tract was represented by little more than a mere cord.

[Illustration: PLATE LII

Cancerous Stricture of Rectum. Bowel Laid Open for Inspection.]

The mildest degree of such malformation refers to partial occlusion
of some portion of the rectum, or extreme smallness of its natural
opening, either of which constitutes essentially a stricture of
congenital origin, which may be sufficiently tight to barely allow
passage of meconium. Such strictures may escape notice for a
considerable length of time and will always tend to produce dilatation
and consequent displacement of bowel above.

Ordinary _imperforate anus_ is produced by its closure by a more or
less thick, membranous diaphragm, which may act, in some cases, like
a thin but imperforate hymen, or, in others, be so dense and massive
as to act more like a plug than a partition. The thinner the diaphragm
and the more perfect its structure as such the simpler the case, for
it simply needs perforation, with sufficiently frequent subsequent
dilatation to maintain the proper size of the aperture.

Complete _absence of the anus and the lower end of the rectal pouch_
may be so marked that scarcely a dimple indicates the point where the
anus should be found. In these cases the external sphincter may or
may not be present, while the rectal pouch may present loosely in the
pelvis, or be defective, or attached to some portion of the abdominal
wall, the intervening space being filled with indifferent tissue.
The fact that there appears to be a slight anal depression is to be
taken for nothing more than an indication of what should be found, and
signifies nothing regarding the deeper condition.

A somewhat mitigated expression of this last defect is seen when the
anus is normal, with a more or less complete sphincter, but where a
distinct partition separates this pouch from the rectum above. This,
again, may vary considerably in thickness. If, then, fluctuation be
detected the condition may prove less unfavorable for the little
patient, since at this point communication may be easily established.
Too often, however, this diaphragm is dense and tough. When
successfully perforated, like the hymen, it may allow a slow dribbling
of material, and will require constant attention and dilatation. Figs.
590 and 591 portray these conditions in some of their expressions.

[Illustration: FIG. 590

Rectum ending in a blind pouch. (Kelsey.)]

[Illustration: FIG. 591

Rectum ending in pouch; anus normal. (Kelsey.)]

The _anus_ itself is by no means a fixed anatomical opening, and its
position may vary considerably. It may be found anywhere along the
middle line of the perineum or even in the sacral region.

Another variety of complication is, with the conditions represented
as above, a practically imperforate anus or rectum which nevertheless
opens into one of the _other pelvic cavities_--the vagina, the bladder,
or the urethra. In female infants an opening into the vagina may
be of a size sufficient to serve its purpose, even throughout life.
This condition has occurred in ignorant women who became wives and
mothers, and were never conscious of anything abnormal. When the rectum
communicates with the urinary passages meconium will escape with the
urine. When the opening is in the urethra it is not so serious, and
patients live to adult life, whereas when the bladder is thus involved
the ureters will become infected and the patient eventually dies of a
terminal infection of the kidney.

There is a somewhat reversed condition similar to this where the
urinary passages connect with the rectum or with the colon.

Most of the anomalies above catalogued produce conditions of acute
intestinal obstruction within the first two or three days of the
newborn infant’s life. The condition is perhaps first made known by the
nurse’s failing to note the presence of meconium upon the diapers. A
suspicion of such a condition should prompt immediate investigation,
which should be made with the little finger or with a soft catheter
properly anointed; the finger making the best probe for purposes of
orientation. The first thing is to determine the patulency of the anus.
This established, the next procedure is a determination of the rectal
condition and of possible communication with other passages. In this
the presence of a small sound or metal catheter in the urethra and
bladder may be of assistance. If a fluctuating sac presenting downward
can be discovered in the location of the rectum its character may be
assumed, and, after exploring with an ordinary aspirating needle, one
may, if meconium be discovered, leave the needle _in situ_ for a guide
and with sharp scissors or pointed knife passed along it carefully cut
into the sac, and then gradually enlarge the opening until it be given
a sufficient size. The surgeon is fortunate in this respect who has a
case of imperforate rectum so simple as to permit of doing this and
finding it sufficient.

Every completely obstructed case becomes instantly a surgical one,
whose outcome depends not on the operator alone, but on the actual
anatomical condition. There is justification, therefore, in going to
almost any extreme in the endeavor to open up a passage-way, for no
danger can be greater than that of failing to establish it. After
a careful search of the pelvis, aided by anesthesia and a metal
instrument in the bladder, if no trace of large bowel can be found or
if tissues be so dense as to completely mask the anatomical details,
then as a last resort an artificial anus may be made in the left
inguinal region, if there be no reason for not violating the usual
rule and opening the large bowel in the right groin. _Colostomy in
an infant_, under these circumstances, is always a hazardous and
serious matter, but it offers the only resource. It is made in exactly
the same way as enterostomy described previously, and the operation
requires no special description here. Very young infants thus affected
make bad subjects, and operation should be performed as expeditiously
as possible. Considering the danger of leakage it would be well if
practicable to wait a few hours after attaching the intestine to the
abdominal surface before opening it, in order that the peritoneal
cavity may be more perfectly protected.

Even those cases where the rectum communicates with the urethra
or bladder should have a natural anal opening. In cases where
communication is into the vagina it may be proper to wait until youth
or adult age is reached, when more may be accomplished.

INJURIES AND FOREIGN BODIES IN THE RECTUM.

The rectum may be the site of injuries of various kinds from both
extrinsic and intrinsic causes. When weakened by disease it may
be burst by accumulation and straining, or it may be the site of
perforation of ulcer, just as may any other part of the intestine.
Although well protected from most directions it may suffer from
penetrating wounds, such as stab or gunshot. It is occasionally injured
in fractures of the pelvis, and possibilities of such injuries should
be excluded in such cases. It may also be lacerated during parturition.
The sphincter and even the muscular tube itself sometimes suffer. It
has been indifferently wounded or punctured in operations, especially
for stone in the bladder and in prostatectomy.

In the absence of disease a laceration occurring in any of these ways
may be repaired by prompt suture, although to make a suitable exposure
may require an extensive removal of sacrum, or the performance of a
laparotomy with the patient in the Trendelenburg position. The rectum
is also frequently injured by accidental or intentional introduction
of _foreign bodies from without_. Museums, especially the foreign, are
full of collections of foreign bodies which have been removed from the
rectum, most of which have been placed there with intent, malicious or
otherwise. They include objects of all imaginable character, shape, and
size, some which are easily introduced and are also easily removed;
others which have been passed inward under no small difficulties are
removed only with a more or less formidable operation, or have even
determined the death of the individual. The ignorant have peculiar
superstitions, and the criminal most vicious tendencies, toward the
insertion of such foreign bodies, and the complications that may be
brought about are too numerous to be rehearsed here.

On the other hand, by actual accident serious injuries may be produced;
as in one case under my observation where a boy of twelve fell, in the
squatting position, over an iron picket nearly one inch in diameter in
such a way as to permit it to pass into the anus, scarcely bruising
the mucous membrane, yet entering the pelvis for nearly six inches,
penetrating the anterior wall of the rectum, the posterior wall of the
bladder, and bruising its anterior wall without perforating it. One
feature of the accident was the carrying into the bladder of a piece
of his trousers. In this case I opened the abdomen in order to be sure
that there was no abdominal complication, closed the major part of the
wound, and drew a good-sized drainage tube through from just above the
pubes out through the anus, after removing the piece of cloth above
mentioned. The boy made a perfect recovery.

The danger in all these cases is of infection, either of the bladder
or of the pelvic cellular tissue. In the female similar perforating
injuries may involve the vagina or the other female organs.

Some of these accidents or conditions above recounted take place during
intoxication. The recurrence of tenesmus, pronounced rectal pain, the
appearance of blood either at the anus or in the urine, should in every
instance prompt a thorough investigation of the rectum, if necessary
under an anesthetic.

PROCTITIS.

Under the term proctitis are comprised acute inflammations of the
rectal mucosa, which are characterized by discharge of mucus, mucopus,
and perhaps blood, and accompanied by more or less tenesmus, pain, and
sphincteric spasm. The conditions which produce proctitis are those
which lead to ulceration. It may be the result of a downward extension
of trouble from above, as in mucocolitis, dysenteric, tuberculous or
other forms of colitis, or it may be the result of infection from below
(_e. g._, gonorrheal). An inflamed rectum may be more or less easily
exposed for study through some form of speculum (see above), and a more
perfect picture of the actual condition thus presented to the eye than
can be seen elsewhere, save in the mouth and pharynx, of the effects
which serious and even ulcerative inflammation may produce in the way
of congestion, swelling, bleeding, and actual breaking down.

_Gonorrheal proctitis_ is not common, yet it may occur either by
extension or by direct infection, and will be of an acute type. The
other forms may vary in severity according to their cause and duration.

=Symptoms.=--The symptoms differ only in degree, and include the
features already mentioned. There are soreness, tenderness, and often
pain, especially when the lower part of the rectum, with its numerous
sensory nerves, is involved, while reflex pains are referred to the
sacrum and the lower part of the back. Sensation of local heat and of
soreness is generally noted, while the patient is more or less tortured
by frequent desire to evacuate the bowel, but passes perhaps a little
bloody mucus with the accompaniment of tenesmus and straining. In acute
cases the condition is an exceedingly painful one.

