Jones Quain.

Quain's Elements of anatomy (Volume 3:4) online

. (page 40 of 44)
Online LibraryJones QuainQuain's Elements of anatomy (Volume 3:4) → online text (page 40 of 44)
Font size
QR-code for this ebook


Krause, W., Anatomischc Untersuchungen, Hannover, 1860.

Luschka, W. , Stcissbc in druse oder Nerrendriise des Be.cke.ns, Arch. f. path. Anat., xviii. , 1860;
Der J/irnanhang u. die Stcissdriise des Mer.schen, Berlin, 1860 ; Anatomied. menschl. Beckens, 1864 ;
Ueber die driisenartige Natur des Svyenannten Ganglion intercaroticum, Arch. f. Anat. u. Phys., Anat.
Abth., 1862.

Marchand, Beitr. znr Kcnntniss d. normal, u.pathol. Aiiat. der Glandula carotica u. d. Neben-
nieren, Festschr. z. R. Virchow, Bd. i., Berlin, 1891.

Pfortner, Unters. it. d. Ganglion intercarot. u. d. Nebennieren, Zeitschr. f. ration. Med., xxxiv., 1869.

Prenant, A., Contrib. a I'e'tude du de"vcloppcment organique et hitttologiquc du thymus, dc la
glande thyroidc et de la fjlancle carotidienne, La Cellule, t. x., 1894.

Schaper, Beitr. z. Histologie der Glandula carotica, Arch. f. mikr. Anat., Bd. xl., 1892.

Sertoli, Ueber die Structur der Steissdriise des Menschen, Arch. f. path. Anat., xlii., 1868.

Stieda, Unters. il. d. Entwickl. d. Glandula thymus, Glandula thi/roidec, u. Glandula carotica,
Leipzig, 1881.

Stilling 1 , Du ganglion inter carotidien, Rec. inaug., Lausanne. 1892.




THE PERITONEUM.



BY J. SYMINGTON.



THE abdominal viscera having been described, as well as the disposition of the
peritoneum in relation to each of them, it remains to give an account of that
membrane in its whole extent, and to trace its continuity over the various parts
which it lines or covers.

The peritoneum lines the whole of the anterior abdominal wall, except along a
narrow line extending from the umbilicus upwards to the diaphragm, and corre-
sponding to the interval between the two layers of the falciform ligament of the liver.




I'oupart'g liga

inent .
anterior crural

nerve



obi. hypugitstri
artery .



fovea feinoralis



Fig. 331. VIEW FROM BEHIND OF THE LOWER PART OF THE ANTERIOR ABDOMINAL WALL AND OF
THE BLADDER. (Gr. D. T., after Joessel. )

This peritoneal fold is usually attached to the abdominal wall slightly to the right
of the median plane. For a short distance above the pubis the peritoneum is loosely



820



THE PERITONEUM.



connected with the abdominal wall, so that when the bladder becomes distended with
urine the serous membrane is detached from the lower part of the abdominal wall. This,
however, can only occur to a limited extent, since the peritoneum as it passes upwards
A \\ towards the umbilicus becomes gradually more

firmly adherent to the abdominal wall. In
cases of great distension of the bladder an area
above the pubic symphysis, two inches in ver-
tical extent, may be uncovered by peritoneum.
Between the anterior wall of the pelvis
and the umbilicus the peritoneum is raised




into five vertical folds, with intervening-
depressions, by certain structures which con-
verge towards the umbilicus. These folds are
a median one, caused by the urachus, and two
lateral, on each side, formed by the obliterated
hypogastric artery and the deep epigastric
artery (see fig. 331). The depression on the
outer side of the deep epigastric artery cor-




