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region, in the axis of the anal canal, until it reaches the cavity of the rectum, the inferior part of which is dilated to form the ampulla. The transverse folds of the rectum or valves of Houston, three in number, project into the cavity of the bowel in the form of prominent crescentic shelves, which are produced by the three permanent or true flexures into which the rectum is thrown (Birmingham); the inferior valve, which may be sufficiently prominent to impede the passage of the finger, must not be mistaken for a pathological condition. Through the anterior wall the finger can palpate from below upwards the bulb of the urethra, the membranous part of the urethra, the bulbo-urethral glands (when inflamed and enlarged), the apex and lateral lobes of the prostate, the vesiculæ seminales, and the external trigone of the bladder. With the left forefinger in the rectum, an instrument passed into the bladder can be distinctly felt as it traverses the mem
Fig. 1108.—THE RECTUM FROM BEHIND. The sacrum has been sawn across through the 4th sacral vertebra, and its inferior part removed with the coccyı.
The posterior portions of the coccygei, levatores ani, and of the external sphincter have been cut away. The " pinching in " of the inferior end of the rectum by the medial edges of the levatores ani, resulting in the formation of the flattened anal canal, is suggested in the illustration, which has been made from a formalin-hardened male body, aged thirty. The lateral inflections of the rectum, corresponding to
Houston's rectal valves, are also shown. (From Birmingham.) branous urethra ; as it lies in the prostatic urethra it is separated from the finger by the prostate. Hence, when a false passage is made through the bulbous or membranous portion of the urethra, the instrument, if pushed onwards towards the bladder, will be felt immediately outside the rectum between it and the prostate. In the child, owing to the rudimentary condition of the prostate, the instrument is distinctly felt close to the rectum, as it lies in the prostatic as well as in the membranous portion of the urethra. When the prostate is not enlarged the tip of the finger can just reach the external trigone, which is most distinctly felt when the bladder is full. The vesiculæ seminales, indistinctly felt when healthy, may be readily palpated when enlarged and indurated from disease. Through the side wall of the rectum may be palpated the ischio-rectal fossa, the bony wall of the pelvis minor, and, when enlarged, the hypogastric lymph glands; through the posterior wall the hollow of the sacrum and coccyx, and the lymph glands lying in the retra rectal cellular tissue.
rectal examination enables one to palpate, in addition to the structures in the pelvis minor, those which occupy the lower segment of the abdomen. When empty even a small calculus can be readily felt by recto-abdominal palpation.
ance of the apex of the recto-vesical pouch of peritoneum from the anus
are empty it reaches to about 2 in. from the anus; when both are dis-
pelvic colon, it is again directed forwards and a little to the left so as to
four inches from the anus.
of the lower part of the sacrum) is excised by dividing the structures ached to its margins, viz., the inferior fibres of the glutæus maximus, the cygeus, and the sacro-tuberous and sacro-spinous ligaments (0.T. greater and sser sacro-sciatic). The parietal pelvic fascia, here very thin and adherent, is emoved along with the bone. The middle sacral artery is ligatured. This is now een, stretching across the floor of the wound, a well-defined sheet of fascia, viz., he rectal layer of the visceral pelvic fascia, which is divided longitudinally and tripped to either side off the posterior surface of the rectum; in doing this the branches of the middle hæmorrhoidal arteries, and, higher up, the two divisions of the superior hæmorrhoidal are encountered and ligatured. Anteriorly, the anal canal is detached from the central point of the perineum, after which the anterior surface of the rectum is freed from below upwards from the urogenital diaphragm containing the membranous urethra, the posterior surface of the prostate, the trigone of the bladder and the vesiculæ seminales and the ductus deferentes. This procedure is facilitated by the existence of a cellular interval between the anterior wall of the rectum and the strong recto-vesical layer of visceral pelvic fascia, which forms the posterior part of the sheath of the prostate, and, higher up, encloses the vesiculæ seminales and ductus deferentes. In order to strike this cellular interspace, the surgeon, after dividing the central point of the perineum transversely, deepens the incision down to the apex of the prostate. In doing this he divides a band of muscular fibres (recto-urethral muscle) which passes from the anterior wall of the lowest part of the rectal ampulla to blend with the sphincter urethræ muscle surrounding the urethra at the apex of the prostate. It is these recto-urethral fibres, which, by pulling forwards the ampulla, bring it into close relation with the urethra ; hence it is especially at this stage of the operation that great care must be taken not to open into the rectum or to wound the urethra. After exposing the apex of the prostate the next step is to
retract the anal canal well backwards and to define the anterior or pubo-prostatic die het die borders of the levator ani muscle. These muscles are then divided, on each side,
a little above their insertion into the rectum. The posterior surface of the prostate covered with recto-vesical fascia, is now exposed.
