286 THE ABDOMEN AND PELVIS 



this gutter may occur by downward spread from Morison's 

 pouch and the omental bursa, and this condition may be suspected 

 in those cases of perforated gastric or duodenal ulcer in which 

 pain is felt over the right iliac fossa. Owing to the presence 

 of this channel, stomach contents may be found in the pelvis,, 

 even when the greater omentum is adherent to the anterior 

 abdominal wall. Pus from a retro-csecal (intra-peritoneal, 

 p. 333) abscess may spread upwards along the right para-colic 

 gutter into the loin and possibly to the subphrenic danger zone. 



Drainage is conveniently carried out through a stab wound 

 just above the iliac crest by means of a tube, which can be 

 drawn out in front through the appendicular incision. The 

 wound must be on the lateral side of the ascending colon, and 

 great care must be taken to avoid injuring the gut. 



The left para-colic gutter extends along the lateral side 

 of the descending and iliac cola and opens freely into the pelvis 

 at its lower end. Its upper extremity is separated from the 

 spleen and the lieno-renal recess by the phrenico-colic ligament, 

 a fold of peritoneum which passes laterally from the left colic 

 (splenic) flexure to the diaphragm. It may be infected from 

 the supra-colic compartment or by upward spread from the 

 pelvis. Drainage may be obtained through a small grid-iron 

 incision in the left iliac fossa, and a stab wound similar to that 

 employed on the right side. A tube may then be passed through 

 from back to front. 



The basin of the Pelvis is formed by the utero-rectal pouch 

 in the female and by the recto-vesical pouch in the male. 

 Primary infection is due to pathological conditions of the 

 vermiform process (p. 331) or the pelvic viscera. Secondary 

 infection is extremely common, as both para-colic gutters, the 

 supra-colic compartment (in the absence of omental adhesions), 

 and both infra-colic compartments drain into the pelvis. 



In the female, owing to the peritoneal relations of the vagina 

 (p. 387), the pelvis may be drained through an incision in the 

 upper part of the posterior fornix. It has been suggested that, 

 in the male, drainage may be obtained through an incision into 

 the rectum from the bottom of the recto-vesical pouch. The 

 usual method, however, is to drain by means of tubes passed 

 downwards and backwards from a median supra-pubic incision, 

 or downwards and medially from iliac grid-iron incisions. 



In all cases of pelvic inflammation, the patient is placed in 

 the Fowler (semi-sitting) posture, and the assistance of gravity 



