Mesenteric Principles of

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MESENTERIC PRINCIPLES OF
GASTROINTESTINAL
SURGERY BASIC AND
APPLIED SCIENCE
MESENTERIC PRINCIPLES OF
GASTROINTESTINAL
SURGERY BASIC AND
APPLIED SCIENCE
CRC Press
Taylor & Francis Group
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Version Date: 20160812

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There is nothing new under the sun.
Ecclesiastes 1:4-11

I could be bounded in a nutshell, and count myself

a king of infinite space.
Hamlet, Act II, Scene 2

To Dee

and

Victor Warren Fazio

Master without peer
Contents

Preface ix
How to access three-dimensional models using QR codes xi
Acknowledgments xiii

PARt 1 1

1 History 3
J. Calvin Coffey and Nicola O’Riordan
2 Mesenteric and peritoneal anatomy 11
J. Calvin Coffey, Peter Dockery, Brendan J. Moran, and Bill Heald
3 Embryologic development of the mesentery, peritoneal reflection, and Toldt’s fascia 41
J. Calvin Coffey, Rishabh Sehgal, and Joep Knol
4 Histology of the mesentery 47
J. Calvin Coffey, Miranda Kiernan, and Leon G. Walsh
5 Toldt’s fascia 57
J. Calvin Coffey and Ravi Kiran
6 Mesenteric physiology 69
J. Calvin Coffey, Rishabh Sehgal, Awad M. Jarrar, and Mattias Soop
7 Pathology of the mesentery 85
J. Calvin Coffey, Jonathon Roddy, Miranda Kiernan, and Shaheel M. Sahebally
8 Radiographic appearance of the mesentery and peritoneum 109
J. Calvin Coffey and Martin Shelly
9 Operative nomenclature 119
J. Calvin Coffey, Bill Heald, and Brendan J. Moran
10 Teaching mesenteric principles 137
J. Calvin Coffey, Deirdre McGrath, and Colin Peirce
11 Gastroenterology 147
J. Calvin Coffey and Manus Moloney

PARt 2 151

12 Mesenteric-based colorectal surgery 153

J. Calvin Coffey and Ian Lavery
13 Appearance of the mesentery during laparoscopic/robotic colorectal surgery 157
J. Calvin Coffey and Manish Chand
14 Appearance of the mesentery during open colorectal surgery 177
J. Calvin Coffey and James O’Riordan
15 Instruments used during mesenteric-based colorectal surgery 199
J. Calvin Coffey and John P. Burke
16 General techniques in mesenteric-based colorectal surgery 211
J. Calvin Coffey and Jeremy Lipman

vii
viii Contents

17 Mesenteric component of sigmoid colectomy 233

J. Calvin Coffey and Mathew Kalady
18 Mesenteric component of rectal resection 251
J. Calvin Coffey and Jonathon Efron
19 Mesenteric component of right colectomy 277
J. Calvin Coffey and Steven D. Wexner
20 Mesenteric component of flexure mobilization 293
J. Calvin Coffey and Neil J. Smart
21 Mesenteric considerations in resection of the transverse colon 301
J. Calvin Coffey and Ian Lavery
22 Mesenteric considerations in small bowel resection 311
J. Calvin Coffey, Eoghan Condon, and David W. Waldron
23 Mesenteric considerations in ileal pouch anal anastomosis 317
J. Calvin Coffey and James W. Ogilvie Jr.
24 Mesenteric considerations in ostomy formation and reversal 323
J. Calvin Coffey, Colin Peirce, and Ann Brannigan
25 Mesenteric considerations in reoperative abdominal surgery 333
J. Calvin Coffey and Feza Remzi
26 Future directions 343
J. Calvin Coffey

Appendix A: Operative templates 347

Index 351
Preface
This work is intended to furnish the Student
and Practitioner with an accurate view of the
Anatomy of the Human Body, and more espe-
cially the application of this science to Practical
Surgery.
Henry Gray (1858)
MESENTERIC-BASED SURGERY DEFINED
Mesenteric-based surgery is where the surgeon exploits
mesenteric and associated structures in guiding an intesti-
nal resection. The associated structures are the peritoneal
refl ction and Toldt’s fascia. Rather than indiscriminately
dissecting through tissue, structures, and planes, the surgeon
selects certain structures and conducts a particular activity
related to that structure. For example, during sigmoid mobi-
lization for colectomy, the surgeon divides the peritoneal
refl ction at the right side of the base of the mesosigmoid
(via a peritonotomy), which exposes the underlying meso-
fascial plane. Th s plane is formed at the interface between
the mesosigmoid and the underlying Toldt’s fascia. The sur-
geon then separates the components of this plane to mobilize
the mesosigmoid.
Nonmesenteric-based surgery is one where the surgeon
does not adhere to a particular anatomic roadmap. The
mesentery is divided directly across and dissociated from
the posterior abdominal wall. During dissociation, the ret-
roperitoneum and contained structures are often not recog-
nized before being damaged.
Examples of mesenteric-based surgery now abound
and include complete mesocolic excision, total mesorectal
excision, and total mesocolic excision. Variations are also
emerging, including transanal total mesorectal excision
and modifi d complete mesocolic excision. As part of these
procedures, the surgeon accesses the mesofascial plane in a
targeted manner (through division of the peritoneal reflec-
tion), then mobilizes an intact mesentery without its disrup-
tion. Similarly, the retroperitoneum and covering fascia are
preserved. When the mesentery is sufficiently mobilized,
the vessels contained within are selected, skeletonized, and
divided, and the mesentery is similarly divided up to the
level of the intestine.
Several terms have been used in reference to nonmesen-
teric-based surgery. These include “conventional” surgery,
“non-CME surgery, and “non-TME surgery.” Unfortunately,
the terms “CME” and “TME” have not been scientifically
defined in the first instance, and so the related terms also
lack defi ition.
Mesenteric-based surgery has been practiced internation-
ally for over a century and thus is far from new. However, it
is certainly not universally practiced, and considerable varia-
tion has been demonstrated. The variation is explained by
the disparity that has persisted between anatomic and sur-
gical approaches to the intestine for the past century. While
mesenteric-based surgery is far from new, it is remarkable that
its anatomic basis has only recently been formally described.
This means that the principles can now be reproducibly
taught and conducted in an entirely standardized manner.
This book is composed of two parts. In the first part, the
mesentery, peritoneum, and associated fascia are charac-
terized. In the second part, the data explained in the first
are applied to all aspects of resectional colorectal surgery.
Surgical anatomy, activities, and operations are carefully
defined to enable all surgeons to reproducibly conduct
mesenteric-based surgery.
J. Calvin Coff y
ix
How to access three-dimensional models
using QR codes

Each figu e legend in this book will direct the reader to a
QR code. The QR code to be accessed is specifi d in the fi st
number in the following annotation: “QR 2/3.” Th s directs
the reader to QR code 2 and annotation 3.
The QR codes are listed below. Using the example above,
the reader should identify QR 2 below and scan the QR code
with a QR reader (i.e., in a smart phone, lap-top, or tablet).
The reader then will be brought to a three-dimensional
model relating to the figu e legend and figu e in question,
with a series of numbers overlaying the model. By clicking
on the number 3, the reader will be brought to a particular
viewpoint of the model.
QR codes and models can also be accessed directly at the
website “www.mpgs.ie.”

QR 1 - Overview of mesentery QR 2 - Mesentery, peritoneum

and intestine and intestine

QR 2d - Mesentery, peritoneum QR 3 - Sectioned view of right

and intestine and left mesocolon
as seen from above I

QR 3d - Sectioned view of right QR 4 - Sectioned view of right

and left mesocolon and left mesocolon
as seen from above II viewed from below up

QR 6 - Sectioned right and left

QR 5 - Sectioned view of the
mesocolon viewed
mesosigmoid as seen
from above down from below up

QR 7 - Colon and mesocolon QR 8 - Medial view of base of small

intestinal mesentery

xi
xii How to access three-dimensional models using QR codes

QR 9 - Splenic flexure in isolation QR 10 - Splenic region with

flexure removed

QR 11 - Hepatic flexure in isolation QR 12 - Hepatic region with

flexure removed

QR 13 - Mesorectum and fascia

Acknowledgments

We the authors gratefully acknowledge the insight and advice offered by the following individuals:
Ann Brannigan Awad M. Jarrar
Consultant Colorectal Surgeon Department of Cellular and Molecular Medicine
Mater Misericordiae Hospital Lerner Research Institute
University College Dublin Cleveland Clinic
Dublin, Ireland Cleveland, Ohio

John P. Burke
Mathew Kalady
Consultant Colorectal Surgeon
Department of Colorectal Surgery
Beaumont Hospital
Digestive Diseases Institute
Dublin, Ireland
Cleveland Clinic
Manish Chand Cleveland, Ohio
Consultant Colorectal Surgeon
Department of Surgery and Interventional Sciences Miranda Kiernan
University College London Department of Surgery
London, United Kingdom Graduate Entry Medical School
University of Limerick
Eoghan Condon
Limerick, Ireland
Consultant Surgeon
Department of Surgery
University Hospital Limerick Ravi Kiran
University of Limerick Department of Surgery
Limerick, Ireland Columbia University Medical Center
Mailman School of Public Health
Peter Dockery Center for Innovation and Outcomes Research
Department of Anatomy Division of Colorectal Surgery
School of Medicine New York Presbyterian Hospital-Columbia
National University of Ireland New York, New York
Galway, Ireland

Jonathon Efron Joep Knol

Ravitch Division of GI Surgery Consultant General and Colorectal Surgeon
Department of Surgery Jessa Hospital
The Mark M Ravitch Professor of Surgery and Urology Hasselt, Belgium
Johns Hopkins University
Baltimore, Maryland
Ian Lavery
Bill Heald Department of Colorectal Surgery
Pelican Cancer Foundation Digestive Diseases Institute
Basingstoke Hospital Cleveland Clinic
Basingstoke, United Kingdom Cleveland, Ohio

xiii
xiv Acknowledgments

Jeremy Lipman Jonathon Roddy

Associate Professor of Surgery Department of Surgery
Cleveland Clinic Lerner College of Medicine University of Limerick Hospitals Group
Case Western Reserve University University Hospital Limerick
Staff Colorectal Surgeon Limerick, Ireland
Cleveland Clinic Foundation
Cleveland, Ohio
Shaheel M. Sahebally
Deirdre McGrath Department of Surgery
4i Centre for Interventions in Inflammation, Infection and University of Limerick Hospitals Group
Immunity University Hospital Limerick
Graduate Entry Medical School Limerick, Ireland
University of Limerick
Limerick, Ireland
Martin Shelly
Manus Moloney
Department of Radiology
Department of Gastroentrology
University of Limerick Hospitals Group
University of Limerick Hospitals Group
University Hospital Limerick
University Hospital Limerick
Limerick, Ireland
Limerick, Ireland

Brendan J. Moran
Peritoneal Malignancy Institute Neil J. Smart
Basingstoke Hospital Department of Colorectal Surgery
Basingstoke, United Kingdom University of Exeter Medical School
Royal Devon & Exeter Hospital
James W. Ogilvie Jr. Exeter, United Kingdom
Department of Colorectal Surgery
Spectrum Health/Ferguson Clinic
Michigan State University Mattias Soop
Grand Rapids, Michigan Department of Colorectal Surgery
University of Manchester
D. Peter O’Leary Manchester, United Kingdom
Department of Surgery Salford Royal Hospital
University of Limerick Hospitals Group Salford, United Kingdom
University Hospital Limerick
Limerick, Ireland
David W. Waldron
James O’Riordan
Department of Surgery
Department of General and Colorectal Surgery
University of Limerick Hospitals Group
Tallaght Hospital
University Hospital Limerick
Dublin, Ireland
Limerick, Ireland
Nicola O’Riordan
Department of Surgery
University of Limerick Hospitals Group Leon G. Walsh
University Hospital Limerick University of Limerick Hospitals Group
Limerick, Ireland University Hospital Limerick
Limerick, Ireland
Colin Peirce
Department of Surgery
University Hospitals Limerick Steven D. Wexner
Limerick, Ireland Digestive Disease Center
Department of Colorectal Surgery
Feza Remzi Cleveland Clinic Florida
Professor of Surgery Weston, Florida
Director, Inflammatory Bowel Disease Center Florida Atlantic University College of Medicine
NYU Langone Medical Center Florida International University College of Medicine
New York, New York Miami, Florida
 PART 1

1 History 3
2 Mesenteric and peritoneal anatomy 11
3 Embryologic development of the mesentery, peritoneal reflection, and Toldt’s fascia 41
4 Histology of the mesentery 47
5 Toldt’s fascia 57
6 Mesenteric physiology 69
7 Pathology of the mesentery 85
8 Radiographic appearance of the mesentery and peritoneum 109
9 Operative nomenclature 119
10 Teaching mesenteric principles 137
11 Gastroenterology 147

