Book - An Atlas of Topographical Anatomy 16

From Embryology

XVI. Transverse section of the same body through the transverse colon at the level of the umbilicus and intervertebral space between the third and fourth lumbar vertebra

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Braune W. An atlas of topographical anatomy after plane sections of frozen bodies. (1877) Trans. by Edward Bellamy. Philadelphia: Lindsay and Blakiston.

Plates: 1. Male - Sagittal body | 2. Female - Sagittal body | 3. Obliquely transverse head | 4. Transverse internal ear | 5. Transverse head | 6. Transverse neck | 7. Transverse neck and shoulders | 8. Transverse level first dorsal vertebra | 9. Transverse thorax level of third dorsal vertebra | 10. Transverse level aortic arch and fourth dorsal vertebra | 11. Transverse level of the bulbus aortae and sixth dorsal vertebra | 12. Transverse level of mitral valve and eighth dorsal vertebra | 13. Transverse level of heart apex and ninth dorsal vertebra | 14. Transverse liver stomach spleen at level of eleventh dorsal vertebra | 15. Transverse pancreas and kidneys at level of L1 vertebra | 16. Transverse through transverse colon at level of intervertebral space between L3 L4 vertebra | 17. Transverse pelvis at level of head of thigh bone | 18. Transverse male pelvis | 19. knee and right foot | 20. Transverse thigh | 21. Transverse left thigh | 22. Transverse lower left thigh and knee | 23. Transverse upper and middle left leg | 24. Transverse lower left leg | 25. Male - Frontal thorax | 26. Elbow-joint hand and third finger | 27. Transverse left arm | 28. Transverse left fore-arm | 29. Sagittal female pregnancy | 30. Sagittal female pregnancy | 31. Sagittal female at term
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THE section in this case passes through the navel dividing the soft parts just above the iliac crest, and the inter- vertebral space between the third and fourth lumbar vertebras. The ribs are no longer seen, and the section is now below the thorax and through the middle of the abdomen. The walls of the abdominal cavity are formed, anteriorly and laterally entirely by the three oblique muscles, behind by the quadratus lumborum and the strong ligaments together with the psoas magnus of both sides. The posterior wall, where no spinous processes are visible, is very thick and strong, and formed by the mass of the dorsal muscles. The contents of the abdominal cavity are the great vessels and ureters, the ascending transverse and descending colon, and the small intestines. The contents of the intestines were carefully removed in order to allow of these viscera being accurately represented in situ. The section is from the same body as the preceding, and is taken about two inches lower down.


Before explaining the details here represented, I have to make some few remarks on the kidneys. They lie entirely above this section and within the region of the ribs, higher than is frequently supposed, and as many are accustomed to seek them. Hence their position may be considered as an independent one as regards the movements of the diaphragm or enlargements of the liver and spleen. I think I can prove that in both respects the relations are otherwise, and that the position of the kidneys is unchangeable.


Both kidneys extend over the bodies of three and a half vertebras, and reach from the upper border of the twelfth dorsal downwards to the middle of the third lumbar ; and it is to be remarked that they do not lie exactly on the same level, but that the left rises somewhat higher than the right.


According to Luschka (Anat., ii, 1, p. 289), they usually lie higher, viz. from the middle of the eleventh dorsal to the lower border of the second lumbar vertebra. I do not lay any stress on this, and I think that these statements may be regarded as coinciding with mine, since half a vertebra makes but little difference. The hilus lies at the level of the first lumbar vertebra, and corresponding with it is the position of the renal vessels in Plates I and II. Pirogoff gives the same (fasc. iv, tab. 4 9) ; but through the hilus in front of the first lumbar vertebra. The upper margin within which the kidneys are divided is determined by the eleventh dorsal vertebra ; the lower by the cessation of the section of the ribs, and corresponds nearly with the third lumbar vertebra.


But the relations are different if there be depression of the diaphragm, or enlargement of the liver and spleen. The kidneys are then pushed out of their position, and undergo a dislocation, which may amount to the extent of several vertebras. In a pleuritic exudation of the right side no kidney is to be seen at the middle of the twelfth dorsal vertebra, Pirogoff (iii, 6, 3) : and in the man of fifty years, with enlargement of the liver and spleen as I have before mentioned, the hilus, as in the woodcut, fig. 1, is met with at the level of the fourth lumbar vertebra. The kidneys were also here directly pushed downwards on to the soft parts.


As regards the intestines, in Plate XYI, the inferior portion of the colon is in front ; behind and on the left side the contracted descending colon ; posteriorly and on the right the ascending colon more distended.