Fig. 332 A. DIAGRAMMATIC OUTLINE OP A SUPPOSED SECTION OF THE BODY, SHOWING THE INFLECTIONS

OF THE PEKITONEUM IN THE FEMALE. (Allen Thomson.) 1

The upper part of the section is a little to the right of the median plane in the body, through the
quadrate and Spigelian lobes of the liver : below these it is supposed to be median : I c, placed above the
diaphragm opposite to the coronary ligament of the liver ; I, hver ; I', lobe of Spiegel ; s, stomach ; c,
transverse colon ; i, small intestine ; pa, pancreas ; a, aorta ; d, duodenum ; v, urinary bladder ; u,
uterus ; r, rectum ; r', its lower part opened ; v a, vagina ; p, p, the parietal peritoneum lining the
front and back of the abdominal cavity. The line representing the inflections of the greater sac of the
peritoneum will be traced from the neighbourhood of I c, where it passes from the diaphragm to the
upper surface of the liver, over the upper and lower surfaces of that organ, forming the front of g h, the
gastro-hepatic oaientum, over the front of the stomach down to o', the outer layer of the great omentum ;
thence passing back to the vicinity of the pancreas, and descending again as the upper layer of the trans-
verse mesocolon. After enclosing the colon it returns as the lower layer of the transverse mesocolon,
m c, to the root of the mesentery, m ; it now forms the mesentery and incloses the small intestine,
returning to the posterior wall of the abdomen, whence it passes over the rectum, r, descends into the
recto-vaginal pouch, u', covers the back and front of the uterus and the bladder partially, and regains
the anterior abdominal wall above the pubis. In connection with the lesser sac of the peritoneum, w
marks the position of the foramen of Winslow as if seen beyond the section ; the lesser sac, with the
cavity of the omentum, is shaded with horizontal lines, and is marked o o ; round this space the line of
the peritoneum may be traced from the diaphragm over the lobe of Spiegel, to the back of the gastro-
hepatic omentum, thence behind the stomach and down into the great omentum ; it then ascends to the
pancreas, which it covers, and thence reaches again the diaphragm.

Fig. 332 B is a sketch of part of a section similar to that of A, but showing a condition more com-
monly found in the adult, according to which the two layers of the mesocolon are continuous with the
posterior pair of the layers of the great omentum.



THE PERITONEUM. 321

responds to the internal abdominal ring, that internal to the artery to Hesselbach's
triangle, while the one below Poupart's ligament is opposite the femoral ring.
The significance of these pouches will be found described in connection with the
anatomy of the groin (see separate Appendix).

After lining the anterior wall of the abdomen, the peritoneum passes round on
each side to the lumbar and iliac regions, where it meets with the right and left
portions of the large intestine. On the right side it completely invests the caecum
and its vermiform appendix, and it also provides the latter with a mesentery. Higher
up it covers the ascending colon in front and on the outer side, the remaining part
of the circumference of the bowel being usually uncovered.

Leaving the right colon, the peritoneum gives a scanty covering to the lower
part of the anterior face of the right kidney and adjoining third portion of the
duodenum where that intestine comes down from behind the transverse mesocolon ;
lower down it continues over muscles and vessels to the root of the mesentery,
proceeds forwards to form the right layer of that fold, passes round the jejunum
and ileum, affording them their peritoneal coat, and returns back to the vertebrae,
thus completing the mesentery on the left side. The membrane now passes in front
of the lower portion of the left kidney to the left colon, which it invests much in
the same manner as the right, and is then continued over the lateral wall on the left
side to the front again, thus completing a horizontal circuit round the abdomen.
Although the descending colon is usually uncovered behind and on its inner side,
yet occasionally it is entirely invested by peritoneum and provided with a mesocolon.
The frequency, however, with which a descending mesocolon occurs has been much
exaggerated.

Where the colon forms its sigmoid loop it is completely invested by peritoneum,
which attaches it by a comparatively free and moveable sigmoid mesocolon to the
fascia of the left iliac fossa.