History
J. CALVIN COFFEY AND NICOLA O’RIORDAN
Introduction
Carl Toldt
Sir Frederick Treves
Limited support for Toldt’s observations
Radiology
Renaissance in focus on the mesentery
Two roads diverged in a wood, and I—
I took the one less travelled by,
And that has made all the difference.
Robert Frost
INTRODUCTION
For centuries, the mesentery and associated peritoneal
lining have been regarded as structurally complex. In 1885,
Sir Frederick Treves provided the fi st comprehensive
description of both, emphasizing that while some mesenteric
regions persisted in adulthood, others regressed and were
lost [1]. For example, the small intestinal mesentery, trans-
verse, and sigmoid mesocolon were consistently identifiable
in adults, while the right and left mesocolon were identifi-
able in a minority only. Treves’ descriptions were welcome
at the time, given the apparent complexity of the topic, and
were subsequently indoctrinated in virtually all anatomic,
embryologic, clinical, and related literature [1–3]. To the
present, the fi st chapter of most reference texts on intestinal
surgery focuses on anatomy and physiology and is based on
Treves’ descriptions. A review of later chapters dealing with
techniques in intestinal removal identifies a remarkable dis-
parity. The right and left mesocolon are invariably present
in the adult and must be resected like any other mesenteric
region. Put simply, intestinal surgery has always relied on
the persistence of all regions of the mesentery.
Numerous factors contributed to the divergence of
anatomic and surgical approaches to the mesentery and
peritoneum. Since the time of Treves’ anatomic-based
research, surgeons focused increasingly on cellular aspects
of disease. With increasing awareness of the molecular basis
1
3 Laparoscopic and robotic surgery: The craft of
3 colorectal surgery 7
4 Anatomic continuity: A simpler principle 8
6 Future directions 8
6 Summary 8
7 References 8
of surgical disease, the emphasis of research shifted away
from the anatomic-based craft component. More recently,
laparoscopic and robotic surgery have increased focus on
the “craft” component of surgery. In keeping with this,
the fi ld of surgical anatomy has increased in relative sig-
nificance and led to the demonstration of continuity of the
mesenteric organ from the small intestinal mesentery to the
mesorectum [4,5]. The following chapter will demonstrate
these shifting trends and clarify the manner in which recent
demonstrations allow a reconciliation of anatomic and sur-
gical approaches to this important organ. This chapter fin-
ishes by demonstrating the opportunities that now occur
across a broad array of clinical and non-clinical sciences.
CARL TOLDT (1840–1920)
Carl Florian Toldt was born on May 3, 1840, in Bruneck,
Austria. After spending much of his childhood repair-
ing clocks, he received his doctorate in 1864 at St. Joseph’s
University in Vienna and was appointed Professor of
Anatomy at the University of Vienna in 1875 (Figure 1.1). He
became Professor of Anatomy at the German university in
Prague. He subsequently returned to Vienna in 1884 to work
with his colleague, Langer, and together they established
the Anatomy Institute of Vienna. Carl Toldt’s best-known
anatomic work was Anatomischer Atlas für Studierende
und Aerzte (An Atlas of Human Anatomy for Students and
Physicians) (Figure 1.2), which was translated into English.
Despite the superb quality of this work, and its anatomic
accuracy, it has been little referenced overall. Toldt died
from pneumonia in Vienna in November 1920 [6–9].
Toldt’s descriptions were based on dissection of fresh
cadavers that had not been exposed to corrosive preservative
3
4 History

agents. He first observed that intestinal mesenteries did not

simply comprise two thin layers of closely apposed cells (i.e.,
the mesothelia) but rather contained vessels, nerves, and fat.
He called the resultant complex of structures the “lamina
mesenteria propria” (Figure 1.3). While Treves described
disappearance of the right and left mesocolon as humans
matured into adults, Toldt maintained they persisted and
attached (i.e., flattened against) to the abdominal wall.
Where they attached, Toldt identifi d a thin seam of con-
nective tissue (Toldt’s fascia) separating mesentery from
abdominal wall, just as two layers of rock might be sepa-
rated by a seam of rock (see Chapter 2). Toldt suggested that
wherever the mesentery attached to the abdominal wall, the
cellular layer lining both (i.e., the mesothelium) underwent
a “gradual disappearance” to “admit contact and fusion of
their connective tissue laminae.” Toldt also suggested that
the outer cellular layer of the intestine, the tunica serosa,
could undergo a similar process and merge with the cov-
ering mesothelium of adjacent mesentery. There is a strik-
ing similarity between current descriptions, and those of
Toldt, and it is remarkable that his work should have been
so infrequently referenced over the past two centuries [6–9].

SIR FREDERICK TREVES

Figure 1.1 Carl Toldt (1840–1920).
Figure 1.2 Cover illustration of Anatomischer Atlas Fur
Studierende und Aertze.
Frederick Treves was born in Dorset, England, in 1853
(Figure 1.4). He received his medical education at the
London School of Medicine and became assistant surgeon
at the London hospital in 1879. In 1883 he was appointed
as surgeon and head of the department of Anatomy. He
famously housed Joseph Merrick, “the Elephant Man,” in his
attic until Merrick died in 1890 [6,10]. Treves was awarded
the Jacksonian prize for dissertations on the pathology,
diagnosis, and treatment of obstruction of the intestine and
numerous Hunterian lectures on the anatomy of the intes-
tinal canal and the peritoneum. He served in the Boer war
in 1899. He was knighted by King Edward VII on whom he
performed an appendectomy in 1902. He was a noted travel
writer and took up final residence in Geneva (Switzerland)
due to poor health. He died of peritonitis in 1923 [6,10,11].
Treves described the human mesentery as fragmented.
Accordingly, the right and left mesocolic components of
the mesentery are, according to Treves, mostly absent in
the adult human. He described the small intestinal, trans-
verse, and sigmoid mesentery as persisting into adulthood
and attaching directly to the abdominal wall (Figure 1.5).
At the time, his descriptions provided a welcome rational-
ization of what was, and still is, regarded as a complex ana-
tomic topic (i.e., mesenteric and peritoneal anatomy in the
adult human). Although some aspects of his descriptions of
the mesentery and peritoneum are now regarded as inaccu-
rate, he was correct in describing a “mesenteric root” at the
origin of the superior mesenteric artery. He was also cor-
rect in describing the mesentery of the appendix as arising
from the undersurface of the mesentery in the right iliac
fossa. Treves’ stunning descriptions were made at a time
when significant advances were occurring in anatomic and
 Sir Frederick Treves 5

Tunica serosa intestini

Tunica Stratum longitudinale
muscularis Stratum circulare
Durchtritt eines Arterienzweiges durch die
Tunica muscularis

Tela subserosa

Tunica serosa mesenterii

Epithelium

Tunica mucosa

Tela submucosa

Lamina mesenterii
propria Fettgewebe
9/
1
Einstrahlung des Bindegewebes der Lamina
mesenterii propria in die Darmwand Venenzweig

Figure 1.3 The mesentery and adjacent intestine is demonstrated. Toldt drew submesothelial connective tissue as well
as a mesenteric connective tissue lattice. He demonstrated a contiguity between these and the connective tissue of the
outer layers of the intestine. (Taken from Carl Toldt’s Anatomischer Atlas Fur Studirende und Aertze.)

Right colonic Left colic

attachment attachment

Figure 1.5 Mesenteric attachments and peritoneal anatomy

Figure 1.4 Sir Frederick Treves (1853–1923).
in the adult human as per Sir Frederick Treves. The mesen-
tery of the small intestine, transverse, and sigmoid colon are
depicted by Treves as having linear attachments to the pos-
terior abdominal wall. The attachment of the right and left
colon is indicated (arrows). These correspond to the regions
where a right or left mesocolon, if present, would be located.
6 History
safe surgery, a factor that is likely to have aided in their
indoctrination in mainstream literature. Not surpris-
ingly, they were adopted comprehensively in most ana-
tomic, embryologic, and surgical texts and to the present
they form the basis of introductory chapters in reference
textbooks. It is remarkable that even today, case reports
continue to emerge describing the presence of a right or
left mesocolon (now known to be correct) as anomalous or
pathologic [1,5,6].
LIMITED SUPPORT FOR TOLDT’S
OBSERVATIONS
Toldt’s findings were supported by the observations of
Broesike (1891), Vecchi (1910), Vogt (1926), and Congdon
(1942) [12]. Gerota (1895) and Southam (1923) described
an “anterior renal fascia” (also referred to as the lat-
eroconal fascia or Gerota’s fascia) as being “fusional in
nature,” thereby touching on Toldt’s concept of adhe-
sion [13,14]. In a review of the topic in 1942, Congdon
noted that only a single reference anatomic text men-
tioned Toldt’s fascia, that is, Poirier and Charpy’s text
of anatomy [15]. Congdon also noted that at that time,
several anatomic texts including that of Waterston,
Last, Cunningham, and Grant omitted the fascia from
contained illustrations. Toldt’s observations received
little if any attention following Congdon’s corroboration
of them. It is not known why this occurred. Reference
in anatomic texts was, and to this day remains, scant.
Although surgical texts can be credited with a little more
emphasis, this has also remained limited [16]. The tide
may be turning however as the most recent edition of ref-
erence anatomic texts such as Gray’s Anatomy acknowl-
edge continuity of the mesentery, as well as the presence
of Toldt’s fascia between mesentery and the retroperito-
neum [4].
‘The mesocolon extends along the entire length
of the colon and is continuous with the small
bowel mesentery proximally and the meso-
rectum distally … Toldt’s fascia lies immediately
posterior to the mesocolon, where it is adherent
to the retroperitoneum of the posterior abdom-
inal wall’ (Culligan et al. 2014).
In the main, Treves’ arguments supporting discon-
tinuity were adopted in general and specialty literature
[5,6]. Mesenteric discontinuity meant that the right and
left mesocolon were, in general, considered absent in the
majority of adult humans. If they were present, then they
were regarded as abnormal or pathologic. In an attempt to
reconcile Treves’ descriptions with theories on the embry-
ologic development of the mesentery, two theories were
developed. These were attempts at explaining mesenteric
regression or obliteration and were called the sliding and
regression theories [17–19].
RADIOLOGY
One of the best ways of appraising living anatomy in its undis-
turbed format is through radiologic imaging. Radiologists
continue to try reconciling the radiologic appearance of
the mesentery and associated peritoneum, with Treves’
descriptions. Not surprisingly, many articles on the topic of
mesenteric and peritoneal radiology open with a statement
asserting the complexity of the fi ld in general [20,21].
As mentioned earlier, and in keeping with other disci-
plines, radiologic appraisals of mesenteric anatomy adhere
to the descriptions of Treves. Earlier radiologic techniques
relied on the injection or consumption of radiopaque con-
trast to outline the intestinal lumen. These provided lim-
ited information on structures outside the intestine, which,
for the most part, had to be inferred. The groundbreaking
development of computerized axial tomography (CT) and
magnetic resonance imaging (MRI) meant that structures
outside the intestinal tract could now be visualized. With
this development, radiologists attempted to reconcile CT
and MRI appearances of the mesentery, with classic ana-
tomic teaching, and difficulty was again encountered.
To address this problem, Oliphant (1982) suggested that
the mesentery was continuous with the retroperitoneum
(Figure 1.6), leading to the concept of the “subperitoneal
space of Oliphant” (Figure 1.6) [22]. In 1986, Dodd indi-
cated that the then current theories of mesenteric anat-
omy could not be correlated with the shapes observed on
CT imaging. He suggested that in order to reconcile both
fi lds (i.e., radiologic and anatomic), the mesentery was
best considered as being entirely extra-retroperitoneal
lt
ghl
gsl
hdl
pcl
dcl
tm
srl
sim
im
Figure 1.6 Schematic illustration demonstrating
Oliphant’s interpretation of the subperitoneal space.
 Laparoscopic and robotic surgery: The craft of colorectal surgery 7
[23]. The theory of Oliphant gained acceptance, while that
of Dodd went largely unnoticed until recently (see the
“Anatomic continuity: a simpler principle” section).
More recently still, Charnsangavej et al. exploited
vascular markings in order to identify mesenteric regions
on abdominal CT [20,21,24]. This approach is practical and
readily adopted, which likely explains its widespread use.
However, the sentiment expressed by Dodd (that the CT
appearance of the mesentery is difficult to correlate with
prevailing anatomic concepts) still holds.
RENAISSANCE IN FOCUS
ON THE MESENTERY
Interest in the mesentery increased with the realization
that when the mesentery associated with the rectum (i.e., the
mesorectum) was fully excised for rectal cancer, the inci-
dence of recurrent cancer decreased signifi antly. The con-
cept was termed “total mesorectal excision.” Although total
mesorectal excision had been conducted worldwide and
for decades, the anatomic basis for its success was a recent
discovery. In 1982, Heald et al. showed that a plane occurs
between the mesorectum and the pelvis and that dissection
in this plane, “the holy plane,” enabled a total mesorectal
excision (Figure 1.7) [25,26]. Th s was a highly signifi ant
anatomic description as it provided surgeons with a fail-
safe anatomic roadmap, which, if adhered to, led to better
outcomes for patients with rectal cancer. Initial uptake of
the anatomic principle was begrudgingly slow, but it has
now gained worldwide acceptance. Surprisingly, Heald and
coworkers did not extrapolate the same anatomic basis to
the remainder of the colon and mesocolon.
Figure 1.7 Professor R.J. (Bill) Heald, OBE, MChir,
FRCS(Ed)(Eng).
LAPAROSCOPIC AND ROBOTIC SURGERY:
THE CRAFT OF COLORECTAL SURGERY
During the 1990s, the development of laparoscopic and
minimally invasive surgery (and subsequently robotic tech-
niques) revolutionized intestinal surgery by providing high
magnifi ation (greater than 20-fold) and high-resolution
anatomic imagery. Just as the principles of laparoscopic
and robotic intestinal surgery emerged, terminologies such
as “mesocolon” and “Toldt’s fascia” were increasingly uti-
lized. For laparoscopic and robotic colorectal surgery to be
safe and repeatedly successful, the surgeon must adhere to a
universally reproducible anatomic roadmap. Unfortunately,
the anatomic basis for laparoscopic and robotic intestinal
surgery was also sketchily developed [5,27]. Th s asser-
tion may be considered as unexpected, given surgeons for
decades practiced technically superb resections in the open
context. It is not surprising, however, when one considers
that descriptions of open, laparoscopic and robotic surgi-
cal techniques are hallmarked by limited reference to the
mesentery, the associated peritoneum and fascia.
A brief illustration of this point is important at this junc-
ture. The mesofascial plane is a key plane throughout colorec-
tal surgery. Access to it is universally gained by division of
the overlying peritoneal reflection. Peritonotomy (i.e., divi-
sion) of the reflection and separation of plane components
are core colorectal activities and are universally required
for colorectal resection. Despite being centrally important,
their anatomic basis has only recently been described.
Focus on the anatomic and surgical importance of the
mesentery increased further when Werner Hohenberger
described superb results for patients undergoing a “com-
plete mesocolic excision” for colon cancer (Figure 1.8) [28].
Figure 1.8 Professor Werner Hohenberger, MD, PhD.
8 History
In his 2009 article, he demonstrated that by applying
anatomic principles, one could achieve an R0 resection
(i.e., clearance of all microscopic disease) in 97% of cases.
Around the same time, West et al. demonstrated the eff cts
of anatomic dissection on colon cancer outcomes. Their
findings suggested that by adopting a strictly anatomic
approach, one could enhance patients’ survival following
surgery for stage three colon cancer [29,30]. These findings
went a considerable distance in demonstrating the associa-
tion between anatomic surgery and better cancer-specific
outcomes.
Remarkably, however, a unifying anatomic principle
that could reconcile anatomic with established surgi-
cal approaches to the colon, rectum, and small bowel
remained elusive.
ANATOMIC CONTINUITY: A SIMPLER
PRINCIPLE
In 2012, a study was performed involving collaboration
between the Department of Surgery in University Hospital
Limerick, Ireland, and the Department of Colorectal Surgery
at the Digestive Diseases Institute at The Cleveland Clinic, in
which the anatomic structure of the small and large intestinal
mesentery was formally clarifi d (Chapter 2) [31]. Crucially,
the authors demonstrated that the small intestinal and colonic
mesenteries are different regions of the same anatomic struc-
ture and that the mesentery itself spans the intestinal tract
from the duodenum to the junction between the rectum and
anus (Figure 1.9). Th s was a considerable departure from
Transverse
Transverse mesocolon
colon
Left mesocolon
Right
mesocolon
Right Sigmoid colon
colon
Rectum
Mesosigmoid
Anorectal
Mesorectum junction
Figure 1.9 (See also QR 1 and 7.) The mesenteric organ.
The illustration is of a model of the mesentery generated
using a 3D printer. Pan-mesenteric continuity is demon-
strated (from the duodenum to the anorectal junction).
the classic depictions as it meant that the mesenteric organ is
a substantive and continuous structure, and not fragmented
or discontinuous as was generally described [32,33].
The newer appraisal was far simpler than the classic
description. Recognition of continuity led to similar obser-
vations on the peritoneal refl ction and Toldt’s fascia. It is
now accepted that Toldt’s fascia is continuous from the origin
of the mesenteric organ (at the superior mesenteric artery)
to its termination at pelvic fl or. Similarly, the peritoneum
is draped in a contiguous manner over intraperitoneal struc-
tures from the root region to the so-called anterior refl ction
in the pelvis [32,33].
FUTURE DIRECTIONS
Anatomic continuity and contiguity of mesentery, fascia,
peritoneal reflection, and gastrointestinal tract has major
implications at numerous levels and across multiple special-
ties (clinical and nonclinical). These form the basis and con-
tent of this book. For the surgeon, continuity and contiguity
mean that the same anatomic technical elements can be uni-
versally used to perform a safe intestinal resection [33]. For
the abdominal radiologist, they enable a clearer understand-
ing of the type and extent of intraperitoneal disease [33].
Perhaps most importantly, identification of continuity and
clarification of anatomy now permits the systematic (i.e., sci-
entific) study of the mesentery and associated structures [33].
SUMMARY
There are numerous incidents in the history of medicine
where an inaccurate understanding of structure was dog-
matically integrated in literature. William Osler wrote that
“the greater the ignorance the greater the dogma.” Recent
clarification of mesenteric structure has presented a far sim-
pler structure than heretofore thought. The following chap-
ters will describe the scientific opportunities that stem from
this clarification. In addition, it will explain the mesenteric
basis of clinical practice.
REFERENCES
1. Treves, F., Lectures on the anatomy of the intesti-
nal canal and peritoneum in man. Br Med J, 1885.
1(1264): 580–583.
2. McConnell, A.A. and T.H. Garratt, Abnormalities
of fixation of the ascending colon: The relation of
symptoms to anatomical findings. Br J Surg, 1923. 10:
532–557.
3. Netter, F.H., Atlas of Human Anatomy. Elsevier
Health Sciences, Philadelphia, PA, 2014, pp. 263–276.
4. Standring, S., Gray’s Anatomy: The Anatomical Basis
of Clinical Practice. Elsevier Health Sciences, London,
U.K., 2015, Chapter 62, pp. 1098–1111, 1124–1160.
5. Coffey, J.C., Surgical anatomy and anatomic
surgery—Clinical and scientific mutualism. Surgeon,
2013. 11(4): 177–182.

