Constipation in adults and children

Front matter

Class Book

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CONSTIPATION

Section I Chapter I

Anatomy of the Intestines. (With reference mainly to the large bowel; its position in the abdominal cavity; the internal arrangement of its mucous membrane.) The vessels. The nerves — showing the relation of the bowels to the cerebral and the spinal centres 27

Chapter VII

Chronic Constipation; Etiology. The various maladies that may give rise thereto — Foreign bodies (with histories of cases) — Malformations of the intestines — Dislocation of the intestine — Essential primary atrophy of the intestine 87

vii

Vlll TABLE OF CONTENTS

CHAPTER XIV Formulary ......... 488 LIST OF ILLUSTRATIONS

Part I

Frontispiece, showing the abdominal organs in position.

The duodenum and surrounding structures 4

The caecum, showing funnel-shaped terminal extremity of the ileum,

and the appendix vermiformis 7

The large bowel in position 8

The caecum laid open, showing orifice of appendix vermiformis . . 10

The sigmoid flexure 12

The sigmoid flexure . 4 13

The external sphincter of the anus, perineal muscles in man . , .15

Sacculi Horneri 18

Diagram of the nerves of the intestinal tract 21

The plexus of Auerbach 23

The plexus of Meissner 24

The male perineum, showing distribution of nerves .... 25

Normal faeces 41

Human colon, congenital giant growth .67

Diverticulum, congenital, of the sigmoid flexure 77

Illustration of enteroptosis .80

Upward dislocation of transverse colon 81

Dislocation of the sigmoid flexure to the right . . . 85

Abdomen, where to examine 119

Arrangement of apparatus for inflating the bowel with gas . . .122 Arrangement of apparatus for inflating the bowel with air . . .123

Crystals of haematoidin 127

Teichmann's haemin crystals Il'7

Colored Plate, showing microscopic appearance of some constipated

faeces, between pages 128 and 129

Demi-schematic view of the external surface of the ampulla of the xiii

XIV

LIST OF ILLUSTRATIONS

Demi-schematic view of the internal surface of the ampulla of the

False diverticula, of the large bowel Distention diverticula, of the small intestine Diverticulum of the ileum Bandages for the abdomen

Abdominal bandage

Effleurage with the tips of the fingers

Frictions with the thumb

Petrissage with the thumb ....

Petrissage with the thumb and finger

Diagrammatic illustration of position of patient for massage

Division of the belly with one hand .

Division of the belly with two hands

Polling of the belly with one hand .

Rolling of the belly with two hands .

Petrissage of the abdominal walls

The Kammgrifi*

Kneading of the belly .....

Punctation

Circular effleurage

Position of hands for operator .

To break up indurated faeces in caecum and ascending colon To break up indurated faeces in transverse colon Manipulation for ascending colon, liver, and gall bladder Transfer movement, for caecum and ascending colon Transfer movement, for transverse colon .... Transfer movement, for descending colon and sigmoid flexure Position of hands for petrissage, of sections of colon Position of hands for petrissage, of sections of colon

Kneading and raising of sigmoic Vibration of solar plexus .

Hacking of the belly .

Clapping of the belly .

Tapotement a Pair comprime Beating of the sacrum Kahn's roller Figs. 1-10, Active movements flexure

134^

1G4 J

222 • 223- 225 227^

229 '

LIST OF ILLUSTRATIONS

XV

PAGE

Figs. 11-18, Movements against resistance 250-255

Figs. 19-23, Passive movements 257-258

Fig. 24, Row boat of Sachs .261

Fig. 25, Row boat of Ewer . . .261

Fig. 26 a, Movements with Sachs restaurateur 261

Fig. 26 b, Goodyear's pocket gymnasium 261

Outline of enlarged spleen 262

Self-acting clysopump 265

Force pump . . . . 267

Application of the wet sheet .274

Sprinklers 279

Rectal electrodes 289

Bipolar rectal electrodes 289

Atzperger apparatus . 337

Winternitz's device 338

Bottle for generating carbonic acid 339

Psychrophor 341

Hsemorrhoidal bandage 349

Tip for syringe (for oil injection) 355

Rectal bougies 361

Whitehead's instrument . . . . . . . . . .361

Part II

Frontispiece I. Abdomen of infant twelve days old laid open, small

intestines in sitn.

Frontispiece II. Same, showing large bowel, liver, and stomach. Congenital contraction of the ascending and transverse colon, etc. Congenital obliteration of the small intestines , Ileum with diaphragms . .