=Treatment.=--Treatment should be begun by a search for and removal
of the cause. Relief is afforded by local anodynes, of which the hot
sitz bath is one of the most comforting, and by hot rectal lavements
of soothing antiseptic fluid, such as linseed tea, to which a little
thiol or ichthyol has been added. These should be retained as long
as possible, then ejected. Local anodynes may be furnished through
the medium of suppositories containing opium, or preferably some of
the milder local anesthetics, such as orthoform. Cases which do not
quickly yield to this form of treatment should be anesthetized in order
that complete exposure of ulcerated areas and vigorous local treatment
may be accomplished. A brushing of the entire surface with a 2 or 3
per cent. solution of silver nitrate will frequently be followed by
relief, which will be further furnished by sufficient stretching of
the sphincter to overcome its painful spasm. The diet should be so
regulated as to leave a minimum of undigested residue that may irritate
the lower bowel, and laxatives should be so administered that there
shall be no coprostasis in the colon, but that whatever enters it
shall be speedily extruded. The specific forms of proctitis require
specific treatment, for which there is perhaps nothing better than the
silver preparations, either the mild, like argyrol, or the active, like
solutions of silver nitrate.

ULCERATION OF THE RECTUM.

The causes of the formation of ulcer in the rectum nowise differ
from those of ulcer elsewhere about the body. They may be summarized
as _catarrhal_, _i. e._, more pronounced and local extensions of
non-specific inflammation of the mucosa, which, in certain areas,
assume more intense and later infective and degenerative form (in this
way are formed the so-called catarrhal ulcers); _specific_, including
primary chancre, which is rarely met with high up in the rectum, or
the later expressions, varying from mere mucous patches which may
abound both within the rectum and around the anus, to the deeper, more
destructive, and usually tertiary ulcerations, with destruction of
tissue, extensive involvement of surface and most pronounced tendency
to subsequent cicatricial contraction when they begin to repair.

What has been said regarding syphilitic ulcer is true also of
_chancroid_, which when found in this region involves most frequently
the anus, but which may extend or even be seen as a primary lesion
higher up.

_Tuberculous ulcers_ are not infrequently primary, usually the
accompaniment of advancing and ulcerative infection of the intestine
above, or secondary, as frequently occurs when the more innocent forms
suffer a secondary tuberculous infection, becoming thus converted into
lesions of pronounced type.

_Typhoid ulcers_ in the rectum are rare, but those connected with
_dysentery_ are common, especially in localities where tropical or
other forms of the disease prevail. The innocent tumors within the
rectum, such as polypi and adenomas, etc., tend to break down because
they are kept continually macerated and exposed to contamination. Even
innocent hemorrhoidal tumors are extremely prone to suffer in this way
because their epithelial covering is thin and they are exposed to both
external and internal contamination. Finally every malignant tumor
which grows into the rectum tends to break down, and sooner or later to
present an ulcerating surface. The causes of rectal ulceration are then
seen to be various. Nearly everyone of them may be an exaggeration of a
condition first producing an acute proctitis.

_Ulcers occupying the anal region_ are usually compressed into a
linear form and present rather as cracks or linear abrasions. These
are known as _fissures_ and are spoken of as _fissures in ano_ or
_rectal fissures_, according to their situation. These fissures occupy
the most sensitive portion, _i. e._, the lower inch and a half of
the rectum, and become in time irritable, erethistic lesions, whose
sensibility is constantly enhanced by the reflex spasm of the sphincter
which they produce. An essential part of the treatment of every such
case is dilatation of the sphincter, as well as the destruction of the
irritable surface, even the former alone often sufficing for the milder
cases. Anal fissures, like corneal ulcers, give rise to exquisite pain
and annoyance, and produce irritability and general distress. Their
treatment is so simple that there is no excuse for allowing patients
thus to suffer.

To a peculiar form of combined infiltration and ulceration involving
the lower part of the rectum, the anus, and, in females, more or less
of the vulva, the French have given the name _esthiomene_. It has been
considered due to more or less mixed forms of infection, including
those of chancroid, syphilis, tuberculosis, and other undescribed
types. It is a mixed infection, and not necessarily of the same type
in all cases. It is usually seen in old syphilitic subjects or in
prostitutes. It produces more or less deforming lesions, and sometimes
such active and protuberant granulations as to cause it to be mistaken
for epithelioma or condyloma. It is essentially chronic, and its
most striking characteristic is the combination of ulcerative and
hyperplastic processes which it presents. Clinically it is a chronic
ulcer, with thickened and deformed base and with all the possible
consequences or complications of ulcer in this region.

The other forms of ulcer above mentioned appear singly or multiply
in any and every possible location, pronounced types presenting
extreme pictures of an ulcerated, inflamed, partially destroyed tube,
which needs only to be seen before recognizing the advisability of a
colostomy for the purpose of rest of the inflamed surfaces.

=Symptoms.=--The symptoms of rectal ulceration are essentially those
of proctitis, mild or severe as the case may be, with local pain, and
escape of pus and blood. Much depends upon their location, _i. e._,
whether within the sensitive area or not. Ulcer low down in the rectum,
no matter how produced, will always cause a disproportionate amount of
suffering, because of the reflex sphincteric spasm which it produces.
On the contrary, ulcers high up give rise to little or no suffering,
and may be discovered only after a history of discharge of blood or
pus prompts a thorough local examination. Therefore, without reference
to the feature of _pain_, every statement that mucus, pus, or blood is
discharged from the rectum should lead to an examination, sufficiently
thorough to detect and expose the cause and permit of proper treatment.
Should local anesthesia prove unavailing for this purpose a general
anesthetic must be administered. Thus the non-specific, the syphilitic,
and the tuberculous ulcers may be scraped and cauterized, care being
taken not to perforate. If ulcerating tumor is found it should be
operated upon at once. Sometimes, however, by these examinations
unsuspected conditions are revealed such as to give the case a serious
aspect. In this event a second anesthetic, with operation, will be
necessary. For all ordinary purposes, however, sufficient specula,
curettes, the actual cautery, and applicator, by which suitable local
treatment can be made to the affected surfaces, should be provided.

=Treatment.=--As indicated above in the treatment of proctitis there
is need also for various local anodynes and soothing applications.
Physiological rest for the inflamed bowel is imperative. Finally, in
extreme cases, it has been shown that it is best to open the colon
above the seat of the principal disturbance, doing this even on the
right side should the whole large intestine be involved, and by thus
relieving it of its duties enable more complete physiological rest and
local treatment.

STRICTURE OF THE RECTUM.

The inevitable consequences of any of the serious forms of ulceration
above described are, if recovery ensues, and usually even if it does
not, the formation of cicatricial constrictions by which varying
degrees of rectal stricture are produced. Rectal strictures, then, are
to be grouped as:

  1. Those due to previous and more or less active, morbid intrinsic
  processes;

  2. Those due to the presence of organized exudate, tumors, or other
  compressing causes from without;

  3. Those due to traumatism.

The _symptoms and signs of rectal stricture_ include those of
ulceration and obstruction, or difficulty in defecation. A history of
alternating constipation and diarrhea, with perhaps tenesmus, and with
discharge of pus or blood, will prove the presence of some obstruction.
One characteristic feature met with in some strictures is the passage
of stools which when solid or semisolid have a characteristic tape- or
cord-like shape, as though extruded through a constricted passage-way.
This is not a feature necessarily present, and may be produced even in
non-malignant cases, as when the rectum is obstructed by uterine myomas.

With respect to any suspected rectal or colonic stricture it is
necessary to determine: (1) Its existence; (2) its location; (3) its
character; (4) any other circumstances bearing upon the case which
might affect the question of treatment. The latter is particularly
important when the question of syphilis is raised.

The above features are determined by careful physical examination
for which the finger alone may be sufficient, or which may require
instruments and postures already described.

=Treatment.=--Treatment of rectal strictures is necessarily mechanical,
but will depend in large measure upon their cause and extent. Thus
a stricture produced by conditions extrinsic to the rectum proper
might require abdominal section and removal of a pelvic tumor or other
similar operation. Many a patient with retroflexed uterus will complain
of a rectal condition which is essentially one of stricture, the
overturned uterine fundus being forced against the rectum and pressing
upon it, demanding not a rectal operation but one for suspension of the
uterus. The obstipation which is produced by ptosis of the sigmoid, or
by hypertrophy and abnormal arrangement of the folds and rectal valves,
may necessitate operation upon the colon (coloplication or colopexy) or
a careful division of hypertrophied mucosa through the proctoscope, as
used by one skilled in its manipulation.

[Illustration: FIG. 592

Stricture of rectum. (Bryant.)]

Strictures of recent origin may yield to a forcible dilatation, which
should, however, be systematically repeated in order to maintain the
desired effect. Old, dense, and chronic strictures will require more
radical procedures, according to their location and extent. Strictures
practically impassable may indicate conditions so extreme as to
necessitate colostomy, while in a small proportion of cases conditions
will be found so favorable as to justify a resection of the rectum,
either from below and from without, or through abdominal section with
the patient in the Trendelenburg position. Nearly every stricture is
accompanied by more or less ulceration, sometimes in extreme degree.