6. Sehgal, R. and J.C. Coffey, Historical development of
mesenteric anatomy provides a universally applicable
anatomic paradigm for complete/total mesocolic
excision. Gastroenterol Rep, 2014. 2(4): 245–250.
7. Toldt, C., Bau und wachstumsveranterungen
der gekrose des menschlischen darmkanales.
Denkschrdmathnaturwissensch, 1879. 41: 1–56.
8. Toldt, C., An Atlas of Human Anatomy: For Students
and Physicians, Vol. 6: Primary Source Edition.
BiblioBazaar, 2013.
9. Toldt, C. and A.D. Rosa, An Atlas of Human Anatomy
for Students and Physicians. Macmillan, New York,
1926.
10. Cohen, M.M., Jr., Further diagnostic thoughts about the
Elephant Man. Am J Med Genet, 1988. 29(4): 777–782.
11. Treves, F., Discussion on the subsequent course and
later history of cases of appendicitis after operation.
Med Chir Trans, 1905. 88: 429–610.
12. Congdon, E.D., R. Blumberg, and W. Henry, Fasciae
of fusion and elements of the fused enteric mesenter-
ies in the human adult. Am J Anat, 1942. 70: 251–279.
13. Chesbrough, R.M. et al., Gerota versus Zuckerkandl:
The renal fascia revisited. Radiology, 1989. 173(3):
845–846.
14. Amin, M., A.T. Blandford, and H.C. Polk, Jr., Renal
fascia of Gerota. Urology, 1976. 7(1): 1–3.
15. Poirier, P. and A. Charpy, Traité D’Anatomie Humaine
Publié Sous la Direction de P Poirier et a Charpy.
BiblioBazaar, Charleston, SC, 2010.
16. Goligher, J., Surgery of the Anus Rectum and Colon.
All India Traveller Book Seller, 1992.
17. Moore, K.L., T.V.N. Persaud, and M.G. Torchia, The
Developing Human: Clinically Oriented Embryology.
Elsevier Health Sciences, Philadelphia, PA, 2015,
pp. 210–239.
18. Sadler, T.W., Langman’s Medical Embryology. Wolters
Kluwer Health, Philadelphia, PA, 2011, pp. 208–232.
19. Schoenwolf, G.C. et al., Larsen’s Human Embryology.
Elsevier Health Sciences, Philadelphia, PA, 2014,
pp. 341–374.
20. Charnsangavej, C. et al., CT of the mesocolon.
Part 1. Anatomic considerations. Radiographics,
1993. 13(5): 1035–1045.
21. Charnsangavej, C. et al., CT of the mesocolon.
Part 2. Pathologic considerations. Radiographics,
1993. 13(6): 1309–1322.
References 9
22. Oliphant, M. and A.S. Berne, Computed tomography
of the subperitoneal space: Demonstration of direct
spread of intraabdominal disease. J Comput Assist
Tomogr, 1982. 6(6): 1127–1137.
23. Dodds, W.J. et al., The retroperitoneal spaces revis-
ited. Am J Roentgenol, 1986. 147(6): 1155–1161.
24. Coffey, J.C. et al., An appraisal of the computed
axial tomographic appearance of the human mes-
entery based on mesenteric contiguity from the
duodenojejunal flexure to the mesorectal level.
Eur Radiol, 2016. 26(3): 714–721.
25. Heald, R.J., The “Holy Plane” of rectal surgery.
J R Soc Med, 1988. 81(9): 503–508.
26. Heald, R.J., E.M. Husband, and R.D. Ryall, The
mesorectum in rectal cancer surgery—The clue
to pelvic recurrence? Br J Surg, 1982. 69(10):
613–616.
27. Coffey, J.C. et al., Terminology and nomencla-
ture in colonic surgery: Universal application of
a rule-based approach derived from updates on
mesenteric anatomy. Tech Coloproctol, 2014. 18(9):
789–794.
28. Hohenberger, W. et al., Standardized surgery for
colonic cancer: Complete mesocolic excision and
central ligation—Technical notes and outcome.
Colorectal Dis, 2009. 11(4): 354–364; discussion
364–365.
29. West, N.P. et al., Pathology grading of colon cancer
surgical resection and its association with survival:
A retrospective observational study. Lancet Oncol,
2008. 9(9): 857–865.
30. Coffey, J.C. and P. Dockery, Colorectal cancer:
Surgery for colorectal cancer—Standardization
required. Nat Rev Gastroenterol Hepatol, 2016.
13(5): 256–257.
31. Culligan, K. et al., The mesocolon: A prospective
observational study. Colorectal Dis, 2012. 14(4):
421–428; discussion 428–430.
32. Coffey, J.C. et al., Mesenteric-based surgery exploits
gastrointestinal, peritoneal, mesenteric and fas-
cial continuity from duodenojejunal flexure to the
anorectal junction—A review. Dig Surg, 2015. 32(4):
291–300.
33. Coffey, J.C. and D.P. O’Leary, The mesentery:
Structure, function, and role in disease. Lancet
Gastroenterol Hepatol. 1(3): 238–247.
 2
Mesenteric and peritoneal anatomy

J. CALVIN COFFEY, PETER DOCKERY, BRENDAN J. MORAN, AND BILL HEALD

Aim 11 White line of Toldt 22

Introduction 11 Mesosigmoid 25
Mesenteric anatomy 14 Mesosigmoid: Transverse axis 25
Mesenteric root region 14 Mesosigmoidal angles 25
Mesentery in the right iliac fossa 14 Congenital adhesions 26
Small intestinal mesentery 14 Mesorectum 28
Right mesocolon 16 The peritoneal reflection 28
Adipovascular and avascular mesenteric regions 16 Flexural anatomy 34
Hepatic flexure 17 Duodenojejunal and ileocecal flexures 34
Transverse mesocolon 20 Hepatic flexure 34
Relationship between transverse mesocolon and Splenic flexure 38
greater omentum 20 Colosigmoid and rectosigmoid flexures 38
Middle colic adipovascular pedicle 20 Mesenteric conformation in general 38
Splenic flexure 20 Future directions 38
Left mesocolon 20 Summary 38
Inferior mesenteric adipovascular pedicle 22 References 38

There is pleasure in recognising old things from
a new viewpoint.
Richard Feynman
AIM
The aim of this chapter is to summarize mesenteric and
peritoneal structure in light of recent advancements in
our understanding of both. A second aim is to indicate the
relevance of both to current clinical practice.
INTRODUCTION
The magnification aff rded by endoscopic techniques
coupled with the resolution of modern displays has revolu-
tionized our appraisal of living anatomy. Nevertheless, ref-
erence anatomic and embryologic texts continue to present
classic anatomic descriptions. In keeping with this, classic
descriptions of mesenteric and peritoneal anatomy continue
to dominate reference texts. Sir Frederick Treves compre-
hensively described the human mesentery and peritoneum
in a study spanning 100 cadavers in 1889 (Figure 2.1) [1].
His descriptions were first presented in a series of classic lec-
tures and thereafter integrated in most reference anatomic,
embryologic, surgical, and radiologic texts [1–11]. Treves laid
down his understanding of mesenteric and peritoneal anat-
omy at a time when anatomic descriptions were providing a
formal basis for safe and anatomic surgery (Figure 2.1) [1,9].
Treves correctly described the small intestinal mesentery
as having a “mesenteric root” at the origin of the superior
mesenteric artery. According to his descriptions, the small
intestinal mesentery then fans out from the duodenum to
terminal ileum. At the gastrointestinal margin, the mes-
entery elongates considerably. This contrasts considerably
with the length of the “attachment” to the posterior abdom-
inal wall. As per Treves, the mesenteric attachment extends
across the posterior abdominal wall from duodenojejunal
flexure to ileocecal level. As it does so, it obliquely traverses
the aorta and inferior vena cava (Figure 2.2a and b) [1,12].
Treves described the right and left mesocolon as being
absent in the majority of cases. If an anomalous right or left
mesocolon was present, then this would be seen to attach
in regions corresponding closely to the attachment of the
right or left colon (Figures 2.1 and 2.2a,b). For example, the
attachment of the right mesocolon corresponds to that of

11
12 Mesenteric and peritoneal anatomy

Mesenteric attachments: classic teaching

Attachment
of transverse
mesocolon

Attachment
of right colon
Attachment
of left colon
(i.e., left
mesocolon)

Attachment of
mesosigmoid
Attachment
of small
intestinal
mesentery

Figure 2.1 Schematic demonstrating the attachments of the mesentery as depicted by Treves. The small intestinal
mesentery attaches along a diagonal line crossing the posterior abdominal wall from the fourth part of the duodenum
to the ileocecal junction.

Mesentery and attachments: classic vs. current

Mesenteric attachments:
classic teaching

Mesentery:
classic teaching Transverse
mesocolon

Right
mesocolon

Left
mesocolon
Vestigial
left mesocolon

Mesosigmoid
Mesosigmoidal
attachment

(a) (b)

Figure 2.2 (a) Schematic summarizing Treves’ descriptions of the attachment of the mesentery and mesocolon (red region).
As per Treves, when an anomalous right mesocolon is present, it attaches along a vertical trajectory from the right iliac fossa
to the hepatic flexure. The transverse mesocolon attaches along a horizontal line that traverses the upper part of the abdo-
men. When an anomalous left mesocolon is present, it attaches along a vertically oriented region, while the mesosigmoid
attaches along a v-shaped line. The attachment of the mesorectum was not defined by Treves. (b) 2.5D snapshot from a
3D digital sculpture of the mesocolon (yellow) as depicted by Treves. The small bowel and associated mesentery have been
conceptually removed for clarity. The right and left mesocolon are vestigial or near absent, while the transverse and sigmoid
regions are substantial. The mesorectum is absent. Overall, the mesentery is fragmented and discontinuous. (Continued)
 Introduction 13

Mesenteric attachments:
current teaching

Mesentery:
current teaching Left
mesocolon

Left
Right mesocolic mesocolic
attachment Mesosigmoid
and small bowel
mesenteric
attachment

Mesorectum

Mesosigmoidal
(c) attachment (d)

Figure 2.2 (Continued ) (c) Schematic summarizing the attachment of the mesocolon (yellow region) as described by
Toldt. The right mesocolon is always present and attaches over a broad region on the right side of the posterior abdomi-
nal wall. The left mesocolon is always present and attaches over a similarly broad region on the left side of the abdomen.
The mesosigmoid is a distal continuation of the left mesocolon. (d) (See also QR 1/1.) 2.5D snapshot from a 3D digital
sculpture of the mesocolon (yellow) as it is currently understood. The distal small bowel and associated mesentery have
been retained in the illustration. The right and left mesocolon are substantial and continuous with adjacent regions of mes-
entery. The right mesocolon is continuous with the small intestinal mesentery medially and with the transverse mesocolon
at the hepatic flexure. On the left, the left mesocolon, mesosigmoid, and mesorectum are similarly continuous. Overall,
the mesentery is continuous from root region to the mesorectum.