From this part, and from the lower end of the mesentery the peritoneum is con-
tinued into the pelvis. It there invests the upper part of the rectum completely,
forming a mesorectum behind. Lower down the membrane gradually quits the
intestine, first behind, then at the sides, and finally in front, whence it is reflected
on the base and upper part of the bladder in the male, and forms here the recto-
vesical pouch, the mouth of which is bounded by a crescentic fold on each side,
named plica semilunaris. From the apex of the bladder the peritoneum passes on
to the urachus as already described. In the female the peritoneum passes from the
rectum to the upper part of the vagina, and over the posterior surface, the fundus,
and upper part of the anterior surface of the uterus, whence it goes to the bladder.
The recto-vaginal -pouch (pouch of Douglas), like the recto- vesical, is bounded above
by its semilunar folds, and the uterine peritoneum forms at the sides the broad liga-
ments of the uterus, along the upper border of which the Fallopian tubes receive
from it a serous covering ; at their fimbriated openings the peritoneum is con-
tinuous with the mucous membrane lining the tubes.

The peritoneum, on being traced to the upper part of the abdomen, is found to
line the vault of the diaphragm, adhering moderately to the muscular and firmly to
the tendinous part, and continuing down behind as far as the hinder surface of the
liver and the O3sophageal opening. It then passes forwards on to the liver, forming
the falciform, coronary, and lateral ligaments of that organ, already specially
described.

Turning round the anterior border it passes back on the under surface ; but, after
covering the quadrate lobe, and arriving at the transverse fissure, it meets with a
peritoneal layer from behind, and in association with it, stretches from the liver to
the stomach, to form the lesser omentum, as will be presently explained. To the
right of this part it invests the gall-bladder more or less completely, and the under

VOL. III. PT. 4. Y



322



THE PERITONEUM.



surface of the right lobe of the liver, covers anteriorly the adjacent part of the
duodenum, and passes to the upper end of the right kidney, forming here a slight
fold, named hepato-renal ligament. It then invests the hepatic flexure of the colon
and reaches the right colon, on which it has been already traced. To the left of the
longitudinal fissure the peritoneum invests the whole of the left lobe of the liver, and
stretches out as the long left lateral ligament above and beyond the cesophageal
opening. It then passes down over that opening and covers the front and left side



vr




Fig. 333. FRONT VIEW OP THK VISCERA OF THE UPPER PART OF THE ABDOMEN IN A CHILD. (Henle. )

The liver is drawn upwards in order to show its under surface and the small omentum, together
with the entrance of the foramen of Winslow, into which a probe is passed.

A, quadrate lobe of liver ; S, left lobe ; D, right lobe ; Lt, ligamentum teres with its peritoneal
covering forming the falciform ligament ; V, stomach ; Ct, transverse colon ; D', duodenum ; 1, small
omentum ; 2, part of great omentum ; 3, right part of small omentum, its anterior layer being divided
to show its contents, viz., Ah, hepatic artery ; Vp, portal vein ; Dch, common bile-duct ; Dh, hepatic-
duct ; and DC, cystic duct ; 4, peritoneum reflected from the liver over the upper part of the right
kidney, or hepato-renal ligament.

of the gullet, spreads over the left end of the stomach, where it passes off to invest
the spleen, forming a dnplicature named the gastro-splenic ligament, or g astro-splenic
omentum, for it is connected below with the great omentum, and often reckoned as
a part of it. When the membrane passes from the diaphragm to the stomach it
forms a small duplicature to the left of the oasophagus, named the gastro-phrenic
ligament; it extends also as a generally stout and well-marked fold (the costo- or
phreno-colic ligament) from the diaphragm opposite the tenth and eleventh ribs
to the splenic flexure of the colon, then passes over the splenic flexure, and reaches
the left kidney and descending colon, where it has been already described.