The abdominal viscera of a new-born infant held i Diagram of the above .....

Diagram showing direction of manipulation Manipulation II. for infants Diagram showing direction of manipulation Manipulation III. for infants Manipulation IX., thumb movement .

erse colon

, etc.

position

PART I

>XKc

SECTION I

Chapter I

The part of the human body that principally concerns us here is the intestinal canal, consisting of two distinct and characteristic parts, — the small intestines and the large bowel.

The small intestines constitute by far the major part of the intestinal tract. The average length in the adult male (between the ages of twenty and fifty) is twenty-two feet, six inches ; in the female it is twenty-two feet, four inches. Exceptionally it is found, both in the male and female, longer or shorter by some feet.

The intestinal tract proper begins at the stomach, from which it is separated by the sulcus pyloricus, with that portion known as the duodenum. Ever since the days of Herophilus the small intestines have been divided into three parts, — the duodenum (twelve fingers, eight to ten inches), the jejunum, and the ileum. There is, however, no line of demarcation that separates the duodenum from the jejunum, or any distinctive feature by which to recognize the one from the other. Luschka has therefore proposed that the duodenum and jejunum be grouped together as one part and be called the pancreatico-bilious intestine (intestinum pancreatico-biliosum).

The duodenum takes its origin at the pyloric extremity of the stomach, on the right side of the epigastrium, about the level of the last dorsal vertebra, and ends on

The Duodenum and surrounding Structures. (Sappey.)

1, Pars horizontalis superior, thrown back to the right; 2, Pars descendens or verticalis ; 3, Pars horizontalis inferior.

the left of the spinal column, about the level of the third lumbar vertebra, in the jejunum. Between the points here described it changes its course three times and is therefore divided into three segments, — some have it four, — the jiars horizontalis superior, the pars descendens or verticalis, and the pars horizontalis inferior. The fourth part described by some is the pars ascendens.

The pars horizontalis superior. Beginning at the stomach, as already described, it runs outward and somewhat upward to the right in a horizontal direction, with a tendency to obliqueness. The position varies, of course, considerably with the movements of the stomach, becoming more transverse when the longitudinal fibres of that organ are contracted, and more oblique when the stomach is dilated. The position undergoes change in gastroptosis, whether this be partial, as when the pyloric portion alone is dislocated, or complete. This portion of the duodenum is the widest of this section of the small intestine and is about two or three inches in length. It is somewhat bottle-shaped, dilated more at its upper extremity to form the antrum duodenale. It is covered by the lobus quadratus and the right lobe of the liver. This segment is freely movable and is almost completely invested by the peritoneum. The pars verticalis (descending segment) runs down in front of the right kidney as far as the third lumbar vertebra. It does not descend in a straight line, but makes a gentle curve and merges almost imperceptibly into the inferior transverse portion. Joined to this latter part it gives to the duodenum the configuration of a horseshoe with the convexity looking to the right and the concavity to the left. In the concavity is received the head of the pancreas. On the inner surface of the vertical segment just below its middle is the orifice of the ductus communis choledochus, and just a little above this the separate orifice for the duct of the pancreas. It is covered by peritoneum on its anterior surface only. The pars horizontalis inferior, the longest and narrowest part of the duodenum, passes over transversely from the right side to the left and at the left border of the spinal column ends in the jejunum. That which by some is described as a fourth change in direction, or fourth segment, is the ascent made by the terminal extremity of the duodenum from the third to the second lumbar vertebra, at which point the jejunum may be said to begin. It has a partial investment of peritoneum on its anterior surface. It is covered in front by the transverse mesocolon and crossed by the superior mesenteric vessels ; it lies upon the aorta, vena cava, and the crura of the diaphragm. Above it is the lower border of the pancreas.

Jejunum and Ileum. — The jejunum is two-fifths of the residue of the small intestine. It begins at the point already described, descends, makes numerous convolutions, and merges into the ileum. The ileum is the residue of the small intestine, and is the narrowest portion of it. The gyri or ansae, which these two segments form, are very numerous, and they lie closely packed together. They are arranged in a very irregular form, from left to right. Leaving the duodenum, they fill the contiguous left epigastric and umbilical regions, then the left hypochondriac and left lumbar regions, descend into the pelvis, reascend into the left iliac, pass over the hypogastric into the lower umbilical, right hypochondriac, and right lumbar regions. The ileum terminates here in that portion of the large bowel known as the caecum. This terminal extremity is rather funnel-shaped, the wide portion of the funnel directed toward the ileum.