the right colon, extending along a vertical orientation from
the right iliac fossa to the subhepatic region. The attachment
of the left mesocolon corresponds to that of the left colon,
extending from the subsplenic region to the left iliac fossa
(Figures 2.1 and 2.2a, b) [1]. To the present, many reference
texts continue to describe these regions as the attachments
of the right and left olon or mesocolon [3–5,13,14].
Treves’ description of the transverse and sigmoid meso-
colon was similar to that of the small intestinal mesentery.
He described the transverse mesocolon as being “attached”
along a horizontal trajectory to the upper part of the posterior
abdominal wall (Figure 2.2a and b). He described the meso-
sigmoid as attaching to the posterior abdominal wall in the left
iliac fossa. The attachment followed an inverted V shape, with
the apex of the “V” providing an important landmark overly-
ing the left ureter (where this crosses the bifurcation of the
common iliac artery) (Figure 2.2a and b) [2,4,6,14,15].
The mesosigmoid, transverse mesocolon, and small
intestinal mesentery were described as mobile, while the
right and left mesocolon were described as absent (or vesti-
gial) [4,6,8,9,13,14]. According to this, the mesenteric organ
is fragmented (present in some regions, absent in others).
If this description were correct, then one would expect to
identify start and end points for each mesenteric region.
These were never described, a point that is explained by
their absence in the first place [10].
A question arises as to how Treves’ generated his fi dings.
His descriptions can be explained if one were to conceptu-
ally slice through the posterior region of the abdomen in a
coronal plane, that is, (1) posterior to the right and left colon
and (2) at the level where the small intestinal mesentery
attaches to the posterior abdominal wall (Figures 2.1 and
2.2b). Doing this would generate the impression of a series of
mesenteric insertions for the small intestine, transverse, and
sigmoid mesocolon [10,16,17]. In addition, it would fail to
identify the right and left mesocolon as well as the attached
region of the mesosigmoid and mesorectum.
In 2012, our group refuted the findings of Treves
demonstrating mesenteric continuity from small intes-
tinal mesentery to mesorectal level (Figure 2.2c and d)
[10]. This led to a general overhaul of our understand-
ing of mesenteric anatomy [2]. We found that the small
intestinal mesentery attaches to the posterior abdomi-
nal wall and extends laterally as the right mesocolon
(Figures 2.2c, d, 2.3, 2.4). Along the line of attachment,
a peritoneal reflection extends from the small intestinal
mesentery to the posterior abdominal wall and bridges
the gap between the two. The line along which the small
intestinal mesentery attaches to the posterior abdomi-
nal wall (and continues laterally as the right mesocolon)
extends diagonally from the duodenojejunal junction to
the ileocecal level.
14 Mesenteric and peritoneal anatomy
Peritoneum, mesentery, Mesentery,
fascia, and intestine fascia, and intestine
(a) (b)
Legend
Mesentery Fascia
Figure 2.3 (a) (See also QR 2/1.) 2.5D snapshot from a 3D digital sculpture of the mesentery, associated peritoneal reflec-
tion, and large bowel. Just as the mesentery is contiguous so too is the peritoneal covering and associated large bowel.
(b) Same model as in (a) but with peritoneum removed. (c) Same model as in (b) but with peritoneum and fascia removed.
(d) Same model as in (c) but peritoneum, fascia, and colon removed.
MESENTERIC ANATOMY
Mesenteric root region
The following is a description of mesenteric anatomy as it
is currently understood. Before commencing, it is impor-
tant to define the terms “attachment” and “suspension.”
“Attachment” refers to the flattening of the mesentery
against the posterior abdominal wall so the mesentery
becomes apposed to the retroperitoneum. As will be seen
from the following, the mesentery does not “insert” into
the posterior abdominal wall in any location. “Suspension”
refers to the suspension of the mesentery to the posterior
abdominal wall at vascular points of suspension.
The mesentery fans out from the “root region” where
the superior mesenteric artery suspends it to the posterior
abdominal wall. This was correctly described by Treves [1].
From this point, the mesentery expands, like a Chinese fan.
In some regions, it is mobile while in others it is attached
to (i.e., flattened against) the posterior abdominal wall. The
continuous mesentery spans the intestine from duodenoje-
junal to anorectal junction.
Mesentery in the right iliac fossa
In the right iliac fossa, the mesentery tapers toward an apex
at the ileocecal junction. Th s region of mesentery can be
Mesentery and intestine Mesentery
(c) (d)
Colon Peritoneum
arbitrarily called “the ileocecal mesenteric confluence,”
a term that is descriptively useful (see section “Flexural
anatomy”). A fatty appendage (the mesoappendix) extends
from the under surface of the ileocecal mesenteric confluence
(Figure 2.5a through c). Retromesenteric origin of the meso-
appendix explains how the appendix often occupies a retroce-
cal location (the clinical relevance of this will be expanded
on in Chapter 7) (Figure 2.5a through c). Treves correctly
described the mesoappendix as originating from the under-
surface of the mesentery in the ileocecal region [1,12].
The ileocecal mesenteric confluence is a substantive tissue
mass separated from the retroperitoneum by Toldt’s fascia.
When the abdomen is first entered, the confluence is obscured
from direct view by a peritoneal reflection. This is an extension
of the peritoneal reflection at the base of the small intestinal
mesentery. Regions of the peritoneal reflection are of surgical
and pathobiologic importance, as mobilization of the mesen-
tery requires their division to permit access to surgical planes.
In addition, they act as a mechanical barrier to the spread of
submesenteric disease (see Chapters 6 and 7) [18].
Small intestinal mesentery
Though the base of the small intestinal mesentery (i.e.,
where it continues as the right mesocolon) is short, the intes-
tinal margin of the small intestinal mesentery is approxi-
mately 4 ft in length [10,18]. As a result, the mesentery
 Mesenteric anatomy 15

Small intestinal mesentery and right mesocolon

Small intestional
mesentery

Right
mesocolon

(a) (b)

Small intestinal
Right mesentery
mesocolon

(c)

Ascending colon

Transverse
Right colon
mesocolon

Small
intestional
mesentery

(d) Transverse mesocolon

Figure 2.4 (a) (See also QR 3/1.) 2.5D snapshot of a 3D digital sculpture of the small bowel mesentery and right
mesocolon. The model has been sectioned and the point of view is looking from above downward. The small intestinal
mesentery is continuous with the right mesocolon. (b) (See also QR 4/1.) The model used in (a) has been sectioned
through at the same level, but the point of view now is from below upward. The small intestinal mesentery is continuous
with the right mesocolon. (c) Cadaveric demonstration of continuity between the small bowel mesentery and right
mesocolon. (d) Intraoperative image depicting mesenteric and mesocolic continuity.
16 Mesenteric and peritoneal anatomy

Mesoappendix

Mesoappendix

Small intestinal
mesentery Mesoappendix

Origin of
(a) mesoappendix (b)

Right
mesocolon

Mesoappendix

Small intestinal
(c) mesentery

Figure 2.5 (a) 2.5D snapshot of a 3D digital sculpture of the mesentery at the ileocecal region. The mesoappendix
arises from the undersurface of the mesentery. Given this origin, it is not surprising that the appendix frequently takes
up a retrocecal position. (b) Digital model of mesentery indicating how the mesoappendix arises as an appendage,
from the undersurface of the ileocecal mesenteric confluence. (c) Intraoperative image demonstrating the origin of the
mesoappendix from the ileocecal region of mesentery.

elongates considerably from its base (Figure 2.6). In the
undisturbed abdomen, it is packed in a concertina-like man-
ner and readily adopts this position once returned intraperi-
toneally [10,18]. The disparity in length between the base of
the mesentery and the mesenteric border of the intestinal
tract means that the small intestinal mesentery cannot be
unfolded and flattened out in its entirety (Figure 2.6).
Right mesocolon
In contrast to the small intestinal mesentery, the right
mesocolon has a smaller surface area and volume. It extends
from the base of the small intestinal mesentery to the mes-
enteric border of the right (ascending) colon. The right
mesocolon is a substantive mesenteric region (Figure 2.4)
that is attached to (i.e., flattened against) the posterior
abdominal wall but kept anatomically separate by Toldt’s
fascia (Figures 2.7a,d and 2.8a) [2,10,16]. Although this ana-
tomic arrangement is exploited in safe colorectal surgery,
these concepts have been adopted in one reference text, i.e.
Gray’s Anatomy [2].
Adipovascular and avascular
mesenteric regions
In the region of the ileocolic vessels, increased mesenteric
adiposity creates a near constant adipovascular pedicle
(Figure 2.8b). Similar mesenteric thickening occurs
throughout the mesocolon in association with major ves-
sels such as the right, middle, and left colic vessels and
 Mesenteric anatomy 17

Small intestinal mesentery

Gastrointestinal
mesenteric margin
Region of attachment
(a)

Mesenteric folding
at intestinal margin

Right
mesocolon

Orientation of
the peritoneal reflection

(b)

Figure 2.6 (a) 2.5D snapshot of a 3D digital sculpture of the small bowel and associated mesentery. At the base of the small
bowel mesentery (i.e., where it continues as the right mesocolon) it is short in diagonal extent (dotted line). At the intestinal
margin it elongates extensively in tandem with the small bowel. Together with the associated bowel it is compactly plicated into
a finite intraperitoneal space. (b) (See also QR 1/1.) 2.5D snapshot of a 3D digital sculpture demonstrating continuity between
the small intestinal mesentery and right mesocolon. The small bowel mesentery elongates extensively at its intestinal margin.

also at the inferior mesenteric/superior rectal artery.
Adiposity increases around the marginal artery and thus
along the full longitudinal extent of the intestinal mar-
gin of the mesentery. Between adipovascular pedicles, the
mesentery thins out considerably and in some instances
adipose tissue is absent (except in obese patients). These
are the largely avascular interpedicular regions. They
are of surgical importance as they are regions in which
mesentery can be safely divided with minimal blood loss
(Figure 2.8b) [18–21].
At the intestinal margin of the mesocolon (but not the
small intestinal mesentery), mesenteric fat is similar to that
of appendices epiploicae (Figure 2.9a and b). The latter arise
from the serosa of the colon and are sufficiently turgid as to
permit grasping and retraction using robotic or laparoscopic
instrumentation. In contrast, mesenteric fat is soft, friable,
and easily bleeds (when denuded of overlying peritoneum)
and as a result it is not suitable for direct grasping during
laparoscopic or robotic surgery (if the surgeon wishes to
avoid troublesome bleeding). Importantly, epiploical fat can
be readily diffe entiated from mesenteric fat as it has a lobu-
lar appearance. In contrast, the surface of the mesentery is
smooth and gently contoured.
Hepatic flexure
At the hepatic flexure, the right mesocolon narrows, sep-
arates from the abdominal wall at its intestinal margin,
and continues as the hepatic component of the transverse
mesocolon (Figures 2.7b and 2.10). Thus, the mesenteric
18 Mesenteric and peritoneal anatomy

Mesentery: regional anatomy

Right mesocolon Transverse mesocolon Left mesocolon

(a) (b) (c)

Small bowel
mesentery

Right
mesocolon

(d)

Figure 2.7 (a–c) (See also QR 1/2 and 3.) 2.5D snapshot of a 3D digital sculpture in which adjacent mesocolic regions are
highlighted in yellow. The mesentery is an adipose structure that lacks distinct boundaries between contiguous zones. As
a result, the optimal means of demonstrating zones is through color coding. In each snapshot, nonhighlighted mesentery
is colored gray and the small intestinal mesentery has been removed to highlight the mesocolon. (d) Cadaveric example of
the right mesocolon after it has been fully mobilized intact, from the retroperitoneum.

component of the hepatic flexure is a confluence between
right and transverse mesocolon [18,20].
The mesenteric component of each flexure is best
described in terms of radial and longitudinal axes. The
radial axis of the hepatic flexure extends radially from the
middle colic vascular pedicle to the intestinal margin of
the mesentery. As it does so, the mesentery changes from
attached (to the posterior abdominal wall) to nonattached
and thus mobile (Figure 2.12a). The longitudinal axis
extends longitudinally from the right mesocolon to the
transverse mesocolon. At the right mesocolic pole of the
longitudinal axis, the mesentery is fully attached across its
breadth. At the transverse mesocolic pole of the longitudi-
nal axis, the mesentery is attached centrally but mobile at
the intestinal margin. Thus, the mesenteric component of
the hepatic flexure undergoes considerable conformational
changes. These have implications for surgical mobilization
and resection of the hepatic flexure.
 Mesenteric anatomy 19

Right mesocolon
Small intestional
mesentery

Peritoneal
reflection

White line
of Toldt

Legend

Mesentery

Fascia

Colon

Peritoneum
(a)

Right colic
adipovascular
pedicle

Ileocolic
adipovascular
pedicle

Avascular
interpedicular
(b) regions of mesentery

Figure 2.8 (a) (See also QR 3/1.) 2.5D snapshot of a 3D digital sculpture showing continuity between the small intestinal
mesentery and the right mesocolon (viewed from above). In addition, the fascia that occurs between the right mesocolon
and retroperitoneum (Toldt’s fascia) is apparent. The fascia extends beneath the colon to form the colofascial plane and
stops at the right peritoneal reflection, where it gives rise to the white line of Toldt (circle). The fascia also extends medi-
ally until it stops at the small bowel mesenteric peritoneal reflection. (b) Overview of the right mesocolon demonstrating
adipovascular pedicles and avascular interpedicular areas. Adipose tissue is minimal in the interpedicular regions leading
to their near translucent appearance.
20 Mesenteric and peritoneal anatomy

Appendices epiploicae and mesenteric adiposity

Appendices
Appendices epiploicae
epiploicae
Mesenteric
fat

(a) (b) Mesentery

Figure 2.9 (a) 2.5D snapshot of a 3D digital sculpture demonstrating appendices epiploicae along the surface of the
ascending colon. (b) Intraoperative photograph of appendices draped along the surface of the right colon. They are vari-
able in shape and similar in color to nearby right mesocolon. They can be differentiated from nearby mesentery due to
their lobular appearance.