Omenta. The arrangement of the remaining part of the peritoneum that



THE PERITONEUM. 323

between the stomach, liver, and transverse colon is somewhat complex, in conse-
quence of the membrane forming in this situation a second and smaller _sac, which
communicates towards the right with the general cavity by a narrow throat, named
the foramen of Winslow. This passage, which readily admits two fingers, is situated
behind the bundle of hepatic vessels which stretches between the liver and duodenum ;
behind the orifice is the inferior vena cava ; above is the caudate lobe of the liver ;
and its lower boundary is formed by the duodenum and a curve of the hepatic
artery. From this opening the lesser sac spreads out to the left behind the general
or main sac of the peritoneum. It covers a part of the posterior abdominal wall,
but in front and below it is applied to the back of the main sac, to which it adheres
except where the stomach is interposed. Moreover, it indents, as it were, the back
of the main sac, and between the stomach and colon protrudes into it in the form of
a great pouch the bag of the omentum, which thus has a double coat, formed by
the apposition of the membranes of both sacs. To trace this arrangement more
particularly : suppose a finger pushed into the foramen of Winslow, and the thumb
brought to meet it from before, to the left of the hepatic vessels ; the membrane
held between is double ; its anterior layer (from the greater sac) turns round the
hepatic vessels into the foramen, and then belongs to the lesser sac. The double
membrane, so constituted, is the small or gastro-hepatic omentum. From the
point indicated it may be followed to the transverse fissure of the liver, where its
laminae separate, the anterior, which has already been traced from above, spreading
on the adjacent part of the liver, the posterior covering the Spigelian lobe, where
it will be again met with. The attachment of the combined layers continues back-
wards from the left end of the transverse fissure along the fissure of the ductus
venosus to the diaphragm on which it runs a short way to reach the oesophagus,
where the anterior lamina covers the end of that tube in front and on the left, and
the posterior lamina invests it on the right and behind, From this point, as far as
the pylorus, the small omentum is attached to the lesser curvature of the stomach,
where its laminas separate one covering the anterior and the other the posterior
surface of the organ but meeting again at the great curvature, they pass down in
conjunction to a variable distance before the small intestine to form the anterior
part of the great omental sac, and then turn up to form its posterior wall. Meeting
next with the transverse colon, the two laminae separate, and enclose that intestine,
but meet again behind it to form the transverse mesocolon. This extends back to the
anterior border of the pancreas, from which its inferior layer passes backwards over
the inferior surface of this organ and then turns downwards over the posterior wall
of the abdomen, and forms the mesentery, where it has been already recognized.
The superior layer, on the other hand, which, as will be understood, belongs to the
lesser sac, covers the front of the pancreas, the coeliac artery and its main divisions,
the upper part of the left kidney, and the portion of the diaphragm between the
aortic and caval orifices, and may extend to the left end of the pancreas and gastric
surface of the spleen, partially investing the latter organ and forming part of the
gastro-splenic omentum. It then goes forward on the Spigelian lobe to the trans-
veise fissure, and the line of attachment of the lesser omentum of which it then
becomes the posterior layer. More to the right the layer in question passes over the
vena cava, and continues into the general peritoneum beyond the foramen of Wins-
low. The gastric and hepatic arteries, especially the former (Htischke), may raise
the membrane into folds which project into the cavity.

From the description given it will be understood that, as the sides or walls of
the great omental bag consist of two peritoneal layers, its whole thickness (in its
usually empty and collapsed state) will comprehend four layers. But although the
bag may be inflated in its whole extent in the infantile body, its sides afterwards
cohere, and it becomes impervious in its lower part. Fat, moreover, accumulates

Y 2



324



THE PERITONEUM.



between its laminas ; long slender branches also pass down into it from the gastro-
epiploic vessels.

The part of the membrane just described, which is attached to the great curva-
ture of the stomach and transverse colon, and which is connected also with the
gastro-splenic ligament (or omentum), is usually named the great or gastro-colic
omentum. This may reach the hepatic flexure and pass a certain way down on the
right colon, and this part has been distinguished by Haller and others as the omentum
colicum. The great omentum (proper) usually reaches lower down at its left border,
and it is said that omentum inguinal hernias are more common on the left side.



UA



i-T



HA




spi



spi



Fig. 334.- -DIAGRAM OF A HORIZONTAL SECTION THROUGH THE ABDOMEN AT THE LEVEL OF THE
FORAMEN OF WINSLOW. (E. J. GodleC. )

LI, first lumbar vertebra ; 12, 11, 10, &c., successive ribs ; r, rectus muscle ; eo, external oblique ;
Id, latissimus dorsi ; spi, serratus posticus inferior ; i, intercostal muscles ; cs, erector spinae ; ms,
multifidus spins ; ps, psoas ; d, diaphragm.