By means of the mesentery, which is a fold from the peritoneum, and which with its two layers, the ascending and descending, forms the peritoneal covering of these two segments of the small intestine, they are hung up, as it were, on the spinal column.

The capacity of the small intestine is equal to six litres (about twelve pints).

The Large Bowel. — The large bowel, intestinum crassum sen amplum, is about five feet in length, with occa-' sional variations as in c

Showing C^cum and Funnel-shaped Terthe Case of the Small minal Extremity of the Ileum. (Sappey.)

intestine. It begins at *> Line of division of the small intestine;

. 2, Opening of the small intestine into the large

the termination of the bowel ; 3, Lower section of ileo-caecal valve ;

• -. -. -j , 4, Upper section of ileo-caecal valve ; 5, Bundles

Ileum ana. enQS at tne f muscle-fibre passing over from the small on

anUS. It is latest at Jo the large bowel ;6, Lower section of c*cum ;

i* <_,v^u i*u ^ Appendix vermiformis; 8, Posterior outer

the C86CUm and STadu- t8en ^ a > 9, Posterior inner taenia ; 10, Anterior

taenia; 11, Haustra (Sacculi).

ally diminishes in calibre until the rectum is reached, where there is again an increase in size. The large bowel in its course describes an arch in the concavity of which the loops of the small intestine are located. From the right iliac fossa, the point of beginning, it runs upward through the right lumbar and right hypochondriac regions to the under surface of the liver, where it makes a curve, which is covered by the overlying liver ; passes then trans-

The Large Bowel in Position. (Hartmann)

a, Ascending colon ; 6, Transverse colon; c, Sigmoid flexure ; d, e, g, Mesocolon and mesentery ; h. Fascia covering inner pelvic muscles. 1, Central tendon (of diaphragm) ; 2, Opening for the oesophagus ; 3, Bundles of muscle-fibre of the under surface of the diaphragm ; 4, Appendix vermiformis.

versely, with a somewhat upward tendency, onward between the borders of the epigastric and umbilical regions into the left hypochondriac region, — near the spleen, about two vertebra higher than to the right, — where it again makes a curve and descends through the left lumbar region and left iliac fossa, where it makes a sort of fold known as the sigmoid flexure ; it then passes downward and terminates at the anus. The large bowel is divided into various parts : the ccecum and appendix vermiformis, the ascending colon, the transverse colon, the descending colon, the sigmoid flexure, the rectum, and the anus.

The caecum (blind pouch) is the largest segment of this section of the intestinal tract. It measures about two and a half inches both in its vertical and transverse diameters. It lies in the right iliac fossa on the right internal iliac muscle, with its end about the middle of Poupart's ligament. It is retained in position by the peritoneum, which passes over its anterior surface and sides, and posteriorly it is connected by loose areolar tissue with the iliac fossa. Occasionally it is almost surrounded with peritoneum, which then forms a mesocsecum.

About the junction of the caecum and the ascending colon the ileum opens into the large bowel by a narrow, elongated, slit-like, aperture at right angles to the axis of the bowel. The mucous membrane forms here two semilunar valvular folds which project into the bowel and constitute the ileo-caecal valve, the valvida Bauhini. At each end of the orifice the valves coalesce, and are continued as a narrow membranous rido-e around the canal of the bowel for a little way, forming the frsena or retinacula of the valve. ' At the left extremity of the slit the aperture is rounded ; at the right end it is narrow and pointed. When the caecum is distended, the borders of the valvular folds are closely approximated and any reflux prevented.

At the lower and posterior portion of the caecum, there is found attached a small worm-like process, the appendix

Ileum

Orifice of Appendix Vermiformis (From Harrison Allen's Human Anatomy.)

vermiformis. It is from three to six inches in length ; exceptionally it may be found longer ; thus Luschka saw one that had a length of twenty-three centimetres (about eighteen inches). Its diameter is about the size of a goosequill. It opens into the caecum by a minute orifice at which an incomplete valve-like projection of the mucous membrane is sometimes found.

The Ascending Colon : that part of the large intestine

ANATOMY OF THE INTESTINES H

lying on the right side of the abdomen between the crest of the ilium and the diaphragm. Continuous with the caecum and smaller than it, it mounts upward and somewhat outward, to the right hypochondrium, passing in front of the lower half of the right kidney. Here it makes a turn, the flexura coli dextra sen hejiatica, runs horizontally and to the left, and terminates in the transverse colon.