Transverse mesocolon Middle colic adipovascular pedicle

The transverse mesocolon is best thought of as the struc-
ture generated where the mesenteric components of the
hepatic and splenic flexure converge with the middle colic
vascular pedicle (Figures 2.7b, 2.11, and 2.12). Its radial
axis extends from the origin of the middle colic artery
(i.e., at the superior mesenteric artery) to the intestinal
margin of the mesentery. It changes from attached to
mobile along this axis. Its longitudinal axis extends from
the mesenteric component of the hepatic to the splenic
flexure (Figure 2.12).
As with the small intestinal and sigmoid mesentery, the
transverse mesocolon elongates dramatically at the intesti-
nal margin. In this region, and due to elongation, it folds
back on to itself and adopts a conformation that varies con-
siderably. Although the transverse mesocolon does not have
a formal insertion as depicted in classic anatomic appraisals,
it does converge on the middle colic artery (see Chapter 3)
(Figure 2.12) [18].
Relationship between transverse mesocolon
and greater omentum
The transverse mesocolon and colon overlie the small
intestinal mesentery, and the greater omentum overlies
the upper surface of the transverse mesocolon. Extensive
adhesions occur between the under surface of the greater
omentum and the upper surface of the transverse meso-
colon. As a result, the lesser sac is frequently obliterated
where the transverse mesocolon and greater omentum are
attached. This arrangement has surgical implications but is
also likely to have pathobiologic significance in limiting the
direct spread of intra-abdominal disease [2].
As occurs in the right and left mesocolon, mesenteric fat is
increased around the middle colic artery (the middle colic
adipovascular pedicle) (Figure 2.12). On either side of this
pedicle, the mesentery thins to the point of being translu-
cent in individuals whose body mass index is low (i.e., the
avascular interpedicular regions) [10,18].
Splenic flexure
At the splenic flexure, the transverse mesocolon contin-
ues distally as the left mesocolon (Figure 2.7c). As with
the hepatic flexure, the splenic flexure is best considered
in terms of radial and longitudinal axes. The radial axis
extends radially from the middle colic vascular pedicle to
the intestinal margin. As it does so, the mesentery changes
from attached to the posterior abdominal wall, to nonat-
tached and thus mobile (Figure 2.12b). The longitudinal
axis extends longitudinally from the transverse to the left
mesocolon. At the transverse pole of the longitudinal axis,
the mesentery is attached at middle colic pedicle and mobile
at the intestinal margin. At the left mesocolic pole of the
longitudinal axis, the mesentery is fully attached across its
breadth. Thus, the mesenteric component of the splenic flex-
ure undergoes considerable conformational changes. These
have implications for surgical mobilization and resection of
the splenic flexure [18].
Left mesocolon
The left mesocolon is continuous with the transverse
mesocolon at the splenic flexure. As one follows it dis-
tally, it rapidly expands in the axial plane (from the
 Mesenteric anatomy 21

Mesentery and mesenteric root region

Hepatic flexure

Hepatic
flexure

Legend
Mesentery

(a) (b) Mesenteric root Fascia

Colon
Mesenteric root
Peritoneum

Hepatic Transverse
flexure mesocolon

Hepatic
flexure

Transverse mesocolon Mesenteric root

(c) (d)

Figure 2.10 2.5D snapshots of a 3D digital sculpture showing how the right mesocolon narrows toward the hepatic
flexure. (a) Anterior view. (b) (See also QR 1/4.) Posterior view from above. (c) Posterior view looking from medial to lateral.
(d) Posterior view looking lateral to medial.

flexure). The full extent of the left mesocolon (i.e., from
nonintestinal to intestinal margin) is attached (i.e., flat-
tened against) to the posterior abdominal wall (Figures 2.7
and 2.13a through c). Toldt’s fascia is interposed between
it and the retroperitoneum (Figure 2.13a through c) and
also between the colon and the retroperitoneum (Figure
2.13b). Unlike the transverse mesocolon, the left meso-
colon does not undergo elongation at the intestinal mar-
gin. Distally, the left mesocolon continues as the attached
component of the mesosigmoid [10,18].
22 Mesenteric and peritoneal anatomy

3D printed mesentery and regional anatomy of transverse mesocolon

(a) (b)

(c) (d)

Figure 2.11 (a–d) (See also QR 1/2.) 2.5D snapshot of a 3D printed model of the mesocolon and colon demonstrating
contiguity throughout its length from ileocecal junction to mesorectal level. The transverse mesocolon is colored green to
demonstrate its appearance from different viewpoints.

Inferior mesenteric adipovascular pedicle White line of Toldt

An accumulation of fat around the inferior mesenteric
artery generates the inferior mesenteric adipovascular pedi-
cle. In thin individuals, the left mesocolon cephalad to this
pedicle is near translucent, while the mesocolon distal to the
pedicle is generally thickened due mainly to the presence of
sigmoidal vessels, the left colic, and the superior rectal arter-
ies (Figure 2.14).
The right and left colon, located at the intestinal margins of
the right and left mesocolon, are generally apposed to the
retroperitoneum (Figure 2.15a and b). As with the mesoco-
lon, they are maintained separate from it, by Toldt’s fascia.
The fascia extends under the mesocolon and colon and is
limited by the peritoneal reflection where the white line of
Toldt occurs (Figure 2.15a and b). The white line can be
 Mesenteric anatomy 23

Transverse mesocolon

Mesenteric
component of Middle colic
hepatic flexure adipovascular
pedicle

(a)

Mesenteric
component of
splenic flexure

Translucent
peritoneum,
i.e., region of
translucent zone

(b)

Figure 2.12 (a) (See also QR 1/6-8.) 2.5D snapshot of a 3D digital model in which the mesenteric components of the
(a) hepatic and (b) splenic flexures converge on the middle colic adipovascular pedicle.
24 Mesenteric and peritoneal anatomy

Left mesocolon

Legend
Mesentery

Fascia

Colon

Peritoneum

Left mesocolon

White line
Toldt’s fascia of Toldt

Retroperitoneum

(a)

Descending colon
Peritoneal
reflection

Toldt’s fascia
(b)

Descending
colon

Peritoneal
reflection

Toldt’s fascia Decending

mesocolon

(c)

Figure 2.13 (a) (See also QR 4/2.) 2.5D snapshot of a 3D digital model demonstrating the left mesocolon. (b) Cadaveric image
demonstrating Toldt’s fascia posterior to the colon. This relationship becomes apparent after division of the overlying perito-
neal reflection. (c) Once the colon has been separated from Toldt’s fascia, the mesocolon and underlying fascia are exposed.
 Mesenteric anatomy 25

Mesocolic continuity
Transverse
mesocolon Left mesocolon

Mesosigmoid

Inferior mesenteric
vascular pedicle

Figure 2.14 Cadaveric images of continuous transverse, left mesocolon, and mesosigmoid. Vascular pedicles and avascular
interpedicular areas are apparent. A small window was inadvertently created in the transverse mesocolon.

observed whenever an interface occurs between perito-
neal mesothelium and Toldt’s fascia. For example, it can
be observed beneath the right and left mesocolon. Thus, it
is inaccurate to suggest that it is confined to the right and
left peritoneal reflections. As will be seen in the chapters on
right and left mesocolectomy, the white line represents an
anatomic landmark that may help the surgeon in deciding
where to commence peritonotomy (i.e., peritoneal inci-
sion) (Figures 2.15 and 2.16) [18].
Mesosigmoid
The mesosigmoid is continuous distally with the meso-
rectum and proximally with the left mesocolon. It is best
considered in terms of longitudinal and transverse axes.
The longitudinal axis extends from the left mesocolon to
the mesorectum and spans the attached region of the meso-
sigmoid. The transverse axis extends from the midline
laterally.
Mesosigmoid: Transverse axis
the posterior abdominal wall. In between these junctions,
the sigmoid elongates and leaves the posterior abdomi-
nal wall, taking the mesosigmoid with it. This means that
the transverse axis is attached medially and mobile later-
ally (Figure 2.16a and b) [10,16,20,21]. Where the mobile
component detaches from the posterior abdominal wall a
peritoneal reflection bridges the gap between the two. The
line along which the mesosigmoid detaches has a diagonal
orientation along the left iliac fossa. The associated perito-
neal reflection has a similar orientation and extends from
the junction between the descending and sigmoid colon to
that between the sigmoid colon and rectum (Figure 2.16a
and b) [9,10].
The mobile component of the mesosigmoid fans out in
a manner similar to that of the transverse mesocolon and
small bowel mesentery. In keeping with this property, the
intestinal margin of the mobile component is considerably
longer than the base region at which it is attached [9,10].
This diffe ential in length is exaggerated in some individuals
and predisposes to volvulus formation, where the sigmoid
twists on its mesentery (see Chapter 7).

The transverse axis varies in breadth depending on the Mesosigmoidal angles

level examined. At the junction between the descending
and sigmoid colon, the transverse axis extends from the
midline to the junction laterally and is fully apposed to the
posterior abdominal wall. At the rectosigmoid junction,
the transverse axis is narrow and again fully attached to
At the junction between the descending and the sigmoid
colon, a mesenteric angle occurs, the proximal mesosig-
moidal angle (Figure 2.17). At the junction between the
sigmoid and rectum, a similar mesenteric angle occurs, the
26 Mesenteric and peritoneal anatomy

Left mesocolon, peritoneal reflection, white line of Toldt

White line
of Toldt

White line
of Toldt

Toldt’s fascia
(a)

Legend
Mesentery

Fascia

Colon

Peritoneum

Peritoneal
reflection

White line
of Toldt

Left mesocolon
(b) Toldt’s fascia

Figure 2.15 (a) (See also QR 6/5.) 2.5D snapshot of a 3D digital model demonstrating the left mesocolon (viewed from
above) and descending colon, sectioned in such a manner as to permit identification of the mesocolon. (b) (See also
QR 6/6.) 2.5D snapshot showing a section through the left mesocolon, viewed from below up. Toldt’s fascia is shown as it
extends from beneath the mesocolon, to beneath the colon, and thereafter to reach the left peritoneal reflection.

distal mesosigmoidal angle. These angles are of surgical and
endoscopic significance (Figure 2.17).
Congenital adhesions
Frequently, the lateral aspect of the mesosigmoid is adher-
ent to the parietal peritoneum of the left iliac fossa across
focal congenital adhesions. While in some individuals
these adhesions are absent, in others they are plentiful
and form a band resembling the peritoneal reflection. It is
this band that surgical trainees (and indeed sometimes
highly experienced colorectal surgeons) can mistake as the
starting point for lateral to medial mobilization of the
mesosigmoid.
 Mesenteric anatomy 27

Mesosigmoid

Sigmoid colon

Attached
mesosigmoid

Mobile
mesosigmoid

Toldt’s fascia
Legend
Mesentery

(a) Fascia

Colon

Mobile Peritoneum
mesosigmoid

Peritoneal
reflection

White line
of Toldt

Peritoneal
reflection
Attached
mesosigmoid
(b)

Figure 2.16 (a) (See also QR 5/1.) 2.5D snapshot of a 3D digital model demonstrating the mesosigmoid viewed from above
down and demonstrating attached and mobile regions. Toldt’s fascia is observed beneath the attached mesosigmoid,
between it and the retroperitoneum. The fascia continues laterally as far as the peritoneal reflection where the attached
region of mesosigmoid continues laterally as the mobile region. (b) (See also QR 6/1.) Same model as in (a) sectioned and
viewed from below up to illustrate the same mesofascial relationships beneath the attached mesosigmoid. The fascia con-
tinues laterally until limited by the lateral peritoneal reflection.
28 Mesenteric and peritoneal anatomy

Sigmoid and associated angles

Distal
mesosigmoid
angle Proximal
mesosigmoid
angle

Figure 2.17 Panel of 2.5 D images presenting sigmoid and rectum from multiple viewpoints. These enable demonstration of
the proximal and distal mesosigmoidal angles. The proximal mesosigmoidal angle occurs at the junction of the descending
and sigmoid colon. The distal mesosigmoidal angle occurs at the junction between the sigmoid and the rectum.

Mesorectum (Figure 2.3). For descriptive purposes, the peritoneal reflec-

The mesorectum is the distal continuation of the mesosigmoid
(Figure 2.18a and b). It encases the upper rectum posteriorly
and laterally. Distal to the anterior refl ction the mesorectum
continues around the anterior rectum to encase this also.
Toldt’s fascia occurs between the mesorectum and surround-
ing structures. Th s relationship holds circumferentially at all
levels and is of considerable clinical relevance (Figure 2.18a
and b). Anteriorly, the fascia is markedly attenuated between
the rectum and prostate (in the case of males) and between
the rectum and the vagina in females (Figure 2.18). Anteriorly,
the complex of mesorectum and fascia is often referred to as
Denonvillier’s fascia. Deep in the pelvis, where the mesorec-
tum tapers toward the anorectal junction, the fascia coalesces
to become more distinct. Several terms are used interchange-
ably for the fascia in this region. They include Waldeyer’s fas-
cia, the retrorectal or presacral fascia (Figure 2.18c and d). In
most individuals, the fascia occupies the interface between the
distal (tapering) mesorectum and surrounding bony pelvis.
However, in some individuals, the fascia is markedly attenu-
ated in this region and an anatomic space arises [10,16,20,21].
THE PERITONEAL REFLECTION
An understanding of the anatomy of the mesentery is essen-
tial in comprehending the associated peritoneal reflection
tion will be subdivided into regions, based on the associated
region of mesentery, and these will be named accordingly.
Although this system greatly aids in the conceptualization
of the reflection, it is not meant to indicate that there are
separate anatomic structures [17,20,21]. Rather, they are dif-
ferent regions of a single, continuous structure.
As mentioned earlier, a peritoneal refl ction occurs where
the small intestinal mesentery attaches to the posterior abdom-
inal wall (the small intestinal peritoneal reflection) (Figure 2.19a
through c). The peritoneal refl ction in this location continues
on the inferolateral aspect of the ileocecal mesenteric conflu-
ence (arbitrarily called the “ileocecal peritoneal refl ction”),
thus obscuring this confluence from direct visualization
(Figure 2.20a and b). The refl ction then continues on to the
lateral aspect of the right colon as the right peritoneal reflection
(Figure 2.21a and b). As with the ileocecal mesenteric conflu-
ence, the right peritoneal refl ction obscures the plane formed
between the right colon and Toldt’s fascia. The right peritoneal
refl ction is often identifiable by the occurrence of a thin white
trace, that is, the white line of Toldt [3,11,16,18].
At the hepatic flexu e, the refl ction continues around the
cephalad aspect of the flexu e, as the hepatocolic refl ction
(Figure 2.22a through c). When this refl ction is surgically
divided via peritonotomy, the interface between the colon
and underlying fascia can be visualized. More medially, the
greater omentum coalesces with the hepatocolic refl ction
 The peritoneal reflection 29

Mesosigmoid, mesorectum and Toldt’s fascia

Mesosigmoid
Mesorectum

Mesosigmoid Legend
Mesentery

Mesorectum Fascia

Colon

Peritoneum
(a) (b)

Sigmoid
colon

Mesorectal
fascia

Denonvillier’s
fascia

Waldeyer’s
fascia
(c) (d)

Figure 2.18 (a) (See also QR 7/1.) 2.5D snapshot of a 3D digital model demonstrating continuity between the mesosig-
moid and mesorectum from a posterior and left-sided viewpoint. (b) (See also QR 7/2.) 2.5D snapshot of a 3D digital
model demonstrating continuity between the mesosigmoid and mesorectum from a posterior and right-sided view-
point. (c) 2.5D snapshot of a 3D digital model demonstrating continuity between the mesosigmoid and mesorectum
with Toldt’s fascia included. (d) 2.5D snapshot of a 3D digital model demonstrating continuity between the mesosig-
moid and mesorectum and fascia included.

making the anatomic arrangement in this location difficult
to defi e. A further refl ction is always evident beneath the
greater omentum bridging the space between this and the
transverse mesocolon [10,11,16,20,21]. Th s has been arbi-
trarily called the omento-colic refl ction.
The cephalad aspect of the splenic flexure is also
obscured from view by the splenocolic reflection. Just as
occurred for the hepatic flexure, coalescence of the greater
omentum with the splenocolic reflection makes it difficult
to diffe entiate anatomic structures at this location
30 Mesenteric and peritoneal anatomy

Small bowel peritoneal reflection

Small bowel
mesentery
Legend
Mesentery

Fascia

Colon Small bowel

peritoneal reflection
Peritoneum (a)

Small bowel
peritoneal reflection

(b) (c)

Figure 2.19 (a) Cadaveric view of the peritoneal reflection at the base of the mesentery and continuing around the ileoce-
cal junction. (b) (See also QR 4/1.) 2.5D snapshot from 3D digital model that has been sectioned through the mesentery
and right mesocolon. This enables demonstration of the peritoneal reflection at the base of the small intestinal mesentery.
The view is from below up. (c) (See also QR 3/1.) Same model as in (b) but with view from above down. The small intestinal
mesentery is continuous with the right mesocolon and at the base of the former, the peritoneal reflection is apparent.
Another random document with
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Paris, 1830-31.
JÉSUS-CHRIST EN FLANDRE.