Dilatation or expansion by some mechanical method is the necessity in
every case. Simple in theory its performance is often difficult because
of density of the structures, and its danger often pronounced because
of the serious surrounding conditions and the possibility of rupture
or perforation of the bowel at some weakened part, or of infection and
phlegmon following division of the stricture and exposure of fresh,
raw surfaces. Various instruments have been devised for dilating
rectal strictures, some of which are ingeniously arranged to be used
at a considerable height above the anus. Danger attaches to their use
in proportion to the amount of force employed and its distance from
sight and touch, _i. e._, from intelligent means of control. The best
method is that which permits of exposure through the speculum and more
accurate division with knife, scissors, or actual cautery, the latter
often being preferable, as hemorrhage is less after its use.

It should be remembered that “once a stricture always a stricture,”
and that the tendency of cicatricial tissue to contract is continuous
and never ceasing, and that wherever there has been a stricture (and
this is true of any tubular portion of the body) there is necessity for
constant and more or less frequent later attention. If possible, then,
milder methods and those more capable of repetition should be adopted.
The best of these is the use of the finger for cases within reach of
it, and of the soft-rubber, conical bougies for those placed higher,
and for the patient’s individual use. Dilatations should be gradual and
increased as rapidly as circumstances permit, and with tight strictures
the endeavor should be with each sitting to make some gain until a
sufficient size has been attained. Local anesthesia may be required,
and is justifiable when needed.

PRURITUS ANI.

This condition, usually accompanied with irritative or ulcerative
conditions of the lower end of the rectum, the verge of the anus,
and the surrounding skin, is one of intense itching, leading to an
uncontrollable desire to rub or scratch, by which temporary relief may
be afforded, but which tends to produce excoriation and ulceration. The
condition is not primary, but secondary to something else, although
the conditions which produce it are widely variant, ranging from the
neuroses due to anemia or other causes, to the toxemias of uric acid
origin, the local irritations produced by lesser degrees of internal
disturbance, or eczema or other itching eruptions on the outside. In
corpulent persons eczema and intertrigo from friction are common, and
these, combined with irregular tags of skin or remains of old piles,
permit of irritation and maceration which still further complicate.
Annoyance is usually greatest at night, when the attention is less
distracted by other things.

=Treatment.=--The treatment should consist in removal of the cause
and local relief. The former may be difficult and require prolonged
effort. Local relief may be afforded by frequent applications of water
as hot as can be borne, with local application, after the parts are
thoroughly dried, of a powder containing menthol, a solution containing
camphophenique, with the addition of a little chloroform, or by
soothing ointments containing carbolic acid, menthol, and orthoform.
When there is abrasion of the skin applications of silver nitrate, in 5
per cent. solution, may be made; but when there is multiple ulceration,
stretching the sphincter and thoroughly cauterizing or excising the
ulcerated surfaces will be more radical and effective.

PHLEGMONOUS AFFECTIONS OF THE RECTUM.

On either side of the rectum, between the dividing folds of the deep
pelvic fascia, is situated the _ischiorectal fossa_, a pyramidal-shaped
cavity filled with fat and cellular tissue. This is not only in close
relation with the outer rectal surfaces, but is peculiarly liable to
infection and acute inflammatory disturbance. Thus it happens that
_ischiorectal_ or _perirectal abscesses_ are of frequent occurrence,
often of marked violence, and not without their peculiar dangers.
Infection may travel from the rectum, or the first excitement may
occur in one of the mucous or skin follicles at or near the anus. The
consequence is what the patient ordinarily calls a _boil_, which to the
surgeon is a phlegmon, first limited by the walls of the cavity within
which it rises. So long as the phlegmonous process be confined within
these walls it is acutely painful.

The _local signs_ of such an abscess are redness and infiltration of
the exterior surface, swelling, which becomes quite distinct, and pain
and tenderness, of which the patient may complain bitterly. The local
soreness is so extreme that defecation becomes difficult or almost
impossible. Any attempt at digital examination of the rectum will give
rise to extreme pain.

=Treatment.=--Could every perirectal abscess be distinctly recognized
and properly treated in its comparatively early and localized stage
there would be few cases of residual trouble. This treatment consists
of early and extensive incision, made externally and directed to the
centre of the phlegmonous mass, sufficiently _deeply_ also to reach
it. The evacuation of even a small amount of pus, followed by more or
less blood, will give prompt and immediate relief, and bleeding may
be encouraged rather than checked for purposes of local depletion.
Such incision may be in most instances made with freezing spray or
local anesthesia. In children and exceedingly nervous patients it
would be better done under general anesthesia, in order that it be
done thoroughly. It is in patients who decline such early relief,
or who, from ignorance or inattention have not received it, that
ischiorectal abscesses sometimes assume serious proportions and become
extensive phlegmons, breaking down anatomical partitions in the
pelvis, burrowing extensively in various directions, since there is
considerable fatty and cellular tissue both inside and outside of the
pelvis in this region. Thus the surgeon may not see such a case until
the entire buttock is involved, or until the process has gone perhaps
even farther. Relief now must come from radical application of the
same principles, by the aid of general anesthesia, multiple incisions
with counteropenings, use of drainage tubes, etc. The patient now is
fortunate if perforation into the rectum has not already occurred so
that no pus is discharged from the bowel. If this has not yet happened
it will probably be prevented by the above measures; but when it has,
and a fistulous communication has already been established, it may be
sufficient to thoroughly cleanse the infected cavity to see both it and
the fistula close by granulation in the course of time. Wide external
incisions are necessary in these cases, for complete access to the deep
fossæ must be made. In more pronounced cases the pus evacuated will be
extremely offensive, and there will be found masses of necrotic tissue,
sloughs of fascia, and evidence of extensive local gangrene. Such
putrid cavities must be thoroughly cleaned out, and will then be found
to quickly resume a healthy aspect when treated by packing with gauze
saturated in brewers’ yeast.

The more chronic and slower expressions of this condition are usually
connected with local _tuberculous_ disease. In fact every _phlegmon
which has passed the acute stage is favorably situated for tuberculous
infection_, and becomes in time a tuberculous lesion, which is to be
treated on the general principles elsewhere enunciated. These fistulas
are often seen in consumptive patients, and apprehension has widely
prevailed that the pulmonary disease might be aggravated by radical
attention to the fistula. This was only when such attention was made
incomplete. To divide the fistulous passage and leave its raw surfaces
unprotected and in contact with tuberculous tissue is to invite the
spread of infection. To do the proper thing, on the other hand, _i.
e._, to radically dispose of all tuberculous tissue and so treat both
fresh and old surfaces that a new infection is not invited, is not to
make a patient worse in any respect, but to relieve him of at least one
focus of disease. There is, therefore, no reason why rectal fistulas
should not be radically treated even when they occur in consumptive
patients.

RECTAL FISTULAS.

Rectal fistulas are always the consequence of ischiorectal abscesses
left to open spontaneously in either or both directions. They may
occur also without the preëxistence of a distinct phlegmon, as, for
instance, when a small ulcer in the rectum gives way and permits the
gradual extension into the perirectal tissues of a mildly ulcerative or
suppurative process.

Rectal or anal fistulas are classified as _blind external_, _blind
internal_, or _complete_, according as they open and discharge
themselves or show a complete passage-way from the rectum to the
exterior. They may be small and single, or numerous and extensive.
Old and especially chronic tuberculous cases are seen when the whole
gluteal region is honeycombed and perforated by numerous fistulas, some
of which probably connect with the interior of the bowel. I have seen
such openings as low as the knee and as high as the dorsal spines, as
the result of extremely insidious advance of tuberculous granulation
and its subsequent breaking down. In such cases a history of an acute
phlegmon occurring years previously may be obtained.

A _blind external fistula_, simple or complicated, naturally discharges
its pus upon the exterior. It may be accompanied by little or no
local tenderness or pain. A _blind internal fistula_ makes itself
known by a certain amount of rectal tenderness and by the discharge
of pus with the stool, or at other times of pus which may possibly
be blood-stained. Here there may be a history of old trouble, with
external evidences of it, which suggests that exterior communication
has been shut off while that with the bowel remains. In _complete
fistulas_ there is discharge not only of purulent material, but of
more or less of that which is distinctly fecal, while gas sometimes
escapes through them. Such a statement made by a patient is of itself
significant. A fistulous passage may be surrounded by more or less
infiltrated and inflamed tissue, or it may appear much like a duct.
While always causing more or less annoyance, it may produce symptoms
which seriously disturb. (See Plate LIII.)

=Treatment.=--The treatment of rectal fistula in any of its forms is
distinctly surgical and should always be radical. A blind internal
fistula can be discovered only with the speculum.