The right colic flexure is in contact with the lower border of the right lobe of the liver and partly also with the gall bladder.

The ascending colon is covered anteriorly and on its sides with peritoneum and sometimes is completely invested by it, so that a narrow mesocolon is formed ; posteriorly it is usually covered by loose areolar tissue which connects it with the quadratus lumborum muscle and the kidney. It is thus retained in position.

The Transverse Colon : the longest part of the large bowel passes transversely across the abdomen between the lower boundary of the epigastric and the upper boundary of the umbilical region to the left hypochondrium, where it makes a turn, the flexura coli sinistra sen linealis, and passes downward to terminate in the descending colon. In its passage across the abdomen it describes somewhat of an arch, the concavity being directed backward toward the vertebral column. This is known as the transverse arch of the colon.

This is the most movable part of the colon ; it is almost completely invested with peritoneum and is attached to the vertebral column by a large and wide duplicature of this membrane, the transverse mesocolon.

It is in relation by its upper surface with the lower border of the right lobe of the liver, with the gall bladder, with the greater curvature of the stomach, and with the lower border of the spleen ; by its under surface with the small intestines ; by its anterior surface with the great omentum and the other constituent parts of the abdominal parietes.

The Descending Colon passes downward through the left hypochondrium and the left lumbar region to the upper part of the left iliac fossa where it enters into the sigmoid flexure.

The Sigmoid Flexure. — This is normally the narrowest portion of the large bowel and lies in the left iliac fossa.

As usually described, the gut makes a double turn upon itself; beginning at the termination of the descending colon it curves upward, then descends and ^ again makes an upward curve, the whole having the shape of the figure " g " — whence the name — and terminates in the rectum. According to Treves, however, this description, though classic, is erroneous; the flexure does not resemble the "§" Komanum ; it has rather the figure of an omega — " 11." He describes it as follows : " The descending colon ends just at the outer border of the psoas. The gut here suddenly changes its direction ; it crosses the muscle at right angles and about

(From Treves' Anatomy of the Intestinal Canal, etc.)

C, Usual shape of the unfolded loop (adult) ; M, Termination of descending colon; N, at the point of ending of the mesorectum.

midway between the lumbosacral eminence and Poupart's ligament. It now descends vertically along the left pelvic wall and may at once reach the pelvic floor. It then passes more or less horizontally and transversely across the pelvis from left to right and commonly comes into contact with the right pelvic wall. At this point it is bent upon itself, and, passing once more to the left, reaches the middle line and descends to the anus." Treves includes in his description of the flexure what is usually denominated the first segment of the rectum. The aver-

A, Most usual arrangement of the loop when in situ.

B, Rarer form of arrangement.

age length of this portion of the bowel in the adult is about 17i inches. It is kept in place by a fold of peritoneum, — the sigmoid mesocolon. The fold, however, is ample and permits of extensive movement on the part of this segment of the large bowel.

The Rectum. — This is the terminal portion of the large bowel. It is narrower at its upper part than the sigmoid flexure, but dilates as it descends and, just before the anus, forms an ampulla, which may reach great size. The rectum, which varies in length from six to eiffht inches, is usually divided into three parts, — the upper, the middle, and the lower portion. (As already stated. Treves recognizes but two segments, counting the first as part of the sigmoid flexure.) It begins at the left sacro-iliac symphysis, passes obliquely downward from left to right to the middle of the sacrum, making a gentle curve to the right. It regains the middle at this point and descends to the lower part of the sacrum and coccyx ; near the extremity of the latter bone it inclines backward to terminate at the anus, a buttonhole orifice, situated a little in front of the coccyx.. The upper part of the rectum is completely surrounded by peritoneum and connected with the sacrum behind by a fold of this membrane, which is known as the mesorectum. In front it is separated, in the male from the posterior surface of the bladder, and in the female from the posterior surface of the uterus and its appendages, by some convolutions of the small intestines. The middle portion is closely connected with the sacrum ; it is covered by peritoneum on its upper and anterior portions only.

The Sphincters of the Anus. The external sphincter. — Like all sphincters, its purpose is to keep an orifice, that of the anus, closed. It consists of planes of muscular fibre which surround the anus. It is elliptical in shape and intimately adherent to the integument about the margin of the anus. It arises from the tip of the coccyx, and is inserted into the tendinous centre of the perineum, merging with the transverse perinei muscle. It has both voluntary and involuntary muscular fibres.