A MARCELINE DESBORDES-VALMORE,
 A vous, fille de la Flandre, et qui en êtes une des gloires
modernes, cette naïve tradition des Flandres.
De Balzac.

A une époque assez indéterminée de l’histoire brabançonne, les

relations entre l’île de Cadzant et les côtes de la Flandre étaient
entretenues par une barque destinée au passage des voyageurs.
Capitale de l’île, Midelbourg, plus tard si célèbre dans les annales du
protestantisme, comptait à peine deux ou trois cents feux. La riche
Ostende était un havre inconnu, flanqué d’une bourgade
chétivement peuplée par quelques pêcheurs, par de pauvres
négociants et par des corsaires impunis. Néanmoins le bourg
d’Ostende, composé d’une vingtaine de maisons et de trois cents
cabanes, chaumines ou taudis construits avec des débris de navires
naufragés jouissait d’un gouverneur, d’une milice, de fourches
patibulaires, d’un couvent, d’un bourgmestre, enfin de tous les
organes d’une civilisation avancée. Qui régnait alors en Brabant, en
Flandre, en Belgique? Sur ce point, la tradition est muette. Avouons-
le? cette histoire se ressent étrangement du vague, de l’incertitude,
du merveilleux que les orateurs favoris des veillées flamandes se
sont amusés maintes fois à répandre dans leurs gloses aussi
diverses de poésie que contradictoires par les détails. Dite d’âge en
âge, répétée de foyer en foyer par les aïeules, par les conteurs de
jour et de nuit, cette chronique a reçu de chaque siècle une teinte
différente. Semblable à ces monuments arrangés suivant le caprice
des architectures de chaque époque, mais dont les masses noires et
frustes plaisent aux poètes, elle ferait le désespoir des
commentateurs, des éplucheurs de mots, de faits et de dates. Le
narrateur y croit, comme tous les esprits superstitieux de la Flandre
y ont cru, sans en être ni plus doctes ni plus infirmes. Seulement,
dans l’impossibilité de mettre en harmonie toutes les versions, voici
le fait dépouillé peut-être de sa naïveté romanesque impossible à
reproduire, mais avec ses hardiesses que l’histoire désavoue, avec
sa moralité que la religion approuve, son fantastique, fleur
d’imagination, son sens caché dont peut s’accommoder le sage. A
chacun sa pâture et le soin de trier le bon grain de l’ivraie.
La barque qui servait à passer les voyageurs de l’île de Cadzant
à Ostende allait quitter le village. Avant de détacher la chaîne de fer
qui retenait sa chaloupe à une pierre de la petite jetée où l’on
s’embarquait, le patron donna du cor à plusieurs reprises, afin
d’appeler les retardataires, car ce voyage était son dernier. La nuit
approchait, les derniers feux du soleil couchant permettaient à peine
d’apercevoir les côtes de Flandre et de distinguer dans l’île les
passagers attardés, errant soit le long des murs en terre dont les
champs étaient environnés, soit parmi les hauts joncs des marais.
La barque était pleine, un cri s’éleva:
—Qu’attendez-vous? Partons.
En ce moment, un homme apparut à quelques pas de la jetée; le
pilote, qui ne l’avait entendu ni venir, ni marcher, fut assez surpris de
le voir. Ce voyageur semblait s’être levé de terre tout à coup, comme
un paysan qui se serait couché dans un champ en attendant l’heure
du départ et que la trompette aurait réveillé. Était-ce un voleur? était-
ce quelque homme de douane ou de police? Quand il arriva sur la
jetée où la barque était amarrée, sept personnes placées debout à
l’arrière de la chaloupe s’empressèrent de s’asseoir sur les bancs,
afin de s’y trouver seules et de ne pas laisser l’étranger se mettre
avec elles. Ce fut une pensée instinctive et rapide, une de ces
pensées d’aristocratie qui viennent au cœur des gens riches. Quatre
de ces personnages appartenaient à la plus haute noblesse des
Flandres. D’abord un jeune cavalier, accompagné de deux beaux
lévriers et portant sur ses cheveux longs une toque ornée de
pierreries, faisait retentir ses éperons dorés et frisait de temps en
temps sa moustache avec impertinence, en jetant des regards
dédaigneux au reste de l’équipage. Une altière demoiselle tenait un
faucon sur son poing, et ne parlait qu’à sa mère ou à un
ecclésiastique du haut rang, leur parent sans doute. Ces personnes
faisaient grand bruit et conversaient ensemble, comme si elles
eussent été seules dans la barque. Néanmoins, auprès d’elles se
trouvait un homme très-important dans le pays, un gros bourgeois
de Bruges, enveloppé dans un grand manteau. Son domestique,
armé jusqu’aux dents, avait mis près de lui deux sacs pleins
d’argent. A côté d’eux se trouvait encore un homme de science,
docteur à l’université de Louvain, flanqué de son clerc. Ces gens, qui
se méprisaient les uns les autres, étaient séparés de l’avant par le
banc des rameurs.
Lorsque le passager en retard mit le pied dans la barque, il jeta
un regard rapide sur l’arrière, n’y vit pas de place, et alla en
demander une à ceux qui se trouvaient sur l’avant du bateau. Ceux-
là étaient de pauvres gens. A l’aspect d’un homme à tête nue, dont
l’habit et le haut-de-chausses en camelot brun, dont le rabat en toile
de lin empesé n’avaient aucun ornement, qui ne tenait à la main ni
toque ni chapeau, sans bourse ni épée à la ceinture, tous le prirent
pour un bourgmestre sûr de son autorité, bourgmestre bon homme
et doux comme quelques-uns de ces vieux Flamands dont la nature
et le caractère ingénus nous ont été si bien conservés par les
peintres du pays. Les pauvres passagers accueillirent alors l’inconnu
par des démonstrations respectueuses qui excitèrent des railleries
chuchotées entre les gens de l’arrière. Un vieux soldat, homme de
peine et de fatigue, donna sa place sur le banc à l’étranger, s’assit
au bord de la barque, et s’y maintint en équilibre par la manière dont
il appuya ses pieds contre une de ces traverses de bois qui,
semblables aux arêtes d’un poisson servent à lier les planches des
bateaux. Une jeune femme, mère d’un petit enfant, et qui paraissait
appartenir à la classe ouvrière d’Ostende, se recula pour faire assez
de place au nouveau venu. Ce mouvement n’accusa ni servilité, ni
dédain. Ce fut un de ces témoignages d’obligeance par lesquels les
pauvres gens, habitués à connaître le prix d’un service et les délices
de la fraternité, révèlent la franchise et le naturel de leurs âmes, si
naïves dans l’expression de leurs qualités et de leurs défauts; aussi
l’étranger les remercia-t-il par un geste plein de noblesse. Puis il
s’assit entre cette jeune mère et le vieux soldat. Derrière lui se
trouvaient un paysan et son fils, âgé de dix ans. Une pauvresse
ayant un bissac presque vide, vieille et ridée, en haillons, type de
malheur et d’insouciance, gisait sur le bec de la barque, accroupie
dans un gros paquet de cordages. Un des rameurs, vieux marinier,
qui l’avait connue belle et riche, l’avait fait entrer, suivant l’admirable
diction du peuple, pour l’amour de Dieu.
 —Grand merci, Thomas, avait dit la vieille, je dirai pour toi ce soir
deux Pater et deux Ave dans ma prière.
Le patron donna du cor encore une fois, regarda la campagne
muette, jeta la chaîne dans un bateau, courut le long du bord
jusqu’au gouvernail, en prit la barre, resta debout; puis, après avoir
contemplé le ciel, il dit d’une voix forte à ses rameurs, quand ils
furent en pleine mer:—Ramez, ramez fort, et dépêchons! la mer
sourit à un mauvais grain, la sorcière! Je sens la houle au
mouvement du gouvernail, et l’orage à mes blessures.
Ces paroles, dites en termes de marine, espèce de langue
intelligible seulement pour des oreilles accoutumées au bruit des
flots, imprimèrent aux rames un mouvement précipité, mais toujours
cadencé; mouvement unanime, différent de la manière de ramer
précédente, comme le trot d’un cheval l’est de son galop. Le beau
monde assis à l’arrière prit plaisir à voir tous ces bras nerveux, ces
visages bruns aux yeux de feu, ces muscles tendus, et ces
différentes forces humaines agissant de concert, pour leur faire
traverser le détroit moyennant un faible péage. Loin de déplorer
cette misère, ils se montrèrent les rameurs en riant des expressions
grotesques que la manœuvre imprimait à leurs physionomies
tourmentées. A l’avant, le soldat, le paysan et la vieille contemplaient
les mariniers avec cette espèce de compassion naturelle aux gens
qui, vivant de labeur, connaissent les rudes angoisses et les
fiévreuses fatigues du travail. Puis, habitués à la vie en plein air, tous
avaient compris, à l’aspect du ciel, le danger qui les menaçait, tous
étaient donc sérieux. La jeune mère berçait son enfant, en lui
chantant une vieille hymne d’église pour l’endormir.
—Si nous arrivons, dit le soldat au paysan, le bon Dieu aura mis
de l’entêtement à nous laisser en vie.
—Ah! il est le maître, répondit la vieille; mais je crois que son bon
plaisir est de nous appeler près de lui. Voyez là-bas cette lumière?
Et, par un geste de tête, elle montrait le couchant, où des bandes de
feu tranchaient vivement sur des nuages bruns nuancés de rouge
qui semblaient bien près de déchaîner quelque vent furieux. La mer
faisait entendre un murmure sourd, une espèce de mugissement
intérieur, assez semblable à la voix d’un chien quand il ne fait que
gronder. Après tout, Ostende n’était pas loin. En ce moment, le ciel
et la mer offraient un de ces spectacles auxquels il est peut-être
impossible à la peinture comme à la poésie de donner plus de durée
qu’ils n’en ont réellement. Les créations humaines veulent des
contrastes puissants. Aussi les artistes demandent-ils ordinairement
à la nature ses phénomènes les plus brillants, désespérant sans
doute de rendre la grande et belle poésie de son allure ordinaire,
quoique l’âme humaine soit souvent aussi profondément remuée
dans le calme que dans le mouvement, et par le silence autant que
par la tempête. Il y eut un moment où, sur la barque, chacun se tut
et contempla la mer et le ciel, soit par pressentiment, soit pour obéir
à cette mélancolie religieuse qui nous saisit presque tous à l’heure
de la prière, à la chute du jour, à l’instant où la nature se tait, où les
cloches parlent. La mer jetait une lueur blanche et blafarde, mais
changeante et semblable aux couleurs de l’acier. Le ciel était
généralement grisâtre. A l’ouest, de longs espaces étroits simulaient
des flots de sang, tandis qu’à l’orient des lignes étincelantes,
marquées comme par un pinceau fin, étaient séparées par des
nuages plissés comme des rides sur le front d’un vieillard. Ainsi, la
mer et le ciel offraient partout un fond terne, tout en demi-teintes, qui
faisait ressortir les feux sinistres du couchant. Cette physionomie de
la nature inspirait un sentiment terrible. S’il est permis de glisser les
audacieux tropes du peuple dans la langue écrite, on répéterait ce
que disait le soldat, que le temps était en déroute, ou, ce que lui
répondit le paysan, que le ciel avait la mine d’un bourreau. Le vent
s’éleva tout à coup vers le couchant, et le patron, qui ne cessait de
consulter la mer, la voyant s’enfler à l’horizon, s’écria:—Hau! hau! A
ce cri, les matelots s’arrêtèrent aussitôt et laissèrent nager leurs
rames.
—Le patron a raison, dit froidement Thomas quand la barque
portée en haut d’une énorme vague redescendit comme au fond de
la mer entr’ouverte.
A ce mouvement extraordinaire, à cette colère soudaine de
l’Océan, les gens de l’arrière devinrent blêmes, et jetèrent un cri
terrible:—Nous périssons!
 —Oh! pas encore, leur répondit tranquillement le patron.
En ce moment, les nuées se déchirèrent sous l’effort du vent,
précisément au-dessus de la barque. Les masses grises s’étant
étalées avec une sinistre promptitude à l’orient et au couchant, la
lueur du crépuscule y tomba d’aplomb par une crevasse due au vent
d’orage, et permit d’y voir les visages. Les passagers, nobles ou
riches, mariniers et pauvres, restèrent un moment surpris à l’aspect
du dernier venu. Ses cheveux d’or, partagés en deux bandeaux sur
son front tranquille et serein, retombaient en boucles nombreuses
sur ses épaules, en découpant sur la grise atmosphère une figure
sublime de douceur et où rayonnait l’amour divin. Il ne méprisait pas
la mort, il était certain de ne pas périr. Mais si d’abord les gens de
l’arrière oublièrent un instant la tempête dont l’implacable fureur les
menaçait, ils revinrent bientôt à leurs sentiments d’égoïsme et aux
habitudes de leur vie.
—Est-il heureux, ce stupide bourgmestre, de ne pas s’apercevoir
du danger que nous courons tous! Il est là comme un chien, et
mourra sans agonie, dit le docteur.
A peine avait-il dit cette phrase assez judicieuse, que la tempête
déchaîna ses légions. Les vents soufflèrent de tous les côtés, la
barque tournoya comme une toupie, et la mer y entra.
—Oh! mon pauvre enfant! mon enfant! Qui sauvera mon enfant?
s’écria la mère d’une voix déchirante.
—Vous-même, répondit l’étranger.
Le timbre de cet organe pénétra le cœur de la jeune femme, il y
mit un espoir; elle entendit cette suave parole malgré les sifflements
de l’orage, malgré les cris poussés par les passagers.
—Sainte Vierge de Bon-Secours, qui êtes à Anvers, je vous
promets mille livres de cire et une statue, si vous me tirez de là,
s’écria le bourgeois à genoux sur des sacs d’or.
—La Vierge n’est pas plus à Anvers qu’ici, lui répondit le docteur.
—Elle est dans le ciel, répliqua une voix qui semblait sortir de la
mer.
 —Qui donc a parlé?
—C’est le diable, s’écria le domestique, il se moque de la Vierge
d’Anvers.
—Laissez-moi donc là votre sainte Vierge, dit le patron aux
passagers. Empoignez-moi les écopes et videz-moi l’eau de la
barque. Et vous autres, reprit-il en s’adressant aux matelots, ramez
ferme! Nous avons un moment de répit, au nom du diable qui vous
laisse en ce monde, soyons nous-mêmes notre providence. Ce petit
canal est furieusement dangereux, on le sait, voilà trente ans que je
le traverse. Est-ce de ce soir que je me bats avec la tempête?
Puis, debout à son gouvernail, le patron continua de regarder
alternativement sa barque, la mer et le ciel.
—Il se moque toujours de tout, le patron, dit Thomas à voix
basse.
—Dieu nous laissera-t-il mourir avec ces misérables? demanda
l’orgueilleuse jeune fille au beau cavalier.
—Non, non, noble demoiselle. Écoutez-moi? Il l’attira par la taille,
et lui parlant à l’oreille:—Je sais nager, n’en dites rien! Je vous
prendrai par vos beaux cheveux, et vous conduirai doucement au
rivage; mais je ne puis sauver que vous.
La demoiselle regarda sa vieille mère. La dame était à genoux et
demandait quelque absolution à l’évêque qui ne l’écoutait pas. Le
chevalier lut dans les yeux de sa belle maîtresse un faible sentiment
de piété filiale, et lui dit d’une voix sourde:—Soumettez-vous aux
volontés de Dieu! S’il veut appeler votre mère à lui, ce sera sans
doute pour son bonheur... en l’autre monde, ajouta-t-il d’une voix
encore plus basse.—Et pour le nôtre en celui-ci, pensa-t-il. La dame
de Rupelmonde possédait sept fiefs, outre la baronnie de Gâvres. La
demoiselle écouta la voix de sa vie, les intérêts de son amour
parlant par la bouche du bel aventurier, jeune mécréant qui hantait
les églises, où il cherchait une proie, une fille à marier ou de beaux
deniers comptants. L’évêque bénissait les flots, et leur ordonnait de
se calmer en désespoir de cause; il songeait à sa concubine qui
l’attendait avec quelque délicat festin, qui peut-être en ce moment se
mettait au bain, se parfumait, s’habillait de velours, ou faisait agrafer
ses colliers et ses pierreries. Loin de songer aux pouvoirs de la
sainte Église, et de consoler ces chrétiens en les exhortant à se
confier à Dieu, l’évêque pervers mêlait des regrets mondains et des
paroles d’amour aux saintes paroles du bréviaire. La lueur qui
éclairait ces pâles visages permit de voir leurs diverses expressions,
quand la barque, enlevée dans les airs par une vague, puis rejetée
au fond de l’abîme, puis secouée comme une feuille frêle, jouet de la
bise en automne, craqua dans sa coque et parut près de se briser.
Ce fut alors des cris horribles, suivis d’affreux silences. L’attitude des
personnes assises à l’avant du bateau contrasta singulièrement
avec celle des gens riches ou puissants. La jeune mère serrait son
enfant contre son sein chaque fois que les vagues menaçaient
d’engloutir la fragile embarcation; mais elle croyait à l’espérance que
lui avait jetée au cœur la parole dite par l’étranger; chaque fois, elle
tournait ses regards vers cet homme, et puisait dans son visage une
foi nouvelle, la foi forte d’une femme faible, la foi d’une mère. Vivant
par la parole divine, par la parole d’amour échappée à cet homme, la
naïve créature attendait avec confiance l’exécution de cette espèce
de promesse, et ne redoutait presque plus le péril. Cloué sur le bord
de la chaloupe, le soldat ne cessait de contempler cet être singulier
sur l’impassibilité duquel il modelait sa figure rude et basanée en
déployant son intelligence et sa volonté, dont les puissants ressorts
s’étaient peu viciés pendant le cours d’une vie passive et machinale;
jaloux de se montrer tranquille et calme autant que ce courage
supérieur, il finit par s’identifier, à son insu peut-être, au principe
secret de cette puissance intérieure. Puis son admiration devint un
fanatisme instinctif, un amour sans bornes, une croyance en cet
homme, semblable à l’enthousiasme que les soldats ont pour leur
chef, quand il est homme de pouvoir, environné par l’éclat des
victoires, et qu’il marche au milieu des éclatants prestiges du génie.
La vieille pauvresse disait à voix basse:—Ah! pécheresse infâme
que je suis! Ai-je souffert assez pour expier les plaisirs de ma
jeunesse? Ah! pourquoi, malheureuse, as-tu mené la belle vie d’une
Galloise, as-tu mangé le bien de Dieu avec des gens d’église, le
bien des pauvres avec les torçonniers et maltôliers? Ah! j’ai eu grand
tort. O mon Dieu! mon Dieu! laissez-moi finir mon enfer sur cette
terre de malheur. Ou bien:—Sainte Vierge, mère de Dieu, prenez
pitié de moi!
—Consolez-vous, la mère, le bon Dieu n’est pas un lombard.
Quoique j’aie tué, peut-être à tort et à travers, les bons et les
mauvais, je ne crains pas la résurrection.
—Ah! monsieur l’anspessade, sont-elles heureuses, ces belles
dames, d’être auprès d’un évêque, d’un saint homme! reprit la vieille,
elles auront l’absolution de leurs péchés. Oh! si je pouvais entendre
la voix d’un prêtre me disant:—Vos péchés vous seront remis, je le
croirais!
L’étranger se tourna vers elle, et son regard charitable la fit
tressaillir.
—Ayez la foi, lui dit-il, et vous serez sauvée.
—Que Dieu vous récompense, mon bon Seigneur, lui répondit-
elle. Si vous dites vrai, j’irai pour vous et pour moi en pèlerinage à
Notre-Dame-de-Lorette, pieds nus.
Les deux paysans, le père et le fils, restaient silencieux, résignés
et soumis à la volonté de Dieu, en gens accoutumés à suivre
instinctivement, comme les animaux, le branle donné à la Nature.
