. Operative surgery, for students and practitioners . of the coccyx and sacrum, and the levator ani, which isattached to the coccyx near its tip, are exposed. These muscles arecovered over by a thin fascia—the anal; they are divided with theknife close to the edge of the sacrum and coccyx. The soft parts are 414 RECTUM. then separated with a periosteum elevator from the posterior surfaceand right horder of the coccyx, and while it is forced forward thesacro-coccygeal joint is opened from behind and the hone seized withthe bone forceps and extirpated. The sphincter ani is cut away fromthe tip o
. Operative surgery, for students and practitioners . of the coccyx and sacrum, and the levator ani, which isattached to the coccyx near its tip, are exposed. These muscles arecovered over by a thin fascia—the anal; they are divided with theknife close to the edge of the sacrum and coccyx. The soft parts are 414 RECTUM. then separated with a periosteum elevator from the posterior surfaceand right horder of the coccyx, and while it is forced forward thesacro-coccygeal joint is opened from behind and the hone seized withthe bone forceps and extirpated. The sphincter ani is cut away fromthe tip of the coccyx close to the bone. If the arteria sacra media,which descends in front of the sacrum, is injured, it may be clampedand tied. The levator ani and coccygeus muscles having been already di-vided, the operator now penetrates through the loose, fatty tissuewhich lies behind the rectum with the fingers so as to expose theposterior surface of the rectum. The rectum moves with respiration,and shows an impulse if the patient coughs or Fig. 172.—Back Part of Ilium and Sacrum. Coccyx removed. A, A, usualline of section through sacrum; A, B, line of section to remove all of lowerpart of sacrum; SI, lower end of sacro-iliac articulation; 1, 2, 3, 4, poste-rior sacral foramina. In many cases one may proceed at once with the second step ofthe operation: the extirpation of the diseased part of the times, however, the space is not sufficiently ample, especially ifthe tumor is adherent and cannot be readily drawn down into thewound, or if the space between the border of the sacrum and theascending ramus of the ischium (spatium sacro-ischiadicum, Kraske)is unusually narrow. In these cases in order to obtain more roomit will be necessary to resect a portion of the sacrum. This may bedone with the chisel, bone forceps, or saw. The soft parts are sepa-rated from the lower part of the left half of the posterior surface ofthe sacrum with the periosteum elevator, and
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