932 THE ORGANS OF DIGESTION. 



mucous and muscular coats, and receive no support from surrounding tissues, and this favors 

 varicosity. Moreover, the veins, after running upward in a longitudinal direction for about five 

 inches in the submucous tissue, pierce the muscular coats, and are liable to become constricted 

 at this by the contraction of the muscular wall of the gut. In addition to this there are no 

 valves in the superior hemorrhoidal veins, and the vessels of the rectum are placed in a depend- 

 ent position, and are liable to be pressed upon and obstructed by hardened feces. The anatomi- 

 cal arrangement, therefoi'e. of the hemorrhoidal vessels explains the great tendency to the 

 occurrence of piles. The presence of the Sphincter ani is of surgical importance, since it is 

 the constant contraction of this muscle which prevents an ischio-rectal abscess from healing 

 and causes it to become a fistula. Also, the reflex contraction of this muscle is the cause of the 

 severe pain complained of in fissure of the anus. The relations of the peritoneum to the rectum 

 are of importance in connection with the operation of removal of the lower end of the rectum 

 for malignant disease. This membrane gradually leaves the rectum as it descends into the 

 pelvis ; first leaving its posterior surface, then the sides, and then the anterior surface to become 

 reflected in the male on to the posterior wall of the bladder, forming the recto-vesical pouch, and 

 in the female on to the posterior wall of the vagina, forming Douglas's pouch. The recto-vesical 

 pouch of peritoneum extends to within three inches from the anus, so that it is not desirable 

 to remove more than two and a half inches of the entire circumference of the bowel, for 

 fear of the risk of opening the peritoneum. When, however, the disease is confined to the 

 posterior surface of the rectum, or extends farther in this direction, a greater amount of the 

 posterior wall of the gut may be removed, as the peritoneum does not extend on this surface to 

 a lower level than five inches from the margin of the anus. The recto-vaginal or Douglas's 

 pouch in the female extends somewhat lower than the recto-vesical pouch of the male, and 

 therefore it is necessary to remove a less length of the tube in this sex. Of recent years, 

 however, much more extensive operations have been done for the removal of cancer of 

 the rectum, and in these the peritoneal cavity has necessarily been opened. If, in these 

 cases, the opening is plugged with antiseptic wool until the operation is completed and then the 

 edges of the wound in the peritoneum accurately brought together with sutures, no evil result 

 appears to follow. For cases 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 

 sacro-sciatic ligaments are divided. A portion of the lateral mass of the sacrum, commencing 

 on the left border at the level of the third posterior 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 portion of the gut, if healthy. The 

 two divided ends of the gut can then be approximated and sutured together in front, the 

 posterior part being left open for drainage. 



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

 surgeons this operation is performed in cases of cancer of the rectum, as soon as the disease 

 is recognized, 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 colotomy 

 may be performed either in the inguinal or lumbar region ; but inguinal colotomy has in the 

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

 operation is that a spur-shaped process of the meso-colon can be formed which prevents any 

 fecal matter finding its way past the artificial anus and becoming lodged on the diseased struct- 

 ures below. The sigmoid flexure being almost entirely surrounded by peritoneum, a coil can be 

 drawn out of the wound and the greater part of its calibre removed, leaving the remainder 

 attached to the meso-colon, which forms a spur, much the same as in an artificial anus caused 

 by sloughing of the gut after a strangulated hernia, 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 sewn to the external skin. The 

 sigmoid flexure is now sought for, and pulled out of the wound and fixed by passing a needle 

 threaded with carbolized silk through the meso-colon close to the gut and then through the 

 abdominal wall. The intestine is now sewn to the skin all round, the suture passing only 

 through the serous and muscular coats. The wound is dressed, and on the second to the fourth 

 day, according to the requirements of the case, the protruded coil of intestine is opened and 

 removed with scissors. 



Lumbar colotomy is performed by placing the patient on the side opposite to the one to be 

 operated on, with a firm pillow 7 under the loin. A line is then drawn from the anterior superior 

 to the posterior superior spine of the ilium, and the mid-point of this line (Heath) or half an 

 inch behind the mid- point (Allingham) is taken, and a line drawn vertically upward from it to 

 jhe last rib. This line represents, with sufficient correctness, the position of the normal colon. 

 An oblique incision four inches in length is now made midway between the last rib and the crest 

 of the ilium, so that its centre bisects the vertical line, and the following parts successively 

 divided: (1) The skin, superficial fascia, with cutaneous vessels and nerves and deep fascia. 

 (2) The posterior fibres of the External oblique and anterior fibres of the Latissimus dorsi. 