The internal sphi?icter is a plane of involuntary muscular fibres about one-half an inch in length, which surrounds the lower part of the rectum about an inch above the margin of the anus.

A third sphincter does not exist. 1

The External Sphincter of the Anus (and the Perineal Muscles in the Adult Male). (Hartmann.)

1, The glutseus maximus; 2, Same, divided; 3, Deeper fasciculi of the same; 4, Levator ani ; 5, 6, 7, Transversus perinei ; 8, Ischio-cavernosus ; 9, Bulbo-cavernosus ; 10, External sphincter of the anus, a, Sacrum covered by its connective tissue ; b, Fascia; c, Point of origin of the muscles of the thigh. *, The latter shown to the right covered with fascia, se, Ligam. anococcygeum.

Certain points in the structure of the large intestine are deserving of consideration.

It strikes the eye of the beholder at once that the

1 See Kelsey, Diseases of the Rectum and Anus.

large bowel does not present the smooth, even surfaces noted in the small intestine, but has a sacculated appearance. This is due to the arrangement of the longitudinal muscular fibres in three large bands, from the beginning of the caecum at the appendix vermiformis to the rectum. One of these bands, or taeniae, is posterior along the attached border of the bowel ; the anterior, the largest, is on the forward surface of the ascending and descending colon and sigmoid flexure, and on the under surface of the arch of the colon. The third, or inferior lateral band, is found on the inner surface of the descending and ascending colon, and on the under surface of the transverse section. These bands, being shorter than the rest of the intestine, draw it together, and so produce the appearance described. When they are dissected off, the bowel can be drawn out and its sacculation disappears.

The mucous membrane, which is quite smooth and without villi, is thrown into crescentic folds, Plicce Sigmoidece, which project forward like valves between the sacculi. Their arrangement is such that their free borders are not all in the same direction. 1

The rectum is not sacculated, but smooth and cylindrical, the taeniae being wanting here. The mucous membrane of the rectum is thicker, more vascular, of darker color, and but looseh* connected with the muscular coat. When the rectum is collapsed, its mucous membrane is thrown into folds which are in apposition with each other, and obliterate, as it were, the lumen of the bowel. When the rectum is distended, the folds disappear.

1 See chapter "Physiology of Peristalsis."

Houston described as valves of the rectum folds of the mucous membrane found protruding into it, and ascribed to them the function of holding up the faeces, i.e. preventing its constant descent, and consequently constant irritation of the sphincter. They were said to be present in all persons, but to vary in number and location. It has, however, been disputed, and the weight of authority is against their existence, as a rule. This much, however, is positive, that even where such protruding folds do exist they have no valvular function ; the rectum has no need of valves. Occasionally a large fold of mucous membrane is found, extending into the lumen of the tube ; Kohlrausch described such a fold, which he calls plica transversalis recti, and it has been seen by others.

About the level of the internal sphincter five or six little semilunar valves are noted, with their concavities directed upward toward the colon. 1 They form an irregular line around the canal. They are thus described by Dr. Horner : " The mucous coat of the rectum is thick, red, and fungous, and abounds in mucous lacunae and glands. It is laid smoothly above, and below it is thrown into superficial longitudinal folds called columns. At the lower end of the wrinkles between the columns are small pouches from two to four lines in depth, the orifices of which point upward; they are occasionally the seat of disease, and produce, when they are enlarged, a painful itching. " 2

1 Handy, W. R., Text-book of Human Anatomy, Philadelphia, 1854.

2 Special Anatomy and Histology. Eighth Edition, Vol. II. Phila. 1857. Bodenhammer, "Observations on the Normal Sacculi of the Anal Canal," etc., Medical Record, May 26, 1888.

The function of these little pouches, Saeculi Horneri, is apparently to collect mucus which may be required to lubricate the moving faeces, and thus facilitate its expulsion.

(From Handy, Text-book of Human Anatomy.)

Represents a section of the anus and rectum, showing the rectal pouches. aa, Columns of the rectum ; bb, Rudiments of columns ; c, Internal sphincter divided ; d, External sphincter divided ; ee, Folds of skin on the nates; /, Pouches ; g, Bristles in the pouches.

Arteries.

I. Pancreatico-Duodenalis, branch of the gastroduodenalis, branch of the hepatic, branch of the cceliac axis, supplies the first part of the duodenum.

