MOVEMENTS AND INNERVA^flON OF THE INTESTINES 1315 



Upon introducing the finger into the rectum, the membranous portion of the urethra can 

 be felt, if an instrument has been introduced into the bladder, exactly in the middle line; behind 

 and above this the prostate gland can be recognized by its shape and hardness and any enlarge- 

 ment detected; above the prostate the fluctuating wall of the bladder when full can be felt, 

 and if thought desirable it can be tapped in this situation; on either side and behind the prostate 

 the seminal vesicles can be readily felt, especially if enlarged by tuberculous disease. Behind, 

 the coccyx is to be felt, and on the mucous membrane one or two of Houston's folds. The 

 ischiorectal fossae can be explored on either side, with a view to ascertaining the presence of 

 deep-seated collections of pus. Finally, it will be noted that the finger is firmly gripped by the 

 sphincter for about an inch (2.5 cm.) up the bowel. 



Applied Anatomy. The small intestine is much exposed to injury, but, in consequence 

 of its elasticity and the ease with which one fold glides over another, it is not so frequently rup- 

 tured as would otherwise be the case. Any part of the small intestine may be ruptured, but 

 probably the most common situation is the transverse duodenum, on account of its being more 

 fixed than other portions of the bowel, and because it is situated in front of the bodies of the 

 vertebrae, so that if this portion of the intestine is struck a sharp blow, as from the kick of a 

 horse, it is unable to glide out of the way, but is compressed against the bone and lacerated. 

 Wounds of the intestine sometimes occur. If the wound is a small puncture, under, it is said, 

 one-quarter of an inch (6 mm.) in length, there may be no extravasation of the contents of the 

 bowel. The mucous membrane becomes everted and perhaps plugs the little opening. The 

 bowels, therefore, may be punctured with a fine capillary trocar, in cases of excessive distention 

 of the intestine with gas, without much danger of extravasation. A longitudinal wound gapes 

 more than a transverse wound, owing to the greater thickness of the circular muscular coat. In 

 closing a wound of the intestine, use Lembert's inversion sutures, which bring the peritoneal 

 surfaces in contact. Halsted showed that these sutures must include the tough submucous 

 coat. The portions of intestine which lie in the pelvis are inflamed in pelvic peritonitis and 

 become embedded in adhesions. The portions of intestine which may be present are the termi- 

 nation of the ileum, the portion of small intestine with the largest mesentery (Treves), the rectum, 

 and the pelvic colon. The small intestine, and most frequently the ileum, may become strangu- 

 lated by internal bands, or through apertures, normal or abnormal. The bands may be formed in 

 several different ways: they may be old peritoneal adhesions from previous attacks of peritonitis; 

 or adherent omentum from the same cause; or the band may be formed by MeckeVs diverticulum, 

 which has contracted adhesions at its distal extremity; or the band may be the result of the 

 abnormal attachment of some normal structure, as the adhesion of two appendices epiploicae, 

 or an adherent vermiform appendix or Fallopian tube. Intussusception or invagination of the 

 small intestine may take place in any part of the jejunum and ileum, but the most frequent situa- 

 ation is at the ileocecal valve, the valve forming the apex of the entering ttibe. This form may 

 attain great size, and it is not uncommon in these cases to find the valve projecting from the anus. 

 Stricture, the impaction of foreign bodies, and twisting of the gut (volvulus) may lead to intestinal 

 obstruction. Volvulus is most common in the sigmoid flexure. Meckel's diverticulum may 

 itself become twisted and strangulated. 



Resection of a portion of the intestine may be required in cases of gangrene of the bowel; in 

 cases of intussusception; for the removal of a newgrowth in the bowel; in dealing with artificial 

 anus; and in cases of rupture. The operation is termed enterectomy, and is performed as follows: 

 The abdomen having been opened and the amount of bowel requiring removal having been deter- 

 mined upon, the gut must be clamped on either side of this portion in order to prevent the escape 

 of any of the contents of the bowel during the operation. The portion of bowel is then separated 

 above and below by means of scissors. If the portion removed is'small, it may be simply removed 

 from the mesentery at its attachment and the bleeding vessels tied; but if it is large, it will be 

 necessary to remove also a triangular piece of the mesentery, and having secured the vessels, 

 suture the cut edges of this structure together. The surgeon then proceeds to unite the cut 

 ends of the bowel. He may do it by the operation termed end-to-end anastomosis. There 

 are many ways of doing this, which may be divided into two classes one, where the anastomosis 

 is made by means of some mechanical appliance, such as Murphy's button, or one of 

 the forms of decalcified bone bobbins; and the other, where the operation is performed by 

 simply suturing the ends of the bowel in such a manner that the peritoneum covering the free 

 divided ends of the bowel is brought into contact, so that speedy union may ensue. 



In some cases after resection each open end of the gut is closed, the side of the terminal portion 

 is sutured to the side of the initial portion, a fistula is made in each, and the suturing is com- 

 pleted so as to cause the two fistulse to correspond. A permanent side-to-side opening is thus 

 made. Lateral anastomosis without resection may be practised between two pieces of intestine, 

 in order to side-track an intervening portion, which is the seat of malignant disease or of an 

 artificial anus. Complete exclusion of a portion of intestine is performed for irremovable tumors 

 or persistent fecal fistulse of the large intestine. The intestine is cut through above and below 

 the diseased area and the ends of the healthy gut are united to each other, or the larger end is 

 closed, an opening is made into the side of the larger end and the smaller end is implanted in it 