Every such fistulous passage should be split up and its tubular
portion thoroughly excised or destroyed with a sharp spoon or caustic.
Furthermore it should be followed to its ultimate ramifications.
For this purpose it is of great assistance to first inject it with
methyl-blue solution, or something else which shall stain it and
make it recognizable wherever it may extend. To incise a superficial
and external fistula is a simple matter, for which local anesthesia
alone may suffice; but to deal radically with an extensive fistulous
tract requires dilatation of the anal sphincter and such thorough
investigation, with complete relaxation of the patient, that general
anesthesia is needed. Now with a probe identifying the tract, and the
knife and spoon made to follow it, or by identification of the stained
tissues colored as above mentioned, the surgeon should proceed to the
extreme of every morbid passage-way, dilating, cutting, trimming,
scraping, as may be needed; while after the work is done every particle
of disturbed raw surface should be cauterized with some reliable
caustic (such as pure carbolic followed by alcohol) so as to sear the
surface and prevent the possibility of reinfection.

To do this operation thoroughly necessitates sometimes multiple and
extensive incisions, with a fierceness of action which may cause
surprise. It is, however, the only effective way in which to proceed.

[Illustration: PLATE LIII

Illustrating Various Forms of Rectal and Anal Fistulas, and the
Conventional Methods of Dealing with Them. (Bernard and Huette.)]

One source of doubt and disappointment is met occasionally in the
radical treatment which requires division of the sphincter, for to
completely divide this muscle is to practically paralyze it and leave
the patient thereafter with fecal incontinence more or less marked.
Such accidents leave more or less disabling consequences. Usually they
are avoidable, for it is rarely necessary to cut completely through a
sphincter muscle, it being possible to avoid the necessity by partial
division, with perhaps more complete exposure above and below. Even
in those instances where it seems unavoidable if the muscle be first
vigorously stretched, and thus temporarily paralyzed, it may then be
safely divided, provided it be neatly and completely sutured _at once_,
and the parts kept at rest for a few days, the intent in stretching
the muscle being partly to so weaken it that it shall be temporarily
disabled. It was suggested years ago by Jenks, of Detroit, and later by
Kelly and others, to make a complete excision of the entire fistulous
tract and then to treat this as any other fresh wound, closing it
completely with sutures. The method is good in theory and occasionally
applicable, and should not be neglected when circumstances favor its
practice.

Every fistulous tract, simple or complicated, not promptly and neatly
closed, should be dressed with gauze, with or without yeast, balsam, or
some one of the other local applications recommended elsewhere in this
work.

PROLAPSE, PROCIDENTIA, AND INVAGINATION OF THE RECTUM.

Prolapse of the rectum is observed in two degrees, either as a mere
_eversion of its mucosa_, which, however, may be profuse and extreme,
or as an actual _escape by process of invagination_ through the anus
of some portion of the rectal tube, with all its coats, including in
well-marked cases even its peritoneal covering. The former is more
common in children as the result of diarrhea, colitis, the presence
of pin-worms, or other parasites, or any other cause which produces
tenesmus and frequent straining, with consequent relaxation of the anal
sphincter. It is amenable to treatment and is usually of insignificant
proportion. It is also frequently seen in adults in connection with
internal hemorrhoids, which are extruded with every stool, carrying
with them more or less mucosa, and which are usually returned within
the rectum by the patient at the conclusion of the act of defecation.

The more complete form of prolapse by true _invagination_ is rarely
seen, save in adults, and in consequence of some serious preëxistent
condition, such perhaps as complete laceration of the perineum in
the female, paralysis of the sphincter from previous accident, or
from the existence of spinal-cord disease. Here and in extreme cases
several inches of bowel may be extruded from the anus, and to an extent
scarcely permitting spontaneous or even individual restoration. So
complete a form is permitted only by some previous lesion of the pelvic
floor, while the mesorectum and even the mesosigmoid become gradually
stretched and useless. The lower portion of the rectum is by far the
more muscular, and such a condition requires that its intrinsic muscles
yield also with those around them.

_Prolapse_ is a condition of general and usually slow development
rather than of abrupt onset. It is made known by the presentation at
the anus of the bright-red mucosa of the rectum, where it pouts and
protrudes, forming a tumor of varying size, with more or less tender
surface, which, with gentle coaxing pressure, is easily made to return
within the rectum. It can usually be made to appear by straining
effort on the part of the patient. Boys with phimosis, who are in
consequence made to strain every time they urinate, will frequently
present minor degrees of the condition, perhaps oftener than when the
rectum itself is at fault, as the act is so frequently repeated. The
oftener such protrusion occurs the more relaxed becomes the anus and
the more irritated the presenting surface, until ulceration and even
keratosis may result. Chronic constipation of children or adults will
also produce the same effect. The presence of hemorrhoidal tumors or of
polypi, or even of parasites, causes the same result.

The most pronounced and complete types of invagination produce a
condition in which reduction is perhaps not possible and procidentia
is constant. There may form here a pouch around the rectum, containing
loops of bowel, bladder, or ovary, or there may even occur a perirectal
hernia.

While patients nearly always become more or less accustomed to the
condition it nevertheless is distressing in proportion to its size and
the individual’s temperament.

=Treatment.=--Treatment depends entirely upon the nature and extent of
the condition. Mild forms occurring in young children may be easily
obviated by attention to their stools, by circumcision if needed, or by
the use of a five-grain capsule of ergotin inserted as a suppository,
it having the effect of invigorating the involuntary muscle and
stimulating the sphincter. Cases not amenable to the milder methods
become surgical and the treatment is then apportioned to the extent of
the lesion. If connected with hemorrhoids or other tumors it becomes
a part of their treatment and is to be dealt with at the same time.
Occurring apparently independently the milder forms will often yield
to the proper use of caustics. The actual cautery being preferable, it
is applied in streaks up and around the rectum, in such a way that,
when the ulcers thus formed cicatrize, the rectum shall be shortened
by cicatricial contraction as by a series of loops drawn up to shorten
it. When permitted by rupture of the perineum and more or less combined
perhaps with cystocele, repair of the perineum, rather than attention
to the rectal condition itself, will be demanded, while the latter
may be combined with an operation for rectocele by excision of an
elliptical portion of the vaginal mucosa and the approximation of its
edges into a line of sutures. This will reduce the capacity of both
the vagina and the rectum and a double indication be thus met. Acute
inflammation sometimes follows exposure of a prolapsed rectum and it
may slough, thus leading to spontaneous recovery, the process not being
without its dangers of thrombosis and septic infection. This procedure
may be imitated by a surgical excision of the entire prolapsed
portion, always with great caution so that if peritoneal surfaces be
exposed they be protected from infection. It has been possible in
many instances to completely excise the protruding portion, and then
to apply a double row of sutures similar to those used in intestinal
resection, only with attention first to the peritoneal rather than
the mucous surface, in such a way as to excise several inches of the
prolapsed bowel and thus meet the indication. Nevertheless cases where
this can be done are exceptional.

Pratt has suggested a _temporary_ purse-string suture of the anus,
effected by a curved needle, completely circumscribing the anal
opening, but kept between the skin and the mucous membrane, to be
brought out through the same puncture at which it was inserted.
The finger of an assistant being passed into the anus, the suture
is now tied around it. This may be used as supplementary to linear
cauterization above mentioned.

Numerous methods of _proctopexy_, or elevation and fixation, have been
devised. Fowler, for instance, made an incision half-way between the
anus and the point of the coccyx, and after separating the rectum from
the latter and the sacrum inserted two fingers in the rectum, holding
it up while its posterior wall was forced into the external wound and
there held by heavy sutures of kangaroo tendon. By further incision he
brought out the ends of these sutures on each side of the coccyx and
tied them across the bone, thus by traction bringing the rectum up into
position.

_Colopexy_ has been practised as a more radical measure for the same
purpose. As advised by Bryant the abdomen is opened by an incision
parallel to Poupart’s ligament on the left side and one inch above it,
and the prolapse is reduced by firmly pulling the rectum upward. It
is then secured to the peritoneum about it, and is held by quilting
sutures, which include the entire muscular coat of the bowel. Save in
exceptionally favorable cases one or the other of these methods may be
considered preferable to the complete amputation above described.

HEMORRHOIDS; PILES.

Hemorrhoids constitute perhaps the most common and, in some respects,
uncomfortable or distressing disease of the rectum. The term implies
a varicose condition of the lower veins, sometimes those of one set
of hemorrhoidal veins being involved, at other times nearly all of
them participating. They are spoken of as _external_ or _internal_. In
the former case it is the external hemorrhoidal veins alone which are
involved, and usually only two or three of them, although occasionally
one sees outside the anus, as within, a general involvement of the
entire venous distribution. A _pile_, then, is essentially a venous
angioma, or a single varicosity, and its peculiar features are due
solely to its location.

Any vein thus involved is liable to the same dangers and accidents
as veins in other parts of the body. Thus it may undergo dilatation,
thrombosis, and suppuration, while the ordinary consequences of the
latter condition may follow here, as elsewhere, with this difference
alone, that when the middle and upper hemorrhoidal plexuses are
involved the thromboseptic process, should it occur, follows the
_portal vein_, and the first metastatic abscess that forms occurs
_within the liver_. Thence it may spread to other parts of the body in
classic form.

The hemorrhoidal veins, save those at the verge of the anus, are
more or less entangled among the fibers of the levator ani and the
sphincter. These muscles are thrown into a condition of more or less
spasmodic contraction when the veins are so involved. In consequence
more pressure is made upon the veins themselves, and the conditions
of spasm and venous engorgement react upon each other in a vicious
circle, each tending to make the other worse. Hence the great advantage
of _stretching the sphincter_ in any operation save that for a small
external pile.

