444 



APPLIED ANATOMY. 



further down. If it is desired to go still higher the peritoneum may be pushed up off 

 the rectum or it may be opened and the mesorectum detached close to the sacrum so 

 as not to injure its vessels. The detached rectum is then brought down, cut off, 

 and its divided end sutured to the skin. 



In approaching the rectum by the sacral route an incision is made across the 

 sacrum opposite the third sacral segment and from its right extremity (Tuttle) down 

 to beyond the tip of the coccyx. The bone is chiselled through opposite the fourth 

 sacral foramina and the flap turned down (Fig. 449). The lateral and middle sacral 

 arteries may have to be ligated. The peritoneum, which is visible in the upper 

 portion of the wound, may then be incised close to the rectum to avoid wounding 

 the ureters, and the mesorectum detached close to the sacrum. This loosens the 

 rectum, which can then be brought out and the opening in the peritoneum sewed 



Peritoneal cavity 

 'opened 



Ixjwer end of sacrum 



FIG. 449. Excision of the rectum. The sacrum has been divided and turned aside. The rectum is drawn to the 

 left, exposing the ureter and vas deferens and seminal vesicle, and the peritoneal cavity has been opened above. 



shut. As much of the rectum as is desired is removed and the cut ends united by a 

 Murphy button or end-to-end suture. 



In carcinoma enlarged lymph-nodes may be found in the mesorectum or hollow 

 of the sacrum and should of course be removed. 



THE BLADDER. 



When fully distended the normal bladder contains approximately 500 c.c., or a 

 pint. Its capacity varies much, and it is capable of great distention without rupture. 

 In cases of retention of urine it may reach up to the umbilicus and contain a quart 

 or more, while if its walls are thickened it may be contracted and hold only a few 

 ounces. The shape of the bladder is dependent on the amount of dilatation and its 

 attachments. 



Position. In front of the bladder is the symphysis and body of the pubes, 

 below and in front is the prostate gland. Beneath is the posterior portion of the 

 prostate, the seminal vesicles, the termination of the ureters, and the rectum. The 

 upper and posterior surfaces are covered by peritoneum and small intestines, which 

 fill the rectovesical pouch. In the female the bladder rests on the upper half of the 

 vagina and the uterus as far as the internal os. 



