Peritoneum

“ The opposed serous surfaces of the ascending and descending mesocola and of the dorsal parietal peritoneum adhere and the process also usually involves the dorsal visceral peritoneum of the ascending and descending colon, so that these portions of the gut obtain a fixed position.
Adhesion of the mesocolon to the dorsal body wall (parietal peritoneum) does not occur at all points at the same time. Usually adhesion proceeds from the midline laterad. The fixation of the ascending colon in the human embryo begins about the fourth month. ”

“ When the peritoneum is eaten through it is called perforation, for it means that there is an opening into the peritoneal cavity, and, unless the cavity is cut into, cleaned and properly drained death will take place in a very short time. I say death is inevitable without surgical treatment. In this I appear to be more radical than the most radical, for the best authors have much to say about perforation, diffuse peritonitis, and of patients who live after perforation, as though it were a common occurrence ”

“ Constipation is absolute in uncomplicated peritonitis of ordinary severity, and I believe is caused by a temporary paralysis of the muscular layer of the intestine. It has already been stated that the blood-supply of the peritoneum is through vessels whose capillaries are shared by that membrane and the tissues which it covers. Inflammatory action in the peritoneum of average severity would naturally extend to this muscular layer and render it inactive. When the inflammation abates it recovers its contractile power. ”

“ Hence, after this process of adhesion is completed, the dorsal wall of the retrogastric space is lined by secondary parietal peritoneum covering the left kidney (original right leaf of primitive mesogastrium) (Fig. 175) . We obtain (Fig. 175 at x) an apparent continuity of the parietal peritoneum with that portion of the mesogastrium which, derived from the original left layer of the membrane, appears now to extend, as the ventral one of two layers, between the stomach and the abdominal parietes near the lateral border of the left kidney. (Primitive gastro-splenic omentum.) ”

“ The position of the patient is of the greatest importance; its essential object is to bring the edges of the incision, and especially of that in the peritoneum, as nearly as possible in apposition, so that the space between them may be more easily filled up by the opposing peritoneum forming the anterior layer of the omentum, or by the outer covering of the intestine if the omentum should not intervene. This is to be effected by the gentlest inclination of the body toward the wound which may be supposed capable of keeping these parts in apposition ”

“ In order to incise the peritoneum without damaging the tumour, cyst, or intestine, a fold of the membrane is picked up with forceps and cautiously pricked with the point of a scalpel; air rushes in, destroys the vacuum, and generally produces a space between the cyst (or intestines) and the belly-wall; the surgeon then introduces his finger, and divides the peritoneum to an extent equal to the incision in the skin.
It is important to remember that the bladder is sometimes pushed upward by tumours, and lies in the subperitoneal tissue above the pubes; it is then liable to be cut. ”

“ If, however, the great predisposing causes of the former—abortion and injury at parturition—be absent, the woman be non-parous, the inflammation will affect the peritoneum rather than the connective tissue. Parametritis is rare before pregnancy has occurred, except in so far as the connective tissue always becomes more or less involved when the peritoneum covering it is inflamed. Perimetritis, on the other hand, is frequent in the single and sterile woman. ”

“ The ligature should be passed from the inner side to avoid including the vein, and thus there will be{10} less chance of wounding the peritoneum from the convexity of the needle being applied to it. If possible, the genito-crural nerve should not be included in the ligature, but probably such an accident would do no great harm.
It is of much more consequence to avoid injuring the peritoneum. This is sometimes very difficult, from the adhesions which are set up between the peritoneum, the artery, and especially the aneurism, as the result of pressure and inflammation. ”

“ Peritonitis is an inflammation of the serous membrane lining the cavity of and covering the viscera contained within the abdomen. It is very rare to see a case of primary peritonitis. It is, however, somewhat common as a secondary disease from extension of the inflammatory action involving organs covered by the peritoneum. Peritonitis is often caused by injuries, as punctured wounds of the abdomen, severe blows or kicks, or, as is still more common, following the operation of castration. It follows strangulated hernia, invagination, or rupture of the stomach, intestines, liver, or womb. ”

“ The colon, sigmoid flexure and rectum; (2) the cloaca with the uro-genital sinus and the duct of the allantois.
PART I. ANATOMY OF THE PERITONEUM AND ABDOMINAL CAVITY.
For the purpose of studying the adult human peritoneum it is in the first place absolutely necessary to obtain a correct appreciation of the disposition of the chief viscera within the abdominal cavity and of their mutual relations. In the second place the visceral vascular supply of the abdomen must be carefully considered in order to correctly appreciate certain important relations of the peritoneal membrane. ”

“ The peritoneum should be incised in the position in which there are fewest blood-vessels. Thus, if the tumor has migrated between the layers of the mesocolon, the incision should be made through the outer peritoneal layer.
Intra-ligamentous cysts often have no pedicular attachments whatever, and may be enucleated without the application of ligature. In other cases a distinct vascular pedicle is found after the peritoneal investment has been opened and its adhesions to the cyst-wall have been separated. ”