Ainsi, d’un côté les richesses, l’orgueil, la science, la débauche, le
crime, toute la société humaine telle que la font les arts, la pensée,
l’éducation, le monde et ses lois; mais aussi, de ce côté seulement,
les cris, la terreur, mille sentiments divers combattus par des doutes
affreux, là, seulement, les angoisses de la peur. Puis, au-dessus de
ces existences, un homme puissant, le patron de la barque, ne
doutant de rien, le chef, le roi fataliste, se faisant sa propre
providence et criant:—«Sainte Écope!...» et non pas:—«Sainte
Vierge!...» enfin, défiant l’orage et luttant avec la mer corps à corps.
A l’autre bout de la nacelle, des faibles!... la mère berçant dans son
sein un petit enfant qui souriait à l’orage; une fille, jadis joyeuse,
maintenant livrée à d’horribles remords; un soldat criblé de
blessures, sans autre récompense que sa vie mutilée pour prix d’un
dévouement infatigable; il avait à peine un morceau de pain trempé
de pleurs; néanmoins il se riait de tout et marchait sans soucis,
heureux quand il noyait sa gloire au fond d’un pot de bière ou qu’il la
racontait à des enfants qui l’admiraient. Il commettait gaiement à
Dieu le soin de son avenir; enfin, deux paysans, gens de peine et de
fatigue, le travail incarné, le labeur dont vivait le monde. Ces simples
créatures étaient insouciantes de la pensée et de ses trésors, mais
prêtes à les abîmer dans une croyance, ayant la foi d’autant plus
robuste qu’elles n’avaient jamais rien discuté, ni analysé; natures
vierges où la conscience était restée pure et le sentiment puissant;
le remords, le malheur, l’amour, le travail avaient exercé, purifié,
concentré, décuplé, leur volonté, la seule chose qui, dans l’homme,
ressemble à ce que les savants nomment une âme.
Quand la barque, conduite par la miraculeuse adresse du pilote,
arriva presque en vue d’Ostende, à cinquante pas du rivage, elle en
fut repoussée par une convulsion de la tempête, et chavira soudain.
L’étranger au lumineux visage dit alors à ce petit monde de douleur:
—Ceux qui ont la foi seront sauvés; qu’ils me suivent!
Cet homme se leva, marcha d’un pas ferme sur les flots. Aussitôt
la jeune mère prit son enfant dans ses bras et marcha près de lui sur
la mer. Le soldat se dressa soudain en disant dans son langage de
naïveté:—Ah! nom d’une pipe! je te suivrais au diable. Puis, sans
paraître étonné, il marcha sur la mer. La vieille pécheresse, croyant
à la toute-puissance de Dieu, suivit l’homme et marcha sur la mer.
Les deux paysans se dirent:—Puisqu’ils marchent sur l’eau,
pourquoi ne ferions-nous pas comme eux? Ils se levèrent et
coururent après eux en marchant sur la mer. Thomas voulut les
imiter; mais sa foi chancelant, il tomba plusieurs fois dans la mer, se
releva; puis, après trois épreuves, il marcha sur la mer. L’audacieux
pilote s’était attaché comme un rémora sur le plancher de sa barque.
L’avare avait eu la foi et s’était levé; mais il voulut emporter son or, et
son or l’emporta au fond de la mer. Se moquant du charlatan et des
imbéciles qui l’écoutaient, au moment où il vit l’inconnu proposant
aux passagers de marcher sur la mer, le savant se prit à rire et fut
englouti par l’océan. La jeune fille fut entraînée dans l’abîme par son
amant. L’évêque et la vieille dame allèrent au fond, lourds de crimes,
peut-être, mais plus lourds encore d’incrédulité, de confiance en de
fausses images, lourds de dévotion, légers d’aumônes et de vraie
religion.
La troupe fidèle qui foulait d’un pied ferme et sec la plaine des
eaux courroucées entendait autour d’elle les horribles sifflements de
la tempête. D’énormes lames venaient se briser sur son chemin.
Une force invincible coupait l’océan. A travers le brouillard, ces
fidèles apercevaient dans le lointain, sur le rivage, une petite lumière
faible qui tremblottait par la fenêtre d’une cabane de pêcheurs.
Chacun, en marchant courageusement vers cette lueur, croyait
entendre son voisin criant à travers les mugissements de la mer:—
Courage! Et cependant, attentif à son danger, personne ne disait
mot. Ils atteignirent ainsi le bord de la mer. Quand ils furent tous
assis au foyer du pêcheur, ils cherchèrent en vain leur guide
lumineux. Assis sur le haut d’un rocher, au bas duquel l’ouragan jeta
le pilote attaché sur sa planche par cette force que déploient les
marins aux prises avec la mort, l’HOMME descendit, recueillit le
naufragé presque brisé; puis il dit en étendant une main secourable
sur sa tête: Bon pour cette fois-ci, mais n’y revenez plus, ce serait
d’un trop mauvais exemple.
Il prit le marin sur ses épaules et le porta jusqu’à la chaumière du
pêcheur. Il frappa pour le malheureux, afin qu’on lui ouvrît la porte de
ce modeste asile, puis le Sauveur disparut. En cet endroit, fut bâti,
pour les marins, le couvent de la Merci, où se vit longtemps
l’empreinte que les pieds de Jésus-Christ avaient, dit-on, laissée sur
le sable. En 1793, lors de l’entrée des Français en Belgique, des
moines emportèrent cette précieuse relique, l’attestation de la
dernière visite que Jésus ait fait à la Terre.
Ce fut là que, fatigué de vivre, je me trouvais quelque temps
après la révolution de 1830. Si vous m’eussiez demandé la raison de
mon désespoir, il m’aurait été presque impossible de la dire, tant
mon âme était devenue molle et fluide. Les ressorts de mon
intelligence se détendaient sous la brise d’un vent d’ouest. Le ciel
versait un froid noir, et les nuées brunes qui passaient au-dessus de
ma tête donnaient une expression sinistre à la nature. L’immensité
de la mer, tout me disait:—Mourir aujourd’hui, mourir demain, ne
faudra-t-il pas toujours mourir? et, alors... J’errais donc en pensant à
un avenir douteux, à mes espérances déchues. En proie à ces idées
funèbres, j’entrai machinalement dans cette église du couvent, dont
les tours grises m’apparaissaient alors comme des fantômes à
travers les brumes de la mer. Je regardai sans enthousiasme cette
forêt de colonnes assemblées dont les chapiteaux feuillus
soutiennent des arcades légères, élégant labyrinthe. Je marchai tout
insouciant dans les nefs latérales qui se déroulaient devant moi
comme des portiques tournant sur eux-mêmes. La lumière incertaine
d’un jour d’automne permettait à peine de voir en haut des voûtes
les clefs sculptées, les nervures délicates qui dessinaient si
purement les angles de tous les cintres gracieux. Les orgues étaient
muettes. Le bruit seul de mes pas réveillait les graves échos cachés
dans les chapelles noires. Je m’assis auprès d’un des quatre piliers
qui soutiennent la coupole, près du chœur. De là, je pouvais saisir
l’ensemble de ce monument que je contemplai sans y attacher
aucune idée. L’effet mécanique de mes yeux me faisait seul
embrasser le dédale imposant de tous les piliers, les roses
immenses miraculeusement attachées comme des réseaux au-
dessus des portes latérales ou du grand portail, les galeries
aériennes où de petites colonnes menues séparaient les vitraux
enchâssés par des arcs, par des trèfles ou par des fleurs, joli
filigrane en pierre. Au fond du chœur, un dôme de verre étincelait
comme s’il était bâti de pierres précieuses habilement serties. A
droite et à gauche, deux nefs profondes opposaient à cette voûte,
tour à tour blanche et coloriée, leurs ombres noires au sein
desquelles se dessinaient faiblement les fûts indistincts de cent
colonnes grisâtres. A force de regarder ces arcades merveilleuses,
ces arabesques, ces festons, ces spirales, ces fantaisies sarrasines
qui s’entrelaçaient les unes dans les autres, bizarrement éclairées,
mes perceptions devinrent confuses. Je me trouvai, comme sur la
limite des illusions et de la réalité, pris dans les piéges de l’optique et
presque étourdi par la multitude des aspects. Insensiblement ces
pierres découpées se voilèrent, je ne les vis plus qu’à travers un
nuage formé par une poussière d’or, semblable à celle qui voltige
dans les bandes lumineuses tracées par un rayon de soleil dans une
chambre. Au sein de cette atmosphère vaporeuse qui rendit toutes
les formes indistinctes, la dentelle des roses resplendit tout à coup.
Chaque nervure, chaque arête sculptée, le moindre trait s’argenta.
Le soleil alluma des feux dans les vitraux dont les riches couleurs
scintillèrent. Les colonnes s’agitèrent, leurs chapiteaux s’ébranlèrent
doucement. Un tremblement caressant disloqua l’édifice, dont les
frises se remuèrent avec de gracieuses précautions. Plusieurs gros
piliers eurent des mouvements graves comme est la danse d’une
douairière qui, sur la fin d’un bal, complète par complaisance les
quadrilles. Quelques colonnes minces et droites se mirent à rire et à
sauter, parées de leurs couronnes de trèfles. Des cintres pointus se
heurtèrent avec les hautes fenêtres longues et grêles, semblables à
ces dames du Moyen-âge qui portaient les armoiries de leurs
maisons peintes sur leurs robes d’or. La danse de ces arcades
mitrées avec ces élégantes croisées ressemblait aux luttes d’un
tournoi. Bientôt chaque pierre vibra dans l’église, mais sans changer
de place. Les orgues parlèrent, et me firent entendre une harmonie
divine à laquelle se mêlèrent des voix d’anges, musique inouïe,
accompagnée par la sourde basse-taille des cloches dont les
tintements annoncèrent que les deux tours colossales se
balançaient sur leurs bases carrées. Ce sabbat étrange me sembla
la chose du monde la plus naturelle, et je ne m’en étonnai pas après
avoir vu Charles X à terre. J’étais moi-même doucement agité
comme sur une escarpolette qui me communiquait une sorte de
plaisir nerveux, et il me serait impossible d’en donner une idée.
Cependant, au milieu de cette chaude bacchanale, le chœur de la
cathédrale me parut froid comme si l’hiver y eût régné. J’y vis une
multitude de femmes vêtues de blanc, mais immobiles et
silencieuses. Quelques encensoirs répandirent une odeur douce qui
pénétra mon âme en la réjouissant. Les cierges flamboyèrent. Le
lutrin, aussi gai qu’un chantre pris de vin, sauta comme un chapeau
chinois. Je compris que la cathédrale tournait sur elle-même avec
tant de rapidité que chaque objet semblait y rester à sa place. Le
Christ colossal, fixé sur l’autel, me souriait avec une malicieuse
bienveillance qui me rendit craintif, je cessai de le regarder pour
admirer dans le lointain une bleuâtre vapeur qui se glissa à travers
les piliers, en leur imprimant une grâce indescriptible. Enfin plusieurs
ravissantes figures de femmes s’agitèrent dans les frises. Les
enfants qui soutenaient de grosses colonnes, battirent eux-mêmes
des ailes. Je me sentis soulevé par une puissance divine qui me
plongea dans une joie infinie, dans une extase molle et douce.
J’aurais, je crois, donné ma vie pour prolonger la durée de cette
fantasmagorie, quand tout à coup une voix criarde me dit à l’oreille:
—Réveille-toi, suis-moi!
Une femme desséchée me prit la main et me communiqua le
froid le plus horrible aux nerfs. Ses os se voyaient à travers la peau
ridée de sa figure blême et presque verdâtre. Cette petite vieille
froide portait une robe noire traînée dans la poussière, et gardait à
son cou quelque chose de blanc que je n’osais examiner. Ses yeux
fixes, levés vers le ciel, ne laissaient voir que le blanc des prunelles.
Elle m’entraînait à travers l’église et marquait son passage par des
cendres qui tombaient de sa robe. En marchant, ses os claquèrent
comme ceux d’un squelette. A mesure que nous marchions,
j’entendais derrière moi le tintement d’une clochette dont les sons
pleins d’aigreur retentirent dans mon cerveau, comme ceux d’un
harmonica.
—Il faut souffrir, il faut souffrir, me disait-elle.
Nous sortîmes de l’église, et traversâmes les rues les plus
fangeuses de la ville; puis, elle me fit entrer dans une maison noire
où elle m’attira en criant de sa voix, dont le timbre était fêlé comme
celui d’une cloche cassée:—Défends-moi, défends-moi!
Nous montâmes un escalier tortueux. Quand elle eut frappé à
une porte obscure, un homme muet, semblable aux familiers de
l’inquisition, ouvrit cette porte. Nous nous trouvâmes bientôt dans
une chambre tendue de vieilles tapisseries trouées, pleine de vieux
linges, de mousselines fanées, de cuivres dorés.
—Voilà d’éternelles richesses, dit-elle.
Je frémis d’horreur en voyant alors distinctement à la lueur d’une
longue torche et de deux cierges, que cette femme devait être
récemment sortie d’un cimetière. Elle n’avait pas de cheveux. Je
voulus fuir, elle fit mouvoir son bras de squelette et m’entoura d’un
cercle de fer armé de pointes. A ce mouvement, un cri poussé par
des millions de voix, le hurrah des morts, retentit près de nous!
 —Je veux te rendre heureux à jamais, dit-elle. Tu es mon fils!
Nous étions assis devant un foyer dont les cendres étaient
froides. Alors la petite vieille me serra la main si fortement que je dus
rester là. Je la regardai fixement, et tâchai de deviner l’histoire de sa
vie en examinant les nippes au milieu desquelles elle croupissait.
Mais existait-elle? C’était vraiment un mystère. Je voyais bien que
jadis elle avait dû être jeune et belle, parée de toutes les grâces de
la simplicité, véritable statue grecque au front virginal.
—Ah! ah! lui dis-je, maintenant je te reconnais. Malheureuse,
pourquoi t’es-tu prostituée aux hommes? Dans l’âge des passions,
devenue riche, tu as oublié ta pure et suave jeunesse, tes
dévouements sublimes, tes mœurs innocentes, tes croyances
fécondes, et tu as abdiqué ton pouvoir primitif, ta suprématie tout
intellectuelle pour les pouvoirs de la chair. Quittant tes vêtements de
lin, ta couche de mousse, tes grottes éclairées par de divines
lumières tu as étincelé de diamants, de luxe et de luxure. Hardie,
fière, voulant tout, obtenant tout et renversant tout sur ton passage,
comme une prostituée en vogue qui court au plaisir, tu as été
sanguinaire comme une reine hébétée de volonté. Ne te souviens-tu
pas d’avoir été souvent stupide par moments. Puis tout à coup
merveilleusement intelligente, à l’exemple de l’Art sortant d’une
orgie. Poète, peintre, cantatrice, aimant les cérémonies splendides,
tu n’as peut-être protégé les arts que par caprice, et seulement pour
dormir sous des lambris magnifiques? Un jour, fantasque et
insolente, toi qui devais être chaste et modeste, n’as-tu pas tout
soumis à ta pantoufle, et ne l’as-tu pas jetée sur la tête des
souverains qui avaient ici-bas le pouvoir, l’argent et le talent!
Insultant à l’homme et prenant joie à voir jusqu’où allait la bêtise
humaine, tantôt tu disais à tes amants de marcher à quatre pattes,
de te donner leurs biens, leurs trésors, leurs femmes même, quand
elles valaient quelque chose! Tu as, sans motif, dévoré des millions
d’hommes, tu les as jetés comme des nuées sablonneuses de
l’Occident sur l’Orient. Tu es descendue des hauteurs de la pensée
pour t’asseoir à côté des rois. Femme, au lieu de consoler les
hommes, tu les as tourmentés, affligés! Sûre d’en obtenir, tu
demandais du sang! Tu pouvais cependant te contenter d’un peu de
farine, élevée comme tu le fus, à manger des gâteaux et à mettre de
l’eau dans ton vin. Originale en tout, tu défendais jadis à les amants
épuisés de manger, et ils ne mangeaient pas. Pourquoi
extravaguais-tu jusqu’à vouloir l’impossible? Semblable à quelque
courtisane gâtée par ses adorateurs, pourquoi t’es-tu affolée de
niaiseries et n’as-tu pas détrompé les gens qui expliquaient ou
justifiaient toutes tes erreurs? Enfin, tu as eu tes dernières passions!
Terrible comme l’amour d’une femme de quarante ans, tu as rugi! tu
as voulu étreindre l’univers entier dans un dernier embrassement, et
l’univers qui t’appartenait t’a échappé. Puis, après les jeunes gens
sont venus à tes pieds des vieillards, des impuissants qui t’ont
rendue hideuse. Cependant quelques hommes au coup d’œil d’aigle
te disaient d’un regard:—Tu périras sans gloire, parce que tu as
trompé, parce que tu as manqué à tes promesses de jeune fille. Au
lieu d’être un ange au front de paix et de semer la lumière et le
bonheur sur ton passage, tu as été une Messaline aimant le cirque
et les débauches, abusant de ton pouvoir. Tu ne peux plus redevenir
vierge, il te faudrait un maître. Ton temps arrive. Tu sens déjà la
mort. Tes héritiers te croient riche, ils te tueront et ne recueilleront
rien. Essaie au moins de jeter tes hardes qui ne sont plus de mode,
redeviens ce que tu étais jadis. Mais non! tu t’es suicidée! N’est-ce
pas là ton histoire? lui dis-je en finissant, vieille caduque, édentée,
froide, maintenant oubliée, et qui passe sans obtenir un regard.
Pourquoi vis-tu? Que fais-tu de ta robe de plaideuse qui n’excite le
désir de personne? où est ta fortune? pourquoi l’as-tu dissipée? où
sont tes trésors? qu’as-tu fait de beau?
A cette demande, la petite vieille se redressa sur ses os, rejeta
ses guenilles, grandit, s’éclaira, sourit, sortit de sa chrysalide noire.
Puis, comme un papillon nouveau-né, cette création indienne sortit
de ses palmes, m’apparut blanche et jeune, vêtue d’une robe de lin.
Ses cheveux d’or flottèrent sur ses épaules, ses yeux scintillèrent,
un nuage lumineux l’environna, un cercle d’or voltigea sur sa tête,
elle fit un geste vers l’espace en agitant une longue épée de feu.
—Vois et crois! dit-elle.
Tout à coup, je vis dans le lointain des milliers de cathédrales,
semblables à celle que je venais de quitter, mais ornées de tableaux
et de fresques; j’y entendis de ravissants concerts. Autour de ces
monuments, des milliers d’hommes se pressaient, comme des
fourmis dans leurs fourmilières. Les uns empressés de sauver des
livres et de copier des manuscrits, les autres servant les pauvres,
presque tous étudiant. Du sein de ces foules innombrables
surgissaient des statues colossales, élevées par eux. A la lueur
fantastique, projetée par un luminaire aussi grand que le soleil, je lus
sur le socle de ces statues: Histoire. Sciences. Littératures.
La lumière s’éteignit, je me retrouvai devant la jeune fille, qui,
graduellement, rentra dans sa froide enveloppe, dans ses guenilles
mortuaires, et redevint vieille. Son familier lui apporta un peu de
poussier, afin qu’elle renouvelât les cendres de sa chaufferette, car
le temps était rude; puis, il lui alluma, à elle qui avait eu des milliers
de bougies dans ses palais, une petite veilleuse afin qu’elle pût lire
ses prières pendant la nuit.
—On ne croit plus!... dit-elle.
Telle était la situation critique dans laquelle je vis la plus belle, la
plus vaste, la plus vraie, la plus féconde de toutes les puissances.
—Réveillez-vous, monsieur, l’on va fermer les portes, me dit une
voix rauque.
En me retournant, j’aperçus l’horrible figure du donneur d’eau
bénite, il m’avait secoué le bras. Je trouvai la cathédrale ensevelie
dans l’ombre, comme un homme enveloppé d’un manteau.
—Croire! me dis-je, c’est vivre! Je viens de voir passer le convoi
d’une Monarchie, il faut défendre l’Église!

