1320 THE ORGANS OF DIGESTION 



of cancer of the rectum which are too low to be reached by abdominal section, and too high to be 

 removed by the ordinary operation from below, Kraske has devised an operation which goes by 

 his name. The patient is placed on his right side and an incision is made from the second sacral 

 spine to the anus. The soft parts are now separated from the back of the left side of the sacrum 

 as far as its left margin, and the greater and lesser sacrosciatic ligaments are divided. A portion 

 of the lateral mass of the sacrum, commencing on the left border at the level of the third poste- 

 rior sacral foramen, and running downward and inward through the fourth foramen to the cornu, 

 is now cut away with a chisel. The left side of the wound being now forcibly drawn outward, 

 the whole of the rectum is brought into view, and the diseased portion can be removed, leaving 

 the anal portions of the gut, if healthy. The two divided ends of the gut can perhaps then be 

 approximated and sutured together. Kraske's operation is in many cases preceded by the per- 

 formance of iliac colostomy. In cancer high up in the rectum removal of the growth through 

 the abdomen is sometimes practised, the divided lower end of the rectum being sutured to the 

 divided upper end (Weir's operation). 



The colon frequently requires opening in cases of intestinal obstruction, and by some sur- 

 geons this operation is performed in cases of cancer of the rectum, as soon as the disease is recog- 

 nized, in the hope that the rate of growth may be retarded by removing the irritation produced 

 by the passage of fecal matter over the diseased surface. The operation of colostomy may be 

 performed either in the inguinal or lumbar region; but inguinal colostomy (Maydl's operation) 

 has at the present day superseded the lumbar operation. The main reason for preferring this 

 operation is that a spur-shaped process of the mesocolon can be formed, which prevents any fecal 

 matter finding its way past the artificial anus and becoming lodged on the diseased structures 

 below. The sigmoid flexure being surrounded by peritoneum, a coil can be drawn out of the 

 wound, and when it is opened transversely a spur is formed, and this prevents any fecal matter 

 finding its way from the gut above the opening into that below. The operation is performed 

 by making an incision two or three inches in length from a point one inch internal to the anterior 

 superior spinous process of the ilium, parallel to Poupart's ligament. The various layers of 

 abdominal muscles are cut through, and the peritoneum opened and sewed to the external 

 skin. The sigmoid flexure is now sought for, and pulled out of the wound and fixed by pushing 

 a glass bar through a slit in the mesocolon. The two parts of the loop are sutured together. 

 The intestine is now sutured to the parietal peritoneum. The wound is dressed, and either 

 immediately or between the second to the fourth day, according to the requirements of the case, 

 the protruded coil of intestine is opened. It is opened transversely with the Paquelin cautery. 



The loose connective tissue around the rectum is occasionally the site of an abscess, the active 

 focus of which, however, may be located elsewhere. This form of abscess may be described as 

 the superior pelvic recf,al; it is placed above the pelvic diaphragm, but beneath the peritoneum. 

 The acute variety is generally due to ulceration or perforation of the bowel (possibly produced by 

 a foreign body) above the level of the attachment of the Levator ani. The abscess may also occur 

 above a stricture (simple or malignant) of the rectum; occasionally it arises from suppuration 

 around the prostate, and more rarely follows abscess of the seminal vesicles. Chronic abscesses 

 also appear in the same region either from caries of the anterior surface of the sacrum or from 

 caseation of the presacral lymph nodes, while in other cases an abscess finds its way down into 

 the pelvis from disease of the anterior surfaces of the bodies of the lumbar vertebrak 



THE LIVER (HEPAR) (Figs. 1063, 1064). 



The liver is the largest gland in the body and is situated in the upper and 

 right part of the abdominal cavity, occupying almost the whole of the right hypo- 

 chondrium, the greater part of the epigastrium, and not uncommonly extending 

 into the left hypochondrium as far as the midclavicular line. In the male it weighs 

 from fifty to sixty ounces: in the female, from forty to fifty. It is relatively 

 much larger in the fetus than in the adult, constituting, in the former, about one- 

 eighteenth, and in the latter, about one-thirty-sixth of the entire body weight. 

 Its greatest transverse measurement is from eight to nine inches (20 to 22 cm.). 

 Vertically, near its lateral or right surface, it measures about six or seven inches 

 (15 to 18 cm.), while its greatest antero-posterior diameter is on a level with the 

 upper end of the right kidney and is from four to five inches (10 to 12 cm.). Op- 

 posite the vertebral column its measurement from before backward is reduced 

 to about three inches (7.5 cm.). Its consistence is that of a soft solid; it is, how- 

 ever, friable and easily lacerated; its color is a dark reddish brown, and its 

 specific gravity is 1.05. 