By continuing the separation of the rectum upwards in the cellular plane above mentioned, the bottom of the recto-vesical pouch of peritoneum is reached; it can usually be stripped for some distance off the rectum, without opening into the peritoneal cavity. In freeing the rectum laterally, bands of connective tissue containing branches of the middle and superior hæmorrhoidal vessels are divided. If the tumour is situated at the superior part of the rectum, the recto-vesical pouch of peritoneum is freely opened in a transverse direction. The colo-rectal junction is then mobilised by dividing the sacral attachment of the pelvic mesocolon and securing the superior hæmorrhoidal artery. After dividing the rectum well above the tumour, the opening into the peritoneal cavity is closed by suturing together the anterior and posterior walls of the recto-vesical pouch. If a permanent colostomy has been established, the divided bowel is closed; if not, a sacral anus is made.
On opening the abdomen by a median incision extending from the umbilicus to the pubes, and looking into the pelvis minor from above, after displacing some coils of the small intestine upwards, the fundus of the uterus, directed forwards and a little upwards, is seen resting upon the superior surface of the bladder. Behind the uterus is the rectum, and between the two the recto-uterine pouch of Douglas, containing the pelvic colon and the inferior part of the ileum. The ovary lies a little below the level of the superior aperture of the pelvis minor upon a triangular shelf, bounded in front by the broad ligament, behind and medially by the uterosacral ligament, and behind and laterally by the pelvic wall. When the vermi. form process overhangs the superior aperture of the pelvis minor its tip may come into close relation with the right ovary, a condition which often leads to a difficulty in distinguishing an inflammation of that ovary from appendicitis. The round ligaments are seen passing forwards and laterally from the upper parts of the right and left borders of the uterus to the abdominal inguinal rings, which lie immediately in front and to the medial side of the terminations of the external iliac arteries Inferiorly and at the medial side of the round ligament, as it leaves the pelvis, is the inferior epigastric artery. By pulling the uterus upwards the attachments of the broad ligament to the floor and side walls of the pelvis are brought into evidence, as also are the utero-vesical and recto-vaginal peritoneal pouches; the former is shallow, while the deepest part of the latter covers the upper fourth of the posterior wall of the vagina, and comes into relation, therefore, with the posterior fornix.
The utero-vesical peritoneal reflection takes place at the level of the junction of the body of the uterus with the cervix. The anterior wall of the cervix comes into relation, therefore, with the superior part of the base of the bladder, from which, however, it is separated by a layer of loose connective tissue. It is the existence of this cellular plane which enables the surgeon to separate the bladder readily from the uterus in the operation of hysterectomy.
While the anterior wall of the vagina is firmly united to the urethra, its posterior wall, on the other hand, can be readily separated from the rectum, in consequence of the interposition between the two organs of the recto-vaginal fascia
The ureter crosses the brim of the pelvis in front of the bifurcation of the common iliac artery 1} in. lateral to and a little below the centre of the sacral promontory. The corresponding point on the anterior abdominal wall is at the junction of the lateral and middle thirds of a line joining the anterior superior spines of the ilium.