Hemorrhoidal angiomas may appear as single tumors or in multiple
form surrounding the lower part of the rectum. The most common cause
for their occurrence is chronic constipation. Occasionally the first
exciting agent is some violent strain in defecation, or possibly the
actual rupture of a small vessel, but such constant overloading of the
rectum as obstructs its return circulation conduces to engorgement and
the other conditions may easily follow. A small pile may be brought
into existence in brief time, but a general hemorrhoidal condition
is one of slow development. Chronic cases are always accompanied by
further changes involving the surrounding connective tissue and the
overlying mucosa, both of which become thickened and infiltrated, while
ulcers form frequently upon the latter, and the occurrence of those
linear ulcers which are ordinarily called _fissures_ is very frequent.
This gives an additionally distressing feature to these cases. As
the condition goes on and the angiomas increase in size there is an
increasing tendency to prolapse. This may be temporary or constant, _i.
e._, it may occur with the straining effort at stool or it may result
in a condition of permanent protrusion at the anus of the engorged
mucosa; or, if the sphincter has finally become prolapsed a true
prolapse of the rectum may result. A mucous surface thus constantly
exposed to irritation will nearly always be more or less ulcerated and
tender, while hemorrhages in either variety are common. It is not an
infrequent event, then, for a patient to lose a number of ounces of
blood with or just after stool, and sometimes the blood loss is even
excessive. There is then added to the local condition a secondary
feature of anemia and its attendant consequences which are sometimes
extreme, and may even make operation somewhat hazardous. The lower
inch and a half of the rectum is the portion particularly supplied
with sensory nerves, and, under these circumstances, the irritated
area becomes erethistic and painful and the patient’s suffering may be
extreme. This is the so-called “_pile-bearing area_,” as it is within
it that the hemorrhoidal condition is practically confined. Even a
small individual pile connected with one of the little external veins
may give rise to a disproportionate amount of discomfort.

There has been so much quack literature upon this general subject
that ignorant patients are very likely to say that they have piles,
no matter what may be the local condition. A statement to this effect
should, first of all, provoke a physical examination with the finger,
then with the speculum. The educated finger will easily detect the
presence of the rugosities or tumors produced by internal piles, the
external being always self-evident. The coexistence of ulceration
will be indicated by an extreme degree of sphincteric spasm and of
tenderness. It should be remembered that, along with hemorrhoids,
there may coexist fissure, ulcer, painful spasm, prolapse, and, in
long-existent cases, even cancer. The average patient with cancer of
the rectum will go to his physician saying that he thinks he has piles.

=Treatment.=--Treatment needs to be something more than merely local
in aggravated cases, as it should also be more comprehensive. Patients
who have thus long suffered have almost inevitably contracted the
constipated habit, postponing defecation whenever possible because of
pain and tenderness, and perhaps the hemorrhage accompanying it. The
large bowel has, therefore, become weakened, and attention should be
given to it as well as to the general digestive process.

_Locally_ very mild degrees of purely temporary disturbance may
be sometimes acceptably and temporarily treated by the use of
suppositories containing some soothing and anodyne drug, as well as
ergotin, the latter being valuable because of its constringent effect
upon the bloodvessels. A five-grain gelatin-coated pill of ergotin
makes a satisfactory suppository for the young, under these conditions.

A freshly formed, external hemorrhoid, which may attain a size no
larger than that of a pea, but which will seem to the patient as large
as a bird’s egg, is best treated by _open division_, turning out the
blood or clot contained within the dilated vein, which will quickly
obliterate, so that recovery will be complete within two or three days.
This may be done under local anesthesia and with prompt relief. There
have been methods in vogue, especially among the charlatans and some of
the specialists, of treating external and the more localized internal
conditions by _injection of carbolic acid_, either pure or reduced
with a little glycerin. A few drops are thrown into the tumor with a
hypodermic needle, the effect being to promptly coagulate the contained
blood, the intent being to produce a final cure by absorption of the
clot and obliteration of the veins. This, in fact, is the secret method
long employed by the travelling charlatans and often connected with the
name of Brinkerhof. It is uncertain in action, and the production of
a clot under these conditions is by no means always free from danger,
nor is the relief prompt. What is desired is to empty the vein and
turn out the clot rather than to provoke its production. The method is
rarely practised by judicious surgeons, who have too often seen serious
sloughing and even general septic disturbance follow it.

For the _radical relief_ of distinctly hemorrhoidal conditions there
is no satisfactory method save the operative. So many measures have
been devised in time past that it is necessary here to be selective
and only mention one or two. On general principles every pile is a
venous tumor, and there is no reason why it should not be treated like
any other tumor, _i. e._, by _enucleation or excision_. The same is
true of the area which contains a number of such tumors, _i. e._, the
so-called pile-bearing area. Hence, surgeons of the largest experience
have practically discarded the more bungling methods and have applied
to these conditions the same radical measures which they recommend
elsewhere.

One important feature which should always be practised is thorough
_dilatation of the sphincter_, not only for reasons above described,
but because of the facility with which the surgeon then exposes
the diseased tissues. Any distinct tumor or series of them may,
for instance, be seized, isolated, and dissected out, either by an
elliptical incision of the mucosa or by a more blunt dissection with
scissors. The base, or pedicle, if sufficiently large to justify
it, may be ligated before the incision is completed, after which
catgut sutures may be used to close the opening in the mucosa. When
the tumor is small the suture may be made to include the bleeding
points so that even a ligature is not required. A more radical method
of extending this same principle to the entire pile-bearing area,
especially when prolapsed, or to so much of it as is affected, is
the so-called _Whitehead’s operation of excision_, which practically
consists in trimming off a ring of exposed mucosa, with its clusters of
enlarged and more or less pendulous veins. This ring extends from the
mucocutaneous border, at the verge of the anus, to a point perhaps 1¹⁄₂
inches above, the intent being to separate the mucosa and the tumors
from the fibers of the sphincter, which can be practically effected
in such a way that sphincter control is not lost. Hemorrhage will be
free for a few moments, but is always within control. Larger vessels
which spurt may be twisted or tied, while oozing surfaces are included
within the row of catgut sutures, which is later placed in such a way
as to unite the divided mucous tube with the skin border at the anus.
The operation is, in effect, an annular excision of the lining of
the rectum, and as such proves satisfactory. There is about it this
temporary disadvantage that the pile-bearing area thus removed is also
the sensitive area, and that for a few weeks, at least until nerve
communications have been reëstablished, there is a lack of peculiar or
normal sensibility about the parts which is annoying, and may perhaps
lead to some incontinence, but this soon passes away. The measure is
the most satisfactory of all for well-marked cases of hemorrhoids
associated with more or less ulceration and prolapse.

An occasional dilatation, scattered here and there around the lower end
of the rectum, perhaps with a mild degree of ulceration, is usually
very satisfactorily treated by a method which it must be confessed
would be rarely used on the exterior of the body, and yet which proves
quite serviceable here, namely, the _actual cautery_. The consequences
of its application are obliteration of the vein, cicatricial
contraction of the overstretched tissues and eventual relief.

[Illustration: FIG. 593

Multiple polypi of rectum. (Potherat.)]

Other methods of operation include the use of the _clamp and
cautery_ for removal of considerable masses, a method ordinarily
less satisfactory than excision, and the use of the ligature, with
or without incision of the mucosa at the base of the tumor, it being
thus cauterized and expected to separate by sloughing, an uncertain
procedure. None of these methods, nor others not worth mentioning,
compare with the newer methods of excision.

Much has been recently written concerning the advantage of local
anesthesia in doing these operations. This seems to have been
advocated largely for effect, although external tumors can be treated
by cocaine applications or by the ordinary injections of cocaine or
one of its substitutes. It is claimed that the infiltration of the
surrounding tissues with normal salt solution affords an effective
local anesthetic. Mere local anesthesia is not sufficient for thorough
work upon parts not easily visible, and the actual stretching of
the sphincter is half the battle in dealing with these conditions.
This cannot be thoroughly accomplished without general anesthesia.
Consequently for any well-marked hemorrhoidal condition chloroform
offers decidedly the preferable method, not alone from considerations
of comfort, but from the standpoint of permitting more thorough and
effective work to be done.

After these operations it is advisable to place within the grasp
of the anus a stiff rubber tube wrapped with gauze. It permits the
escape of flatus without distress to the patient, and it effects a
better coaptation of surfaces recently united by suture than would
otherwise be secured. Such a tube may be left _in situ_ for from six to
thirty-six hours.

TUMORS OF THE RECTUM.

The rectum is the frequent site, more especially in children, of
_polypoid degenerations_ similar to those seen in the nose. In
consequence there are formed the so-called _rectal polypi_, which, in
origin, consistence, and course correspond to the common nasal polypi.
Such a pedunculated tumor may attain considerable size, especially when
solitary, while, on the other hand, the mucosa may be studded with
small pedunculated growths, giving the appearance represented in Fig.
593.