Paris, février 1831.

 MELMOTH RÉCONCILIÉ.

A MONSIEUR LE GÉNÉRAL BARON DE POMMEREUL,

En souvenir de la constante amitié qui a lié nos pères et

qui subsiste entre ses fils.
De Balzac.

Il est une nature d’hommes que la Civilisation obtient dans le

Règne Social, comme les fleuristes créent dans le Règne végétal
par l’éducation de la serre, une espèce hybride qu’ils ne peuvent
reproduire ni par semis, ni par bouture. Cet homme est un caissier,
véritable produit anthropomorphe, arrosé par les idées religieuses,
maintenu par la guillotine, ébranché par le vice, et qui pousse à un
troisième étage entre une femme estimable et des enfants
ennuyeux. Le nombre des caissiers à Paris sera toujours un
problème pour le physiologiste. A-t-on jamais compris les termes de
la proposition dont un caissier est l’X connu? Trouver un homme qui
soit sans cesse en présence de la fortune comme un chat devant
une souris en cage? Trouver un homme qui ait la propriété de rester
assis sur un fauteuil de canne, dans une loge grillagée, sans avoir
plus de pas à y faire que n’en a dans sa cabine un lieutenant de
vaisseau, pendant les sept huitièmes de l’année et durant sept à huit
heures par jour? Trouver un homme qui ne s’ankylose à ce métier ni
les genoux ni les apophyses du bassin? Un homme qui ait assez de
grandeur pour être petit? Un homme qui puisse se dégoûter de
l’argent à force d’en manier? Demandez ce produit à quelque
Religion, à quelque Morale, à quelque Collége, à quelque Institution