Ao, aorta ; V.C, inferior vena cava ; C A, coronary artery ; S A, splenic artery ; S V, splenic vein ;
S, splenic vessels cut as they enter the spleen ; H A, hepatic artery ; P V, portal vein ; B D, commou
bile duct.

L, liver ; L T, ligamentum teres or round ligament of the liver ; St, stomacli ; Sp, spleen ; P,
pancreas ; K, kidney ; L S, large sac of peritoneum ; S S, small sac ; S 0, small omentum ; G S 0,
gastro-splenic omentum ; F W, foramen of Winslow ; PI, pleura.

The peritoneum is represented by a thick dark line. It can be traced from the middle line anteriorly,
where it is seen investing the round ligament of the liver and forming the commencement of the falci-
form ligament, along the right side of the abdominal wall, over the front of the right kidney, to the
inferior vena cava where it forms the posterior boundary of the foramen of Winslow ; from the latter
spot the small bag extends over the pancreas and left kidney nearly as far as the spleen, and then is
reflected backwards along the back of the small omentum to the front of the foramen ; here becoming
large bag again, it turns round the hepatic vessels, forms the anterior layer of the small omentum,
covers the front of the stomach, forms the gastro-splenic ligament or omentum as it is reflected on to
the spleen, which it invests almost completely, and is thence continued along the diaphragm and
abdominal wall back to the middle line.



The description now given of the relation of the omentum to the mesocolon
agrees with the appearances most frequently seen in the adult subject, the exterior
(here also posterior) layer of the great omentum being described as separating from
the layer within, belonging to the omental sac, when it reaches the transverse colon
so as to pass behind or below that viscus, and as proceeding thence backwards to the
abdominal wall as the posterior or lower layer of the transverse mesocolon. In the
young foetus, however, two layers of peritoneum pass from the greater curvature of
the stomach upwards and backwards to the posterior abdominal wall forming the
mesogastrium, and the transverse colon possesses an independent mesocolon. Sub-



THE PERITONEUM.



325



sequently the posterior layer of the mesogastrium fuses with the anterior layer of
the transverse mesocolon (see Development, Vol. I., Pt. I., p. 107). _0ccasionally
in the child, and even in the adult, these layers remain distinct.




Fig. 335. TRANSVERSE SECTION THROUGH THE ABDOMEN OF A F<ETUS 3J INCHES LONG. (J. S. )
V, body of lumbar vertebra ; K, left kidney ; B.C., descending colon ; P, peritoneum.

Various peritoneal fossae or pouches are often found on the posterior wall of the
abdomen. They are of importance surgically on account of the fact that portions



8. A.



S. F.



D. C.




Fig. 336. VIEW OP INTER-RIGMOID FOSSA. THE PELVIS HAS BEEN DIVIDED IN A CORONAL PLANE

OPPOSITE THE BOTTOM OP THE REOTO-VESICAL POUCH, AND THE SIGMOID LOOP HAS BEEN TURNED
UPWARDS AND TO THE RIGHT. (JenneSCO.)

D. C., descending colon ; S. F., sigmoid colon ; R., rectum covered by peritoneum ; R 1 , rectum un-
covered by peritoneum ; R.V. , recto-vesical fold of the peritoneum; S. A., branches of the sigmoid
artery ; L. U., left ureter ; I. V., external iliac artery and vein ; H. A., obliterated hypogastric artery.

of the intestine are liable to become lodged in them, giving rise to retro-peritoneal
hernias.

