THE PERITONEUM 1269 



peritonitis is not nearly so dangerous as peritonitis in the small intestine or Diaphragm areas, and 

 that peritonitis in the region of the Diaphragm is the most fatal form of the infection. Aftei 

 abdominal operations in infected cases, it is well to elevate the head of the bed (Fowler's position), 

 so as to obtain the aid of gravity in draining septic fluids away from the dangerous region and 

 toward the safer region. 1 In area^ in which absorption is rapid, protective exudation is not apt to 

 form. In areas in which absorption is slow, inflammatory exudation is apt to circumscribe the 

 area and prevent diffusion. After an operation in a noninfected case, if salt solution has been 

 left in the abdominal cavity because of shock or hemorrhage, raising the foot of the bed will aid 

 rapid absorption of the fluid by favoring the natural current toward the Diaphragm and hurrying 

 the fluid to a region in which absorption is rapid. Dr. John B. Murphy's plan of treating general 

 peritonitis has proved remarkably successful. He does not remove the exudation of lymph which 

 is seen upon the peritoneum. This exudation is conservative, blocks up lymph spaces, and lessens 

 the absorption of dangerous toxins. He inserts a drainage tube into the peritoneal cavity above 

 the pubes, puts the patient erect or semierect in bed (Fowler's position), and administers salt 

 solution continuously by low pressure proctolysis. According to Murphy, the lymph circulation 

 is reversed and the peritoneum becomes a secreting surface. Certain it is that the salt solution 

 absorbed from the rectum reaches the peritoneal cavity in large amounts and flows out of the 

 drainage tube. 



The greater omentum stores up fat, and, being movable, it is able to pass to different parts of 

 the peritoneal cavity. Dr. Robinson, in his work on the Peritoneum, describes its functions as 

 follows: "The omentum is the great protector against peritoneal infectious invasions. It builds 

 barriers of exudates to check infection. It is like a man-of-w r ar, ready at a moment's notice to> 

 move to invaded parts. It circumscribes abscesses, it repairs visceral wounds, and prevents 

 adhesions of mobile viscera to the anterior abdominal wall. It resists infectious invasions by 

 typical peritoneal exudates, and not by succumbing to absorbed sepsis. It is a director of peri- 

 toneal fluids, a peritoneal drain." 



In abdominal wounds the greater omentum often protrudes. This structure frequently con- 

 stitutes or is part of a hernia, and is almost invariably present in umbilical hernia. As a result 

 of inflammation, it may become adherent to adjacent structures. Adhesions may be of service 

 by matting together the intestines and circumscribing infections. They may be harmful by 

 constricting the bowels and producing obstruction. A portion of the omentum may become 

 adherent to some other part and form a band, and under this band the gut may be caught and 

 strangulated. The omentum may adhere to and plug a perforation in a hollow viscus, and the 

 surgeon may utilize it for the same purpose, or to cover a raw surface or overlie a suture line. 

 The omentum may be in the surgeon's way while operating. If it is, the patient is placed ia 

 the Trendelenburg position (pelvis elevated). 



Any tear or opening found by the surgeon in the greater omentum must be closed with sutures,, 

 because of the danger that intestine might enter and be caught in such an opening. A tumor 

 cut off from its proper blood supply, for instance, an ovarian cyst with a twisted pedicle, may 

 continue to receive nourishment from adherent omentum, and gangrene may thus be prevented. 



The lax character and shifting tendency of the subserous tissue explains the occurrence of 

 ptosis of the abdominal viscera and kidneys. 



The vast number of nerves in the peritoneum accounts for the profound shock which follows: 

 a wound, attends an intraperitoneal calamity, or which develops from infection. An infective 

 process of any portion of the peritoneum produces pain and reflex symptoms (vomiting, ab- 

 dominal rigidity, intestinal paresis, etc.). 



The parietal peritoneum is' very sensitive to pain, but not to touch; hence, after injecting a 

 local anesthetic and opening the abdomen, a fairly satisfactory exploration can be made with 

 the finger. 



The intestine, the mesentery, the stomach, the anterior margin of the liver, and the gall-bladder 

 are insensitive, and may be cut or even burned without pain. 2 Viscera which obtain their inner- 

 vation purely from visceral nerves are insensitive; those which receive branches from somatic 

 nerves are sensitive (Lennander). 



The oblique origin of the mesentery causes this structure to form a sort of shelf. A hemor- 

 rhage or extravasation into the abdomen, to the right of the mesentery, tends to flow into the 

 right iliac fossa; one occurring on the left side flows into the pelvis. Monks shows how the 

 mesentery can be utilized to determine the direction of an intestinal loop: 



" Now, let us suppose that the surgeon has between his fingers a loop of bowel, and wishes 

 to determine its direction. He knows that one side of the loop is the left side of the intestine, 

 and that the corresponding side of ^the mesentery, if closely followed down to the mesenteric 

 root, will conduct him into the left fossa; he also knows that the other side of the bowel is its 

 right side, and that the mesentery on that side will conduct him into the right fossa. Now, 

 if his finger goes into the great fossa on the left side of the abdomen, after having closely fol- 



1 George R. Fowler, in Medical Record, April 14, 1900. 



2 Dr. K. E. L. Lennander, in Mittheilungen aus dem Grenzgebieten der Medicin und Chirurgie, Band x, 

 Heft 1. 2. 