Pathologically these polypi are originally of myxomatous or adenomatous
type. They may bleed easily and may be passed with stool. In their
multiple and smaller expressions they give rise rather to rectal
uneasiness and tenesmus than to more distinct symptoms. On the other
hand an isolated tumor, so pedunculated as to become gradually
stretched out, may attain considerable size and give rise to all the
sensations of a foreign body in the rectum, with constant tenesmus and
desire to expel it, while it may even present at the anus or bleed
freely.

Only exceptionally will these tumors be recognized previous
to examination, which, however, should easily disclose their
characteristics. Isolated polypi should be removed, either by being
twisted off or by excision and ligature of their bases. General
polypoid degeneration may be treated with the curette or with the
actual cautery. In all these instances surgical intervention in some
form will be required.

Other _benign tumors_ in the rectum are mainly of the _adenomatous_
type. Owing to their location it is rare that they are seen early by
one competent to judge of them. In consequence the surgeon sees them
usually as more or less ulcerated, sometimes extensive growths, perhaps
bleeding freely, and much changed by maceration and by compression from
their original condition.

In such cases it becomes a question of importance to distinguish
between the benign and the cancerous growths. This is not always easily
done, especially when they are high up and ulcerated. The matter is
usually decided by the presence or absence of actual infiltration
around the base of the growth, and perhaps the involvement of lymph
nodes. A movable tumor with an infiltrated base is usually clinically
benign, nevertheless it should be radically removed. It is in many
of these instances that one may see expressions of transformation of
adenoma into carcinoma.

=Cancer of the Rectum.=--This will be considered here rather from
its clinical side; hence what is said refers alike to sarcoma and
carcinoma, the latter being far more common. _Carcinoma of the rectum_
may assume the type either of epithelioma, as when it begins low and
spreads upward, or of adenocarcinoma, when it arises from that portion
of the tube not lined with squamous epithelium.

It usually begins _insidiously_, and for a considerable length of time
furnishes scarcely any recognizable symptom. The first indications
noticed by the patient are usually more or less frequency of stool,
with tenesmus, and the passage of mucus, perhaps stained with blood,
rather than of fecal matter. By the time those conditions are noticed
there will usually be more or less mechanical difficulty of defecation,
due to the presence of the tumor and obstruction of the rectal tube.
Pain may be a long-deferred feature, and local soreness may be absent
until late in the case or until its terminal stage, when the growth
is above the peculiarly sensitive part of the rectum, _i. e._, when
it does not approach to within 1¹⁄₂ inches of the sphincter. As time
goes on there is more and more suffering in the rectum, with backache,
referred pain, while the tenesmus and other local conditions cause
increasing distress. It often happens that it is not until this period
is reached that the patient consults a physician, and then he usually
goes with the statement that he is suffering from piles.

[Illustration: FIG. 594

Epithelioma of anus and rectum. (Grant.)]

So frequently is this the case, and so prone are many practitioners
to accept such a statement, that the proper examination which should
permit the recognition of the condition is perhaps not made until the
patient is really in a pitiable condition. _I do not recall ever having
seen a case of cancer of the rectum which had not been regarded, by
some physician as piles, and in most cases locally treated by him,
usually without any adequate local examination_, and usually also until
the time had passed when a radical operation could be practised with
any degree of hope. The first examination at least will be digital,
and if the malignant growth be within reach of the finger it should be
possible to appreciate it, to estimate its size, degree of attachment,
and the amount of infiltration, as well as the extent to which it is
breaking down. A soft, rapidly growing cancer will give a fungous
sensation to the finger, while the more dense, scirrhous forms produce
hard masses, growing in irregular shapes, sometimes involving one side
of the bowel, sometimes appearing in annular form, and tending sooner
or later to produce malignant destruction. The only difficulty would
be in cases seen exceptionally early or in those beyond reach. The
circumstances above detailed should lead to a careful _proctoscopic
examination_ with suitable instruments, perhaps in the knee-chest
position, when the growth is not easily appreciated from below. _Any
complaint of tenesmus, with discharge of blood and mucus, with more or
less pain and tenderness, local or referred, demands an examination
sufficiently careful to reveal the nature and extent of the lesion and
indicate the treatment._ If such an examination call for an anesthetic,
it should be administered. Practically every rectal cancer is a
malignant ulcer by the time it is recognized, ulceration being favored
by warmth and moisture.

=Treatment.=--There are few malignant lesions anywhere about the body
which require more good judgment in treatment than cases of cancer of
the rectum. So much depends upon their location, their extent, the
degree of infiltration, the age and general condition of the patient,
that it is almost impossible to lay down succinct rules. The question
of treatment hinges, first, upon the location and extent of the lesion;
is it operable or is it not? When the lymph nodes of the pelvis or the
groin are noticeably involved it is practically too late, under any
circumstances, to hold out prospect of radical cure. When the disease
has extended far above reach of the finger it is again late to expect
much even from radical measures. When the prostate, the floor of the
bladder, the vagina, or any of the pelvic viscera are involved it is
again too late to justify them. There are wide differences of opinion
between surgeons as to the propriety of extensive operations in serious
cases. Mild cases are certainly much benefited and even actually cured
by early and thorough removal, but this occurs too infrequently,
because such cases are rarely seen sufficiently early.

The class of cases universally acknowledged to be inoperable, so far
as radical measures are concerned, are nevertheless much benefited and
their lives prolonged by a _colostomy_, the effect being to provide
an easy and manageable outlet for fecal discharge, and to avoid the
irritation and attendant difficulties associated with an obstructed and
malignantly ulcerated rectal outlet. The surgeon has to select between
some method of excision and colostomy. My own opinion is growing in
favor of the latter, save when the prospect of complete excision is
good. The opening is more manageable, the progress of the disease
seems much checked, patients have better fecal control and live in
far greater comfort, while their lives are placed in less jeopardy,
and, in general, are actually prolonged. Thus a colostomy performed
in a well-marked case of inoperable cancer of the rectum may permit
of prolongation of life for two or three years, something not often
attained by any other method of treatment.

Of the various _radical operations_ some are made from below, _i. e._,
by the perineal route, some by the so-called sacral route, and some
from above. Of the latter it may be said that occasionally an annular
cancer of the rectum is seen so favorably located that by opening the
abdomen with the patient in the Trendelenburg position it is possible
to make a complete excision of the growth, to remove enlarged lymph
nodes, and to make an end-to-end reunion with success. In a case in my
own practice nearly six years have elapsed since this operation was
done, and the patient, a young woman, is still absolutely free from the
disease.

Through the _perineum_ the lower portion of the rectum may be attacked
either by splitting the sphincter and dividing it posteriorly,
completely dissecting out the gut from its surroundings, removing all
infiltrated tissue, and then, by dividing the bowel above the growth,
amputating the lower part. It may be possible to bring down the upper
end and attach it to the mucocutaneous border of the anus, reuniting
the divided sphincter, and aiming for a restoration to something like
the original condition, which under quite favorable conditions is
attainable. At other times it will be impracticable to thus attach the
lower end of the tube because it has been too much shortened, and in
these cases it should be brought out through a posterior incision just
below the tip of the coccyx, or higher up if the bone has been removed.
Here the rectal outlet is placed posteriorly, but is devoid of a
sphincter. Something like sphincteric action can be provided by giving
it a third or half of a revolution on its axis before fastening it to
the external wound. After this expedient more or less control of solid
fecal matter is afforded.

The more complete and radical operations, associated with the names
of Kraske and other operators, include removal of the coccyx, and of
the lower portion of the sacrum, which are usually completely excised,
although certain “trap-door” operations have been devised. If the
sacrum be not cut away above the third sacral foramen there is not
much damage done to the nerves, while sufficient room is afforded for
any removal that is justifiable. Some operators open the peritoneum,
others attempt to avoid it. If the growth be attached to that membrane
it becomes necessary. If peritoneal invasion can be avoided it is
desirable. It is possible to completely expose the contents of the
pelvis through such an opening, while from this direction, the gut
being withdrawn after the peritoneum is divided, the pouch of Douglas
may be opened and further removal of diseased tissue be effected. In
all these operations the endeavor should be to disturb the mesosigmoid
and the mesorectum as little as possible, in order to not interfere
with blood supply, for reasons already mentioned when discussing the
mesentery.

In all these operations contamination of the wound should be avoided,
especially of the peritoneum, by clamping or ligating the bowel, or by
amply packing and by every possible additional precaution. Bowel should
be divided between two clamps and the divided edges at once thoroughly
cleansed with compresses and with hydrogen peroxide.

One may read in the works on operative surgery descriptions of most
extensive and elaborate operations of this general character, and of
extensive and even daring feats of removal, where portions of the
bladder, of the tubes, of the ovaries, even the uterus, have been
removed. It has seemed to me that the surgeon should avoid operative
gymnastics, especially in this region, so far as possible, and confine
himself to measures which if successful would improve conditions rather
than complicate them. My own judgment then is that in any case where so
formidable an operation would be attempted by some, the best interests
of the patient will be served rather by simple colostomy.