Several of these fossae are found in relation with the csecum and have already
been described (see p. 111). Another fossa, the inter-sigmoid, is very commonly met
with during the fifth and sixth months of foetal life. This recess is funnel-shaped and
opens below, behind the root of the mesentery of the sigmoid colon. It extends
upward for a variable distance along the course of the ureter. In the young foetus (see
fig. 335) the descending colon is connected by a relatively long mesentery to the



326



THE PERITONEUM.



posterior abdominal wall near the median plane. The posterior layer of the
descending mesocolon eoon unites with the peritoneum in front of the kidney, but
internal to this organ the fusion of the two layers of peritoneum does not occur .so
readily, hence the formation of a tubular recess, which communicates below with
the general peritoneal cavity. This fossa is only occasionally met with, in a wel
developed condition, in the adult. Several fossae, duodenal and duodeno-jejunal, are



IM V



SDF




M D

Fig. 337. SUPERIOR AND INFERIOR DUODENAL FOSS-E. THE TRANSVERSE COLON AND THE GRKAT

OMENTUM HAVE BEEN TURNED UPWARDS AND THE CONVOLUTIONS OF THE JEJUNO-ILEUM TO THE

RIGHT SIDE. (Jonnesco. )

J, upper end of jejunum ; M, the mesentery ; D, terminal or 4th part of duodenum ; SDF,
superior duodenal fold of peritoneum ; S F, superior duodenal fossa ; 1 1) F, inferior duodenal fold ;
I F, inferior duodenal fossa ; I M V, inferior mesenteric vein ; L C A, left colic artery.

sometimes present near the termination of the duodenum. According to Jonnesco
there are five varieties of fossae met with in this region ; viz., inferior duodena!,
superior duodenal, retro-duodenal, para-duodenal, and duodeno-jejunal. The most
frequent of these fossae, inferior duodenal, lies on the outer side of the terminal part
of the duodenum and has its orifice above. It is bounded anteriorly by a thin fold
of peritoneum, which is attached to the posterior abdominal wall along a vertical
line to the left of the duodenum, while on the right side it is attached to the
duodenum. This fold possesses an upper, free and somewhat crescentic margin. In
other cases the fossa, superior duodenal, has its orifice directed downwards, or these
two fossae may both occur in the same subject (see fig. 337).

For the recent literature of the Peritoneum, see pp. 69, 70.



INDEX AND GLOSSARY TO VOL. III., PT. IV.



ABDOMEN, 68
Abdominal mammae, 291

regions, 68

surface of bladder, 209

viscera, 68

Aberrant biliary ducts, 1 36
Accessory bronchi, 178

liver, 128

lobes of lung, 176

mammse, 291

pancreas, 142

pancreatic duct, 142

spleen, 296

suprarenal capsules, 305

thyroids, 312, 313
Adarnantoblasts (a5a/xas, adamant ; 8\a.<TT6s,

germ), 43, 45, 46
Adams on prostatic secretion, 250
Admaxillary glands, 19
Adrenals (ad, near to ; renes, kidneys), 302
Aeby on calibre of trachea, 162

eparterial bronchial tube, 177
morphology of pulmonary lobes, 176
Agminated glands, 95
Air-cells of lung, 181
Ala (wing) of thyroid cartilage, 147
Albumen of ovum, 279
Albuminous or serous alveoli, 19
Alimentary canal, i

literature of, 69
Alveolar passage, 181

Alveoli (alveolus, small hollow or bowl), dental,
formation of, 48

of fcetal lung, 184

of lung, 181, 183

mammary, 288

mucous, 19

of parotid gland, 19

of salivary glands, 18, 22

serous or albuminous, 19, 20

of snblingual gland, 19
Alveolo-labiaJ sulci, I
Alveole-lingual snlcus, 4
Amphibia, dentition of, 29

larval epithelial teeth of, 38

pulmonary capillaries of, 185
Ampulla (flask-shaped vessel) of Fallopian tube,
269, 270

rectal, 116

of vas deferens, 233
Ampullae of galactophorous ducts, 288
Amygdalae (almonds), 59
Anal canal, 1 16
Ante -prostatic gland, 247
Antrum pylori, 72
Anus (ring), 116



Apex of lung, 174

of prostate, 247



Online LibraryJones QuainQuain's Elements of anatomy (Volume 3:4) → online text (page 40 of 44)