Both the ascending and descending colon lie in the angle formed by the psoas magnus and quadratus lumborum. More in the middle of the cavity of the abdomen are coils of small intestine, though not so many as one might expect. From the descending colon to the anterior border of the transverse colon is seen the cut surface of the great bag of the peritoneum passing across to the ascending colon.


It is remarkable that the intestines should show such extreme differences in calibre. According as they are empty, full, or distended with gas, they exhibit a larger or smaller cut surface. The ascending and transverse colons are large, and so also is a coil of small intestine, which has considerably compressed the end of the latter.


The other portions of the small intestine are only slightly distended ; and the descending colon is nearly empty.


FIG. 1. Male, set. 50. Dislocation of the kidneys. .

1. Kidney. 2. Vena cava inferior. 4. Abdominal aorta.

The vertebra shown is the fourth lumbar.


The following woodcut from Pirogoff (iii, 10, 1), which represents all the intestines fully distended, does not correspond with the natural state of things, but is the result of excessive and equally distributed artificial distension.


Pirogoff states that by inflating the intestines of a subject in all respects normal, before freezing it, he has completely distended the abdomen.


The external contour of the abdominal walls corresponded with this artificial distension of the intestines. This contour is almost in the form of a circle, whereas mine corresponds with the normal relations, and presents a flat oval. It will be observed from the condition of the oblique muscles how considerably the distension of the abdominal walls has compressed them ; and we can estimate from their stretching and thinning the form they must assume in pregnancy, ovarian tumours and ascites, and regulate the depth of an incision when required.



FIG. 2. Male adult. The intestine inflated with air and greatly distended. Pirogoff, iii, 10, 1. 5.

1, 1. Inferior margins of the kidneys. 2. Abdominal aorta. 3. Inferior vena cava. 4. Ascending colon. 5. Descending colon.


We must notice the position of the spinal column. As in Plate XYI the intervertebral substance lies nearly in the middle of the circle, while in PirogofFs plate the position of the vertebra is far behind it.


The distance of the anterior wall of the abdomen from the spine in Plate XVI is nearly 3 inches ; in fig. 1, 2*5 inches ; and in Pirogoff s nearly 6 inches, the section passing immediately below the navel.


A less distance between the spine and the abdominal walls than that shown in Plate XVI is not uncommon. This depends on the position of the diaphragm and the contraction of the lung on the one hand, and on the distension of the intestines on the other : and it is easily understood how, with normal lungs and empty intestines, the abdomen in the dead body can be pressed in so much, and the lumbar vertebra present such a marked prominence through the abdominal walls, the distance being thus reduced to a minimum.


Therefore, in compressing the abdominal aorta, care must be taken to obtain a high position of the diaphragm, and that the intestines be as empty as possible. This compression is indispensable, for example, in disarticulation of the head of the thigh-bone. Pressure must be brought to bear immediately in the region of the navel, as the aorta divides just below the umbilicus, and still further downwards the finger would fall into the pelvis.


Lying near is the aorta in the middle line, and the cava, which is more to the side, also the ureters, and close to them and more externally the spermatic vessels. Behind and partly internal to the psoas are the sections of the lumbar nerves.


The oblique muscles are divided immediately above the crest of the ilium. The relations of their tendons to the sheaths of the rectus abdominis and quadratus lumborum are so clearly shown in the plate that we need not refer to them again. The anterior iliac spines spring forward as projections in the external contour.


It remains now to describe the position of the descending colon, and the operation for opening it, which is practicable in this region without wounding the peritoneum. This proceeding was described by Callisen, but was first performed by Amussat in 1839, and it afterwards obtained the name of Callisen- Amussat 's operation for artificial anus.


This operation is preferred by most surgeons to that of opening the iliac flexure in the left inguinal region (Littre), as the descending colon has a fixed position, and, being incompletely invested by peritoneum, an incision can be made into it without wounding this membrane. It is usually stated that the descending colon lies along the outer border of the quadratus lumborum ; and, in conformity with this, an incision is to be made vertically along the outer border of this muscle. This is not always correct. At the lower border of the kidney the colon lies further outwards than it does in the neighbourhood of the ilium ; and, the quadratus lumborum being narrower above than below, the rule is true as far as regards the level of the third lumbar vertebra, but not so for the deeper regions. At the level of the symphysis between the third and fourth vertebra, and at the fourth below the kidney and therefore exactly in the field of operation the quadratus lumborum covers in the colon posteriorly,- and must be cut in order to reach it. It is only when much distended, a condition which is not so constant as one would expect in operations, that the intestine increases in breadth forwards and inwards, or overlaps the outer border of this muscle (PirogofF, iii, B., tab. 14). Consequently the incision, which is to be directed along the border of the great extensors of the trunk from the ilium to the twelfth rib, would divide the strong tendons of the transversalis until the quadratus is exposed, and subsequently the fibres of this muscle, when the extra-peritoneal fat and cellular tissue would be met with.