_Early_ operations upon cancer of the rectum afford comforting
prospects. It is not so much to the discredit of surgery as to the
discredit of the patient’s judgment, and of the carelessness of the
practitioners who first see these cases, that cancer of the rectum has
become such a _bête noir_ and is justly regarded as so serious and
unpromising a measure.[60]

  [60] It becomes a question of importance just when and where we
  should cease to attempt operation on the colon from above or on the
  sigmoid from below; in other words, the exact location of the tumor
  should decide the measure when it can be accurately determined.
  Moreover, a wide margin of bowel on either side of any new-growth
  which is about to be resected should be excised. The question of
  blood supply to the margins of the wound thus made is also of
  importance, as the most ideal operation in appearance may be marred
  by gangrene due to lack of sufficient blood supply. When there is
  sufficient uninvolved gut below the tumor to permit of complete
  operation within the abdomen it is not advisable to do anything from
  below; but there are some cases in which anything like complete
  removal can only be effected by a combination of abdominal and sacral
  routes. A thorough extirpation should be made above the growth as
  well as of the involved tissue below. Those vessels which require
  ligation should be tied accurately at the level of their division,
  and no ligation of trunks or larger vessels should be attempted at
  any distance from the line of division. If this be carefully carried
  out and the divided mesentery, with its ends, and all the fat between
  the rectum and the sacrum be carefully dissected out, there will
  rarely be difficulty in making an end-to-end reunion of the divided
  bowel.

  It is rarely necessary to include a colostomy with this procedure; in
  fact, when a permanent opening has become necessary there is little
  possibility of removing the main growth. Colostomy is a procedure
  for the hopeless cases; resection is rarely to be thought of as an
  alternative. It should be an early not a late measure, the reverse
  being true of colostomy, though even this should not be _too_ late.

=Colostomy.=--Colostomy for relief of rectal cancer is not a radical
operation, but in many cases is far more humane and satisfactory than
are those alluded to above. The intent is to make an opening in the
left side of the groin at a point where it is easily made. There are
two methods of performing colostomy here. One is to make an opening
through the abdominal wall, attach to it the presenting surface of
the sigmoid or colon, and either open it at once or some hours later,
when adhesions have cemented the desired union. Such an opening may
be made for emergency purposes under local anesthesia, but when the
colon is movable, and when the disease has not yet involved the area
thus exposed, or any portion above it, a more desirable method is a
deliberate one. An opening is made such as is usually made on the
right side when operating upon the appendix. The bowel thus being
accessible is divided between two clamps, while the end of the lower
segment is inverted and closed with chromic or silk sutures, after
which it is dropped back. This leaves the upper portion with its open
end corresponding to the abdominal opening, into which it is fastened
by a series of sutures, being attached to the peritoneum and to the
deep musculature rather than to the skin, for if it be brought out too
freely and attached externally there is greater tendency to prolapse
and subsequent discomfort. Into the opening thus afforded a large-sized
rubber or bent glass tube is inserted for a few inches, around which
gauze is packed, and every effort is made to conduct fecal matter to
the exterior, as well to protect, at least for a few hours, the wound
itself from fecal contamination. Improvements in this technique have
been suggested, such as tying into the bowel a curved glass tube, thus
conducting its contents into a rubber bag or receptacle placed outside
the dressing. Another method which has been suggested by Stewart is to
connect the interior of the colon by a Murphy button with a rubber bag
or rubber dam upon the outside of the abdomen, by which protection for
this purpose can be afforded.

This operation makes a complete and final division of the colon, and
permanently excludes the rectum with its cancerous involvement. It
is not, therefore, in this respect, a radical measure. The result,
however, is that if the rectum be washed from below each day it is kept
far cleaner and freer from contact with irritative foreign material
than it otherwise would be. Furthermore, being disused it tends to
undergo to some degree a species of physiological atrophy, and, in
consequence, the cancer grows more slowly, if there do not occur an
apparent temporary cessation of malignant activity.

By suitable management of the artificial anus, including the deliberate
emptying of the bowel every morning and the use of protective pads
for receptacles, it can be made far less disagreeable than patients
ordinarily fear (Figs. 595 and 596).

[Illustration: FIG. 595

Gleason’s pouch and supporter.]

[Illustration: FIG. 596

Colostomy pad and bag, worn as is a truss. (Kelsey.)]

The colostomy opening in the abdominal wall should be made as small
as practicable lest there occur not only more or less ventral hernia
through the weakened outlet, but even, as I have seen in one case, a
most extensive prolapse of the colon, in which two or three years after
performance of the operation the colon could be made to prolapse to an
extent of twelve or fifteen inches.

CHAPTER LI.

HERNIA.

The term hernia of itself implies protrusion or escape of a contained
organ or part through its containing walls, yet covered by some of
them. Thus we may have hernia of the iris, of the brain, and the like;
but when no particular part of the body is specified, by common consent
the term is understood as implying hernia either of the _intestine or
the omentum, or of both_. Such hernia may be either of _congenital
or acquired character_, the former condition being permitted by some
defect or abnormality in the abdominal parietes, the latter being the
immediate or remote result of accident or of operation; and in the
latter case they are referred to as _traumatic_ or as _postoperative_.
Of these the former is usually of rapid and the latter of slow
development. Increased abdominal pressure doubtless has much to do with
the occurrence even of a truly congenital hernia, as this would hardly
develop were it not for the former. Such pressure may be the result of
occupation, of pregnancy, or of certain morbid conditions--for example,
those which cause constant coughing or straining at stool, or straining
during urination--as from prostatic hypertrophy or phimosis, or such
intra-abdominal conditions as tumors, which distort the abdominal
walls, or accumulations of fluid which weaken them. Accident produces
hernia mainly by causing the effects of pressure to be manifested in
a brief space of time. Thus pressure or strain on abdominal muscles
may part them in such a way as to permit the immediate appearance of
a hernia, or its more slow development. The postoperative hernias are
usually of the so-called _ventral_ type, and occur most often after
wounds which could not be immediately closed because of necessity for
drainage, or in those which were closed in such a way as to permit of
gradual warping or stretching of the resulting scar.

The surgical anatomy of hernia is described in works on anatomy. It
is necessary, therefore, here only to remind the reader that the
conditions existent in an old hernia may be different from those so
described, for the original anatomical outlines may perhaps have long
been lost and the original coverings more or less blended together so
as to become indistinguishable. Particularly is it true of strangulated
hernia that the more minute details are lost, and that in such
cases there is great difficulty in the effort to recognize distinct
anatomical layers and coverings. In old cases the _sac_--namely, the
original peritoneum--may be greatly thickened, while in strangulated
cases it will be discolored, perhaps even gangrenous, and will bear but
slight resemblance to the original condition. The same is true of its
contents, which may be _adherent_, _strangulated_, or _gangrenous_,
according to circumstances.

The opening through which the hernia appears is usually referred to as
the _ring_, to which, however, it may bear very little resemblance.
Thus it may be an elongated buttonhole-like, or a warped, irregularly
rounded sac opening, whose margins are thick or thin and easily
distinguished or otherwise.

By all writers hernias are classified according to their anatomical
characteristics as follows: _Inguinal_, indirect and direct; _femoral_,
_umbilical_, _ventral_, _diaphragmatic_, _gluteal_ or _ischiatic_,
_obturator_, _perineal_, _lumbar_, _sacrorectal_, _retroperitoneal_
(including the recently described _paraduodenal_ or Treitz variety),
and _properitoneal_.

Of these the most common are the inguinal and the femoral, the
umbilical ranking next, while the other forms are rare.

=Causes.=--Regarding the _cause_ and _nature_ of the common
forms--namely, the inguinal and femoral--I propose here to introduce
the views enunciated by Russell, of Melbourne, which seem to me
to furnish the actual explanation for nearly all instances. This
explanation refers to the _congenital origin of the condition, even
though it do not appear until the middle years of life_. In the case of
inguinal hernia it refers also to the persistence of the canal of Nuck,
or of at least incomplete obliteration of the original vaginal process
or prolongation of the peritoneum, which comes down with the migrating
testicle and whose lower portion furnishes the cavity of the tunica
vaginalis. It is more rational to explain the occurrence of hernia in
connection with this preformed sac than by the view that there are so
many instances of congenital weakness of the abdominal wall. That such
weakness exists in many cases of hernia is undeniable, but this is to
be regarded as the effect rather than the actual condition. From this
last statement it follows also that there is great advantage in early
operation, and in complete removal of the sac, which when performed
early will not only cure the hernia but prevent the weakening of the
abdominal wall itself. It follows, further, that the use of a truss,
save possibly in the case of young infants, is an improper method of
treatment. In other words, upon it is based the crux of the whole
matter of successful treatment, _i. e._, operative removal of the sac.

It will be seen, then, that the cause of inguinal hernia is closely
related with the cause of so-called congenital hydrocele of the cord
(_q. v._), the latter condition being one of sacculation of the canal,
with accumulation of fluid; and it is interesting to recall that
such sacculations are occasionally found in the ordinary so-called
congenital hernias, when they are seen early, and before all anatomical
surroundings have been merged together. _The existence of a hernia
implies the presence of a sac, and a congenital defect furnishes this
latter, while the variations in the type of hernia are due mainly to
the variations in the sac itself_, i. e., _in its location_.

[Illustration: FIG. 597

Congenital hernia.]

[Illustration: FIG. 598

Infantile hernia.]

