284 Anatomy Applied to Medicine and Surgery. 



iliac vein, while others the superior hemorrhoidal go 

 to the portal system. The nerves are derived from the 

 superior and inferior hypogastric plexuses (sympathetic), 

 with, in addition, branches from the fourth sacral nerve 

 that ramify in the lower part of the rectum. The lower 

 part of the rectum and its affections will be considered, 

 along with the reflexes of the pelvic viscera, when dealing 

 with the perineum, so that at present it will suffice to 

 describe, briefly, excision of the upper part of the rec- 

 tum for carcinoma. When it is found necessary to remove 

 this portion, Kraske's method, or some mollification of it, 

 is followed so as to permit freer access to the bowel. In 

 these operations a portion, or the whole of the lower 

 part of the sacrum, below the third sacral foramen, is re- 

 moved. The bone should not be divided above this point, 

 since there would be danger of permanent paralysis of the 

 bladder resulting. The incision begins about two inches 

 to the left of the middle of the sacrum, and is then direct- 

 ed towards the median line, on reaching which it is ex- 

 tended along the fold between the buttocks towards the 

 anus. The soft parts are turned back from the bone, the 

 sacro-sciatic ligaments divided, and a periosteal elevator, 

 passed beneath the sacrum, separates the soft parts from 

 its anterior surface ( Kelsey ) . The bone is then divided at 

 the level selected. The rectum is identified after incising the 

 connective tissue between it and the sacrum, and the fin- 

 ger is worked around the bowel, keeping a little distance 

 from the muscular wall to avoid branches of the superior 

 hemorrhoidal artery, for, if these be severed, the nutrition 

 of the lower part of the proximal end will be seriously 

 interfered with. The diseased portion is removed after 

 opening up the peritoneal cavity. The peritoneum is su- 

 tured and the proximal portion of the rectum is brought 

 down to the anus and attached there, or sutured to any 

 part of the distal portion that may have been left. 



