REPRINT from JOURNAL of AUG. 4, 1883 
LEFT LUMBAR. COLOTOMY AND THE 
POSITION OF THE DESCENDING 
COLON. 
BY L. MC LANE TIFFANY, M. D., 
Professor of Surgery, University of Maryland. 
Lumbar colotomy is so often done at the 
present time, and directions for operating are 
so clearly laid down in all text books, that a 
single case scarcely offers food for comment. 
The following instance, however, when consid- 
ered with others which I have reported (Am. 
Journ. Med. Sci., cxlviii, p. 413; Trans. Med.! 
and Chir. Fac., Md., 1882, p. 90) suggests! 
strongly that the usual theoretical line for the 
colon is not in all instances quite accurate, 
namely, the anterior border of the quadratus 
lumborum muscle. Indeed, if I rely on my 
own experience exclusively, I should expect to 
find the gut always posterior to the above line. 
I have had occasion to do lumbar colotomy 
tour times always through the left loin; all 
the patients have been greatly relieved and 
have recovered from the operation. All the pa ! 
tients suffered from obstruction of the rectum 
by cancer, the lumbar anus being established 
as a palliative measure. 
In every case the quadratus lumborum was 
freely divided, twice because the gut came 
into view peritoneum intervening, and twice 
because the gut was felt to be posterior to 
the edge of the muscle. In one case I found 
it necessary to hook the colon forwards with 
my finger from the kidney so as to make it 
present at the wound. It may be that when 
the rectum is obstructed the descending colon 
becomes heavy with retained excrement, and 
so moves nearer the spinal column by its weight 
when in the usual colotomy position, but I am 
greatly inclined to think that the colon gen 
erally lies under cover of the quadratus lum-! 
borum rather than at its edge. It is always 
agreeable to find one’s opinion supported by 
authority, though of minor importance, in 
addition to the living body, and this Braune 
does in his Topographical Atlas, edited by 
Bellamy, plate xvi, with accompanying text, 
in which the extra-peritoneal portion of the 
descending colon is made to look backwards 
towards the spinous process of the fourth 
lumbar vertebra, and corresponding advice 
about operating is given. Again a no less 
excellent anatomist than Harri>on Allen says ■ 
of the quadratus lumborum that it is-to be1 
“incised in colotomy,” a statement by the way 1 
to which exception is taken in a recent review. : 
Cas;i,—Patient stout, aged 35 years, mother ; 
of three children, the youngest three years 
old. The history obtained was that Mrs. 1 
had suffered from disturbance of the bowels,1! 
more or less pronounced, during the past 
eighteen months; sometimes diarrhoea some- 
times constipation existed; gradually defeca- 
tion became more difficult, and was effected 
only with much straining; tenesmus was de- 
veloped, blood and pus were noticed in the 
stools, and pain became very great. Dr. 
Aronsohn. of this city, when the patient ap- 
plied to him for treatment, made a rectal ex- 
amination, recognized cancer and asked me 
to see the sufferer. Sept. 14th, 1882, I found 
a rectum surrounded with cancer, epithelioma 
in all likelihood, not involving the sphincter 
ani but extending along the bowel beyond the 
reach of the finger. About three inches from 
the anus the lumen of the rectum was so much 
diminished as not to admit more than the tip 
of the index finger. Through the vagina 
there could be felt a hard tumor, oblong in 
shape, occupying the place of the rectum; 
uterus not over movable; no enlarged glands 
to be felt in the groins. Extirpation of the 
growth was not thought to be indicated, owing 
to its extent and probable attachments, so 
palliatives were made use of, namely, simple 
nourishing food, rectal injections, and opium, 
with colotomy in the future, if pain became 
unbearable or obstruction pronounced. June 
4th, 1883, I again saw Mrs. M. with her phys- 
ician, Dr. A. Complete obstruction had existed 
three or four days, and the pain was intense. 
It was thought best to do left lumbar colotomy 
the following day. Nothing of moment took 
place during the operation. It was done in the 
usual way by oblique incision the centre of the 
incision corresponding to a vertical line drawn 
half an inch behind the middle point between 
the anterior and posterior superior iliac spines. 
The patient was very stout, notwithstanding 
the length of time that the rectum had been 
diseased, and the wound correspondingly deep. 
A more than usually thick subperitoneal layer 
offat existed; cuttinglhroughthisat the anterior 
edge of the quadratus lumborum, 1 saw the gut 
very soon,moving freely with respiration. I was 
able also to pinch up and move from the gut the 
overlying tissue at the bottom of the wound 
and therefore judged that I had peritoneum 
between the gut and my knife. I then divided 
the quadratus lumborum transversely to the 
extent of an inch or an inch and a half, cut 
through the subjacent connective tissue, came 
upon gut, rolled it forward so as to bring the 
postero-lateral aspect to the wound, recognized 
a couple of transverse creases by sight, also a 
contained bit of feces by touch and finished the 
operation in the usual manner by passing my 
stitches and then opening the intestine. A 
great deal of fecal matter flowed at once. A 
pad of oakum with great cleanliness constituted 
the after treatment. All went well, and conva- 
lescence from the operation calls for no comment.