der die It/~morrhoiden bereits im 18. Jahrhundert als ,,traubenfSrmig, maschige Geschwfilste im Zusammenhang mit Arterien" bezeichnete, und BARDE~TI~EUEI~ (1860), tier in seiner Operationslehre ausffihrt, L~ D~A~r habe sich entschieden geirrt, wenn er angab, ,,dag sie (die H/~morrhoiden) mit den Arterien zusammenhingen".Sehen wir einmal yon L~ D~AN ab, so findet man seit alters her im Schrifttum bis zum heutigen Tage die einhellige Meinung, die H~mor-rhoiden seien ,,Krampfadern", d.h. dysplastische Vsnenkonvolute des unteren Enddarms. Nur MILES (1919) stellte lest --ohne indessen auf das Wesen der tt/~morrhoiden einzugehen --dab sie in Abh~ngigkei$ yon den drei End/s der A. rectalis cranialis entwickelt werden. Diese Arterie verl~uft bekanntlich zun/ichst in dem am Promontorium fixierten Meso des Colon pelvinum, das sehr erhebliche Variet/~ten in bezug auf seine L/~nge aufweist, und zieht dann retrorectal innerhalb der dorsalen Grenzlamelle abw/irts. Etwa im Bereich des 3. Sacralwirbels bzw. in HShe der Kohlrauschschen Falte, teilt sie sich in einen linken und in einen rechten Ast. Letzterer gabelt sich meist nochmals, so dag in der Regel drei Hauptarterien die ,,Regio haemorrhoidalis" an der Linea * tterrn Prof. Dr. L. Z~XSC~WERDT zum 60. Geburtstag gewidmet.
Since 1991 we have known that the entire abdominal musculature has a distinct resting tone. All other muscles lose their tension almost completely during the resting phase. Only the craniopharyngeal and anorectal sphincter systems retain natural spontaneous activity, which ceases only when a hollow organ is opened. This permanent natural spontaneous activity is extremely sensitive. For example, it increases during coughing and speech. With combined positron emission and computed tomography, it is possible to observe and measure this natural spontaneous activity in the adjacent musculature very clearly. This fact is important for understanding and therapy of the function and failure of sphincter systems.
This report is based upon 27 patients with severe perineal injuries treated in a 30-year-period. Four groups of injuries could be identified. Severity of the trauma, correct diagnosis of concomitant injuries, right usage of antibiotics and protection of the perineal wound by a temporary colostomy represented key factors for a favorable outcome. There is evidence from our data that primary repair should be carried out immediately for tears of the anorectal sphincter. Even if the organ of continence as a whole is separated from the pelvic floor, good functional results can thus be achieved. Extensive scar formation must be prevented as secondary sphincter reconstruction (gracilis muscle transposition) was never successful in our patients. All these cases required a permanent colostomy. Concomitant tears of the membranous urethra frequently caused urethral stenoses and irreversible impotence. Mortality rates were low in patients with severe perineal injuries.
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