When the surgeon has carefully arrived at the cellulo-fatty tissue through the fascia beneath the quadratus lumborum, making the incision of an equal length with the primary one, so as to avoid a funnel-shaped wound, the main point is to fix the colon at its free surface and to open it. In doing so he must avoid the kidney, which from its deep position (cf., fig. 1) can easily obstruct the field of operation, and which must therefore be carefully pushed on one side. From the impossibility of recognising the peritoneum from its posterior aspect, success can only be safely calculated on by measuring the distance of the point of reflection of the peritoneum, and how far from the colon this position is constant.


In the first place, as regards the descending colon, which I here particularly refer to, after measurements on frozen bodies of full grown men, I find that this distance, in a straight line (therefore not corresponding with the curvature of the wall of the intestine), is from four fifths of an inch to one inch, supposing the intestine empty and contracted (at a level between the third and fourth lumbar vertebraa) ; further, that the free side of the intestine, as in Plate XVI, does not look posteriorly but somewhat inwards, exactly towards the angle which the psoas and quadratus lumborum make with each other. If, on the otheiv hand, the small intestines are much distended, the peritoneum between the psoas and colon would be pushed further downwards ; and the colon, by means of the traction of the parietal portion of the peritoneum, would be rotated on its axis, so that its free surface would be directed more outwards.


Should the colon itself be distended, its surface free of peritoneum becomes considerably larger, and may assume a breadth of from 2 to 2' 5 inches. Tympanitis of the small intestine appears to have a rotatory influence on the distended colon ; and on comparing Pirogoff's plates it is shown with its free surface turned somewhat outwards (cf. Pirogoff, iii, B, tab. xiv).


In the performance of the operation of colotomy a distended abdomen will probably often be met with. I therefore do not consider these remarks superfluous, and I hope that they may contribute to make the avoidance of the peritoneum more certain than heretofore where it was so much left to chance ; and, as a third part of the cases show wound of this membrane, the value of Amussat's method appears problematical.



Historic Disclaimer - information about historic embryology pages 
Mark Hill.jpg
Pages where the terms "Historic Textbook" and "Historic Embryology" appear on this site, and sections within pages where this disclaimer appears, indicate that the content and scientific understanding are specific to the time of publication. This means that while some scientific descriptions are still accurate, the terminology and interpretation of the developmental mechanisms reflect the understanding at the time of original publication and those of the preceding periods, these terms and interpretations may not reflect our current scientific understanding.     (More? Embryology History | Historic Embryology Papers)
Braune Plates (1877): 1. Male - Sagittal body | 2. Female - Sagittal body | 3. Obliquely transverse head | 4. Transverse internal ear | 5. Transverse head | 6. Transverse neck | 7. Transverse neck and shoulders | 8. Transverse level first dorsal vertebra | 9. Transverse thorax level of third dorsal vertebra | 10. Transverse level aortic arch and fourth dorsal vertebra | 11. Transverse level of the bulbus aortae and sixth dorsal vertebra | 12. Transverse level of mitral valve and eighth dorsal vertebra | 13. Transverse level of heart apex and ninth dorsal vertebra | 14. Transverse liver stomach spleen at level of eleventh dorsal vertebra | 15. Transverse pancreas and kidneys at level of L1 vertebra | 16. Transverse through transverse colon at level of intervertebral space between L3 L4 vertebra | 17. Transverse pelvis at level of head of thigh bone | 18. Transverse male pelvis | 19. knee and right foot | 20. Transverse thigh | 21. Transverse left thigh | 22. Transverse lower left thigh and knee | 23. Transverse upper and middle left leg | 24. Transverse lower left leg | 25. Male - Frontal thorax | 26. Elbow-joint hand and third finger | 27. Transverse left arm | 28. Transverse left fore-arm | 29. Sagittal female pregnancy | 30. Sagittal female pregnancy | 31. Sagittal female at term

Reference

Braune W. An atlas of topographical anatomy after plane sections of frozen bodies. (1877) Trans. by Edward Bellamy. Philadelphia: Lindsay and Blakiston.


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Cite this page: Hill, M.A. (2019, September 21) Embryology Book - An Atlas of Topographical Anatomy 16. Retrieved from https://embryology.med.unsw.edu.au/embryology/index.php/Book_-_An_Atlas_of_Topographical_Anatomy_16

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