“ 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. ”

“ 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. ”

“ It is readily seen that adhesion between the left leaf of this free descending mesocolon and the parietal peritoneum down to the level of the iliac crest would produce the conditions found in the human adult, with an attached descending colon and a free sigmoid flexure ”

“ Inflammation of the peritoneum, when idiopathic, is generally treated by the physician. But it occurs in consequence of wound, obstruction from hernia, or affection of the lower bowels. There is a burning heat in the belly; the pain is constant and increasing, much aggravated by the slightest pressure or exertion of the abdominal muscles, and the patient, in consequence, lies with these muscles in a state of relaxation. ”

“ Peritomous, pe-rit′ō-mus, adj. (min.) cleaving in more directions than one parallel to the axis, the faces being all similar. [Gr. peri, round, temnein, to cut.]
Peritoneum, Peritonæum, per-i-tō-nē′um, n. a serous membrane which encloses all the viscera lying in the abdominal and pelvic cavities.—adjs. Peritonē′al; Peritonit′ic.—n. Peritonī′tis, inflammation of the peritoneum. [Gr. peritoneion—peri, around, teinein, to stretch.]
Perityphlitis, per-i-tif-lī′tis, n. inflammation of the cæcum, appendix, and connective tissue, or of the peritoneum covering cæcum and appendix. ”

“ A diseased texture can affect those near it, but the primitive affection seizes only upon one. I have examined a great number of bodies in which the peritoneum was inflamed either upon the intestines, the stomach, the pelvis, or universally; now very often when this affection is chronic, and almost always when it is acute, the subjacent organs remain sound. I have never seen this membrane exclusively diseased upon one organ,51 while that of the neighbouring ones remain untouched; its affection is propagated more or less remotely. ”

“ After dividing the integuments with a common scalpel, and making a small opening in the peritoneum, I introduced my finger, and with a blunt pointed scalpel divided the peritoneum, so as to make it correspond with the external opening, which was between two and three inches. I then besmeared my hand with oil, and carried it into the abdomen, in order to feel for the indurated part. Scarcely had I introduced my hand, than an attack of the pain came on, and a portion of the intestines was protruded through the wound, which was immediately replaced by my assistant. ”

“ That inflammation of the cellular tissue can exist without also involving the peritoneum in its neighborhood is scarcely to be conceived, and vice versâ; but the one has always a predominating influence over the other, and differs somewhat in its cause, course, and consequences. ”

“ Sometimes the color is rendered very dark by the pitchy blood contained in the veins. The surface of the peritoneum, like all the tissues, is singularly dry, and often has a soapy or sticky feel, caused by a layer of albuminous matter, which forms a lather when rubbed between the fingers, and causes the intestinal folds to adhere to one another. If death takes place during the stage of reaction, these appearances are less distinct, and the intestines, which in collapse are usually retracted, are then somewhat distended. ”

“ Such a hard, freely movable tumor often causes a great deal of peritoneal irritation. A serous fluid may be thrown out by the peritoneum, and a moderate degree of ascites may occur. Adhesions may be formed between the fibroid tumor and contiguous structures—the abdominal parietes, the omentum, or intestines. These adhesions are often exceedingly extensive, firm, and vascular, so that in some cases the tumor derives its chief blood-supply and mechanical support from such adventitious attachments. ”

“ Protection of the Intestines and Omentum.—During all manipulations within the abdomen the peritoneum, intestines, and omentum should be handled most gently. Injury of the peritoneum increases the danger of shock, sepsis, and intestinal adhesions. The intestines should never be allowed to protrude through the abdominal incision unless it is necessary for the performance of the operation. Such a necessity rarely, if ever, arises in gynecological operations. All the intestines may be removed from the field of operation—the pelvis—by placing the woman in the Trendelenburg position. ”

“ Exudation, which was demonstrable both by palpation and percussion. It was the natural consequence of inflammation of the peritoneum, and was both of diagnostic value as indicating general peritonitis and of special value in that, more definitely than the pain, it pointed to the original seat of the affection, which, according to present indications, could only have been an internal incarceration following right-sided inguinal hernia, or femoral hernia, or appendicitis. ”

“ INJECTION OF UMBILICAL HERNIA. Reduce the hernia and examine the margins of the hernial ring with care so as to be thoroughly acquainted with the character and situation of these margins. Remember that the tissues are often very thin and that an injection in the center of the hernia may simply go through the peritoneum and thus be placed directly in the abdomen. Injections of paraffin into the peritoneal cavity of animals have not proven to be dangerous, the agent not causing irritation of the surface of the peritoneum when sterile. ”

“ Rupture of the ureter is a very rare injury. Poland has collected the histories of four cases, one of which ended in recovery after the evacuation by puncture, at intervals, of about two gallons of fluid resembling urine. The other cases terminated in death during the first, fourth, and tenth weeks respectively. Peritonitis was apparently not present in any of the cases, the urinary extravasation having occurred into the cellular tissue behind the peritoneum. ”

“ 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. ”