944 



PERITONEUM. 



The peritoneum passes over the anterior sur- 

 face of the kidneys and suprarenal capsules, but 

 is not usually in immediate contact with them ; 

 a large quantity of loose areolar and adipose 

 tissue being interposed. 



The jejunum and ilium have a complete in- 

 vestment of peritoneum, except along the little 

 linear space where the mesentery is attached to 

 them. 



The ccecum and the ascending and descending 

 colon are always invested with a peritoneal coat 

 in front, and this extends to a variable distance 

 around their sides, sometimes completely cover- 

 ing them except at the little posterior linear 

 spaces where their respective mesenteries, in 

 such cases existing, are attached to them. 



The transverse portion of the colon is com- 

 pletely covered by peritoneum except along two 

 little linear spaces on the opposite sides of it, 

 namely, on its anterior and posterior aspects, 

 where the great omentum and transverse meso- 

 colon respectively, as described above, are 

 attached. 



The sigmoidjiexure of the colon and the first 

 portion of the rectum are invested completely 

 with peritoneum, except along the line of at- 

 tachment of their respective mesenteries. 



The second portion of the rectum has a peri- 

 toneal investment on its front only : its lateral 

 and posterior aspects are destitute of such co- 

 vering. The peritoneum, as above stated, 

 passes across from the rectum to the bladder 

 without descending low enough to afford any 

 investment whatever to the lowermost or third 

 portion of the rectum. The conventional divi- 

 sion of the rectum into three portions is, in 

 fact, founded upon this circumstance of its 

 being first completely, then partially, and lastly 

 not at all invested with peritoneum, as you 

 proceed from above downwards. The summits 

 of the recto-vesical folds landmark the point of 

 junction of the upper and middle portions. 



The whole of the posterior aspect, the fundus 

 and the three upper fourths of the anterior as- 

 pect of the uterus are invested with a peritoneal 

 coat. The os uteri, which projects into the va- 

 gina, the lower fourth of the anterior aspect, 

 which is in immediate contact with the bladder, 

 and the little lateral linear spaces where the 

 broad ligaments are attached, are destitute 

 of it. 



The peritoneum reaches the vagina behind 

 the uterus, and invests a small portion of it in 

 that situation, but does not come into relation 

 with it in front of the uterus. 



The ovary is very closely and completely 

 surrounded with peritoneum, which reaches it 

 at its attachment to the broad ligament; we 

 must in this case as heretofore describe a little 

 linear space, at the point of attachment, as des- 

 titute of peritoneal vestiture. 



The bladder is covered by peritoneum over a 

 different extent in the two sexes. In both male 

 and female its anterior aspect is destitute of 

 peritoneal covering ; and its fundus, in both 

 sexes, has a peritoneal investment equally com- 

 plete : with regard to the posterior aspect, 

 however, in the male, the peritoneum covers it 

 often as far down as the prostate, whilst it leaves 



uncovered a large portion of the lower part of 

 this aspect of the bladder in the female. 



The parietal portion of the peritoneum in- 

 vests the anterior and lateral abdominal walls 

 completely, except at the lower part, where it 

 is borne off from the anterior walls by the 

 bladder and along the linear attachment of the 

 falciform ligament of the liver; the under 

 surface of the diaphragm, except between the 

 layers of the coronary ligament of the liver, and 

 along the linear attachments to it of the falci- 

 form and triangular hepatic ligaments, the 

 phrenico-gastric ligament, and the splenic 

 omentum ; the posterior parietes, except where 

 the viscera, ducts, and vessels enumerated 

 above as invested with the peritoneum on then- 

 front only, intervene. It does rot, however, 

 reach the inferior abdominal parietes, that is to 

 say the levator ani, at any point, a quantity of 

 loose cellular tissue occupying the interspaces 

 of the pelvic viscera between that muscle and 

 the lowest point to which the peritoneum 

 extends. 



NVe now come to the last of our propositions. 



TlIE EXTERNAL OR ADHERENT SURFACE OF 



THE PERITONEUM is attached to the apposed 

 tissues with different degrees of intimacy in 

 different situations a circumstance of great 

 importance with regard to certain surgical 

 operations. This attachment is intimate or 

 otherwise, according as the areolar tissue that 

 constitutes the connecting medium is abundant 

 or scarce, loose or compact, in different situa- 

 tions. The connecting areolar tissue is con- 

 tinuous through the openings in the abdominal 

 parietes with the other areolar sheets of the 

 body. The parietal portion of the peritoneum 

 is strengthened by a fibrous layer, so that 

 abscesses seldom burst through it; whilst the 

 visceral portion, being destitute of this layer, 

 is not unfrequently burst through by abscesses 

 of an abdominal viscus, as the liver. The 

 peritoneum lining the under surface of the 

 diaphragm is the most firmly attached of all 

 the parietal portion. That which lines the 

 anterior abdominal parietes is very intimately 

 adherent along the linea alba and sheath of the 

 rectus, but very loosely just above the pubis 

 and about the internal abdominal ring. It is 

 extremely loosely attached to the posterior 

 abdominal parietes and immediately superjacent 

 organs, and in the lumbar and pelvic regions 

 and iliac fossae a very fortunate circumstance 

 with regard to placing ligatures on the large 

 abdominal and pelvic vessels without laying 

 open the peritoneal cavity. 



The visceral portion, as it covers the liver 

 and spleen and the alimentary tube, is very 

 intimately adherent to them except at the 

 middle portion of the rectum. That which 

 partially covers the bladder adheres very loosely 

 to it; owing to which, together with the loose- 

 ness of the peritoneal attachment above the 

 pubis in front, to the rectum behind, and to 

 itself in the recto-vesical folds, the bladder 

 when distended rises high above the pubis 

 between the abdominal parietes and perito- 

 neum, pushing the latter up so as to diminish 

 the depth of the recto-vesical cul-de-sac and 



