, by rubber bags of the same. ”

“ If the taxis is gone about, however, in proper time, and in the right way, it ought almost always to prove successful. It is very desirable indeed that this should be the case, seeing that all the bad symptoms in ninety-nine out of a hundred cases instantly subside; whereas, after the reduction by incision, there is always great risk from the opening of the peritoneal sac alone. ”

“ If time be given these faithful guards to mass themselves in the peritoneal lymph channels, they will prevent the extension of the peritonitis from this point. The surgeon, having evacuated the pus, removed the appendix, and inserted the drainage apparatus, is tempted, because of its bad smell, to wash out the wound. Such a measure would not only give the patient detrimental annoyance, but would inflict a new traumatism upon the tissues. “This traumatism calls out an unnecessary number of leucocytes, and an unnecessary degree of reactive inflammation ensues. ”

“ Agglutinated point of rupture at the median periphery of the cecum near the ileo-cecal valve. The perityphlitic pus appeared to be sacculated by adherent intestinal coils, but beyond the adhesions in the free abdominal cavity below the omentum there was diffuse, fresh, fibrinous peritonitis and distributed here and there small quantities of thin, putrid pus (many bacteria, large quantities of streptococci and cold bacilli) . The peritoneum was injected. ”

“ In the chronic stage there is usually an old necrotic shaft perforated by sinuses, and often freely movable, inclosed by a shell of dense periosteal bone. The sequestrum must be removed, but the bony defect fails to heal, and for months persists as a filthy, discharging cavity, with the constant danger of secondary infection and phlegmon, or erysipelatous inflammation. The healing of this cavity is very difficult and requires a very long time. ”