After crossing the termination of the common iliac artery from lateral to medial side, the ureter dips vertically into the pelvis minor behind the peritoneum covering the hypogastric artery. It then courses medially in the parametric cellular tissue below the base of the broad ligamenta. In this position it lies a little above the lateral fornix of the vagina, about three-quarters of an inch lateral to the superior part of the cervix uteri; finally, just before it pierces
gle of the bladder, it lies in front of the antero-lateral aspect of the
liable to injury, more especially in the operation of hysterectomy
The larger vestibular glands, about the size of a bean, are placed on each side of the posterior third of the orifice of the vagina, below the urogenital diaphragm. Their ducts, nearly one inch in length, open posteriorly between the hymen and the posterior commissure (fossa navicularis). Abscesses and cysts not infrequently develop in connexion with these glands. The bulbs of the vestibule are two piriformn collections of erectile tissue situated on each side of the vestibule, between the bulbo-cavernosus muscle and the inferior fascia of the urogenital diaphragm. Rupture of these bodies gives rise to the condition known as pudendal hæmatocele.
The cervix uteri projects downwards and backwards into the roof of the vagina so as to leave a distinct fornix between the two. The relations of the fornix are of so much practical importance that for descriptive purposes it is customary to subdivide it into an anterior, a posterior, and two lateral portions. The anterior fornix, which is shallow, is related to the base of the bladder and to the utero-vesical pouch of peritoneum. The posterior fornix, which is deeper, extends upwards for some little distance in front of the anterior wall of the lowest part of the pouch of Douglas. The septum between the two is formed merely by the wall of the vagina; hence the readiness with which the pelvis may be drained by puncturing it and pulling a tube through the opening from the pelvis into the vagina.
The lateral fornix lies below the medial part of the base of the broad ligament. An incision carried through it would therefore open into the parametric cellular tissue and would expose the uterine artery as it passes transversely to the uterus, after crossing above and in front of the lower part of the ureters.
Vaginal Examination. In making a vaginal examination the patient should be placed in the dorsal position, with the thighs well flexed; the index-finger of the right hand is now carried along the fold of the buttock towards the median plane, where it will impinge against the posterior aspect of the introitus vaginæ, whence it is inserted
Exposure of Kidney from behind.—In exposing the kidney from the loin, by a vertical incision between the lateral border of the sacrospinalis and the free
abdominal muscles still further downwards 2
The upper part of the ureter is exposed posterior border of the external oblique muscle, the following structures are
After stripping the peritoneum off the quad divided from without inwards (1) the integuments; (2) the lower fibres of the
will be found to cling to the deep surface o latissimus dorsi and serratus posterior inferior muscles ; (3) the middle layer of the
10 injure the internal spermatic or ovarian lumbar aponeurosis, just lateral to the sacrospinalis compartment, and parallel to the
Seally, and from the medial to the lateral lateral fibres of the quadratus lumborum muscles; (4) the anterior layer of the lumbar aponeurosis (which forms the aponeurotic origin of the transversus muscles), and the
quantity of love cellular tissue, and, owing
adventitious coat, is very elastic, so that it transversalis fascia; (5) the paranephric fat; (6) the perinephric fascia; (7) the To deliver an enlarged kidney out perinephric fat surrounding the true capsule of the kidney. The kidney may be prolong the incision upwards so as to readily mobilised and brought to the surface by shelling it out of its fatty capsule
may be necessary to divide, fracture this it is not always possible to avoid sus, which descends in front of the
In operating on the kidney, t's bo-inguinal nerves, which lie betbe injured; the last thoracic he other two downwards and
A needle passed throws
pane will transfix the supra 0
The pus of a perinephis peinephric fat), and lie
in a psoas abso
a psoas absce Sned by the lateral
the deeper part of t SPLEEN
the ransverse proces
Diaphragm, Liv LIVER
Se of the diaphrag
be aggle of the Rib x
nach lie one in
Se eighth thoracic
Rib XI Rib XI
the eighth to the t KIDNEY KIDNEY
& line draw Descending colon
Posteriorly, the supe -Ascending com
fesor limit merge
The cardiac orific
Beards to the leveangle of the scapula. Erst and second Jumb right of the first lumba The ten th, eleventh, and
Viewed from behind
border of the kidneys an
useles The peritoneum wall along a line drawn ver lett fezure of the colon, whic and be tenth rib, lies abo Eres on a level with the first
Spleen. — The spleen, situa of the stomach, is overlapped of the organ corresponding a superior third of the spleen ar is the base of the left lung, th the pleura reaches down as fa bimit of the organ cannot the or displaced downwards, the 8
the level of the tenth E
ing the pleural as well as the