II. Superior Mesenteric Artery : a large vessel arising from the abdominal aorta a little below the cceliac axis. It passes forward between the pancreas and transverse portion of the duodenum and descends between the layers of the mesentery to the right iliac fossa, where it terminates, considerably diminished in size. It supplies the whole length of the small intestine except the first part of the duodenum. It also supplies the caecum, ascending and transverse colon.

Branches: Vasa intestini tenuis, fifteen or twenty branches, arising from the convex side of the artery. They anastomose with each other in a series of arches which become smaller and more numerous as they approach the small intestines, to which they are finally distributed.

Inferior pancreatico-cluodenal is distributed to the transverse and descending portion of the duodenum ; it anastomoses with the pancreatico-duodenal.

Ileo-colic, distributed to the lower portion of the ileum, caecum, and vermiform appendix. Anastomoses with branches from the inferior mesenteric artery.

Colica dextra to the ascending colon.

Colica media to the transverse colon.

The artery is accompanied in its course by the superior mesenteric vein, and is surrounded by the superior mesenteric plexus of the sympathetic nervous system.

III. Inferior Mesenteric Artery arises from the left side of the abdominal aorta just before the point of bifurcation. It is not so large a vessel as the superior mesenteric artery. It supplies the descending colon, the sigmoid flexure, and the greater part of the rectum.

Branches : Colica sinistra to the descending colon.

Arteria sigmoidea to the sigmoid flexure.

IV. Hemorrhoidals Superior is the continuation of the inferior mesenteric artery from the iliac fossa downward. It descends between the mesorectum to the rectum, and at about its middle divides into two branches which descend on either side of the rectum, where they divide into several smaller branches, which are distributed to the muscular and mucous coat of this section of the bowel near its lower end. These anastomose with each other, with the middle hemorrhoidal and inferior hemorrhoidal arteries, and with branches from the internal iliac and internal pudic arteries.

This artery is accompanied by the inferior mesenteric vein, and is surrounded by the inferior mesenteric plexus of the sympathetic nervous system.

V. Middle Hemorrhoidal Arteries. Branches of the internal iliac, distributed to the anterior part of the rectum.

VI. External Hemorrhoidal Arteries. Two or three small arteries — branches of the internal pudic, distributed to the muscles and integument about the anus.

Veins. — Superior mesenteric vein,

Inferior mesenteric vein, unite with others to form the portal vein.

Nerves of the Intestinal Tract. — The nervous system of the intestinal tract is almost altogether part of the great sympathetic system. The nerve filaments and

Ret.

Diagram to illustrate the Nerves of the Alimentary Canal in the Dog. Foster, Human Physiology.

The figure is for the sake of simplicity made as diagrammatic as possible, and does not represent the anatomical relations.

Oe to Ret. — The alimentary canal, oesophagus, stomach, small intestine, large intestine, rectum.

L. V. Left vagus nerve ending on front of stomach, r.l. recurrent laryngeal nerve supplying upper part of oesophagus. R. V. right vagus, joining left vagus in oesophageal plexus, oe. pi., supplying the posterior part of stomach and continued as R' . V . to join the solar plexus, here represented by a single ganglion and connected with the inferior mesenteric ganglion (or plexus) m. gl. — a. branches from the solar plexus to stomach and small intestine, and from the mesenteric ganglion to the large intestine.

Spl.maj. Large splanchnic nerve arising from the thoracic ganglia and rami com municantes r.c. belonging to dorsal nerves from the 6th to the 9th (or 10th).

Spl. min. Small splanchnic nerve similarly arising from 10th and 11th dorsal nerves. These both join the solar plexus and thence make their way to the alimentary canal.

C.r. Nerves from the ganglia, etc., belonging to 11th and 12th dorsal and 1st and 2nd lumbar nerves, proceeding to the inferior mesenteric ganglia (or plexus) m. gl. and thence by the hypogastric nerve n. hyp. and the hypogastric plexus pi. hyp. to the circular muscles of the rectum.

l.r. Nerves from the 2nd and 3rd sacral nerves, S.2, S.3 (nervi erigentes) . proceeding by the hypogastric plexus to the longitudinal muscles of the rectum.

plexuses are derived more directly from the following plexuses, which are themselves but part of the great solar, or epigastric, plexus :

The superior mesenteric plexus, The inferior mesenteric plexus, The aortic plexus, The hypogastric plexus.

The superior mesenteric plexus accompanies the superior mesenteric artery into the mesentery, and there divides into a number of plexuses which follow the branches of the artery to the parts supplied by it ; namely, the small intestines, the cecum, the ascending and the transverse colon.