Russell has traced out the relations between the peritoneal pouches of
the lower abdomen and the principal bloodvessels, and has shown how the
former arrange themselves about the latter and are carried with them
as they develop, assuming in consequence the type either of inguinal
or femoral hernia, according as they are placed to the inner or outer
and lower side of the same. He has insisted, and I think properly, that
the variations observed in the clinical manifestations of a hernia are
mainly determined by the size and the position of the sac, and that
these depend upon its relations to the femoral and epigastric vessels,
the associated sac and vessel being subject to the same vicissitudes in
development. In this way the occurrence at one time of a _congenital_
and at another of a so-called _infantile_ type of inguinal hernia may
be easily explained, as well as the differences between the so-called
_funicular_ and the partial form, and also the occurrence of the
_retroperitoneal_ or _properitoneal_ forms, which, as variations are
rare, and as clinical manifestations perplexing, but which nevertheless
are easily explained when viewed in this light (Figs. 597 and 598).

[Illustration: FIG. 599

Adhesions in hernial sac. Scarpa. (Lejars.)]

Thus viewed, then, what are the _relations of traumatism to congenital
defects_? When thus explained they seem to be as follows: By no means
every individual who sustains an injury to the abdomen suffers from
hernia, but when the parts are already weakened or prepared by the
preëxistence of these congenital defects, then a small amount of
strain or injury may serve to open them up and to produce a condition
apparently due to accident which otherwise could not have occurred.
The more I have studied the entire question the more I have come to
the conclusion that hernias of the ordinary type, save in case of
extreme violence, would not occur were it not for such a congenital
prearrangement and tissue permission, as it were; so that we are
justified in assuming that inguinal and femoral like umbilical hernias
are really of congenital origin.

=The Signs of Hernia.=--The signs of hernia include the existence of a
_tumor_, usually at one of the common outlets, which may be variable
in size, and fixed, changeable, or otherwise, according to whether it
consist of intestine or omentum. To a hernial protrusion consisting
of intestine alone may still be given the old term _enterocele_. One
consisting of omentum is known as _epiplocele_. Hernial protrusions
may attain tremendous dimensions, especially those appearing at the
umbilicus, and some of these sacs contain perhaps the larger proportion
of the intestine or even of the entire abdominal contents. Scrotal
tumors, again, may attain large size, _e. g._, that of the individual’s
head or even much larger. According to the nature of the contents such
a tumor will be more or less resonant on percussion, and more or less
compressible as well as reducible. _Reducibility_--namely, the ability
to be returned to the abdominal cavity--is the most characteristic
feature of a hernia and one possessed by nearly every such tumor, at
least at its inception. It may, however, be lost.

Loss of reducibility, when occurring gradually, is replaced by what
is known as _incarceration_, _i. e._, more or less complete fixation,
at the same time without such pressure on bloodvessels as to produce
necrosis. Incarceration may be the result of reduction in caliber
of the hernial outlet, or of the formation of adhesions between the
walls of the sac and its contents, such adhesions being common alike
to omentum and large or small bowel. (See Fig. 599.) _Strangulation_
is an acute process which may terminate either a reducible or
an incarcerated hernia. It implies some sudden change, such as
overcrowding of the bowel within the sac, or some peculiar kinking, by
which intestinal caliber is shut off, as well as blood supply affected
because of pressure, by which the vitality of the gut and of the sac
is compromised or perhaps quickly lost. Strangulation, then, includes
at least the possibilities and usually the simultaneous occurrence of
acute obstruction of the bowel with more or less gangrene of the sac
itself, as well as of the compromised gut.

_Reducibility_ as an ordinary feature of hernia is one with which the
patient himself is quite familiar, most patients with reducible hernias
being able to effect reduction in the horizontal position, accompanied
by some manipulation or maneuver. When in such cases reduction cannot
be accomplished incarceration or perhaps strangulation has begun and
the case immediately assumes serious proportions. Reduction is usually
accompanied by a peculiar gurgle, as well as disappearance of the
tumor itself, while the opening through which it has disappeared can
usually be identified with the finger, by invagination of the scrotum,
or by pressure over the femoral region. Such a tumor usually reappears
when the patient stands, or particularly when he coughs or makes any
straining effort, and the occurrence and recurrence of these phenomena
clearly establish the diagnosis of hernia.

Irreducible or incarcerated hernias usually give some _impulse upon
the patient’s coughing_, as do the reducible forms, yet in some cases
they lead to more difficulty of diagnosis. Ordinarily in the male
the question is mainly as between inguinal (or scrotal) hernia and
_hydrocele_. In the latter there is a pear-shaped tumor whose apex
should be found below the level of the inguinal outlet; a tumor which
will fluctuate, whose shape does not change, which gives no impulse
when the patient coughs, which is not influenced by pressure, even with
the patient in the horizontal position. It is only in incarcerated or
in peculiar types of congenital hernias, or in those combined, as they
may be, with hydrocele, in which doubt should not be easily dissipated.
While incarceration predisposes to acute obstruction it is not always
followed by it, but may produce a more chronic type of constipation,
with tendency to fecal impaction, because of the mechanical impediment
to freedom of bowel motility. This condition is more frequently met in
the aged.

_Inflammation of the hernial sac_, as well as of its coverings, leads
to a condition described as _inflamed hernia_. It is essentially one of
circumscribed cellulitis. It may be due to the irritation of a badly
fitting truss or to other external causes. The inflammation may extend
so as to involve the sac wall itself, and thus produce adhesions and
later incarceration, or it may set up actual peritonitis, which may
extend to the general abdominal cavity and terminate fatally. The more
superficial and less acute forms are scarcely distinguishable from a
local erysipelas which may terminate by abscess. Such a condition might
be mistaken for one of suppurating bubo. Nevertheless the existence
of the hernia itself should guard one against this error and make him
extremely cautious in using the knife, even though it be necessary for
the evacuation of pus.

[Illustration: FIG. 600

Gangrenous strangulated hernia; artificial anus; prolapse of bowel
requiring intestinal resection; eventual recovery. (Preindlsberger.)]

_Strangulated hernia_ has already been considered as the most common
cause of _acute obstruction of the bowel_. Its possibility should
be excluded in every case of this serious condition. While such are
its general features, locally there is added to the general bowel
obstructive condition that of more or less local destruction, which may
vary from the presence of exudate, fluid or solid, with infiltration of
adjoining tissues, to the most prompt and disastrous consequences of
venous stasis, namely, extensive _gangrene_, which, involving first the
bowel itself or the omentum, will later spread to the sac wall and its
surroundings. In this instance around the loop or loops of gut involved
will be seen a tight constriction or sulcus, above which the bowel
will be more or less discolored and distended, while below it will
be completely necrotic and perhaps actually sloughing. Minor degrees
of strangulation may produce conditions which would lead up to this,
but have not yet actually reached the stage of gangrene. Around such
bowel will be found more or less fluid, the result of transudation,
which will be swarming with bacteria and often offensive. The sac wall
closely corresponds in appearance to that of the bowel, and everything
about the sac and its contents will be infected and contaminated with
bacteria, often of most virulent activity. The gangrene may involve an
area of exceedingly small size, or the entire contents of the hernial
sac. In the former instance the condition is comparatively simple as
compared with the latter, which may require resection of several feet
of necrotic bowel. The proper treatment of these conditions will be
more fully dealt with below (Fig. 600).

=Symptoms.=--The symptoms of strangulation are those of acute
obstruction, plus the local evidences of a hernia, usually with added
pain and tenderness, sometimes acute. These symptoms may come on as
the result of strain or accident or without any known cause. Their
intensity will depend in some measure upon the completeness of the
blood stasis and the rapidity of the consequent gangrenous process. The
latter may vary in degree. Thus the death of the compromised bowel may
be practically determined within a few hours or within two or three
days. The hernial tumor, within which strangulation has occurred,
becomes more tense and incompressible, and, at the same time, more
tender. Sometimes there is marked augmentation in volume; at other
times this changes but little. So soon as a loop of bowel has lost
its blood supply and become actually necrotic it will have also lost,
when exposed, all of its luster or “sheen,” and will appear not only
black and lusterless, but will be more or less offensive in odor, and
of extremely septic character. The surrounding fluid will be found
swarming with bacteria, and will seriously and perhaps fatally infect
anyone inoculated with it.

Concerning the color of the exposed bowel and its appearance, it is
a fairly safe rule to follow that gut which has not lost its luster,
even though darkly discolored, is still viable, and may with safety be
returned to the abdomen, which is probably the safest place for it;
but when its sheen is actually lost the case becomes one either for
resection or for artificial anus. It is possible that such a case may
be seen only after absolute necrosis and fecal escape have occurred.
When actual sloughing is thus met it is a question for resection or
some other expedient.

=Varieties of Hernia. Inguinal Hernia.=--The inguinal form of hernia
comprises nearly four-fifths of cases in males, a much smaller
proportion in females. The hernial protrusion is always through the
external abdominal ring, either by way of the inguinal canal, which it
enters through the internal ring, or directly through the abdominal
wall. The former is called _indirect_, the latter _direct_. Such
a hernia is considered _complete_ or _incomplete_ according as it
descends below the lower margin of the inguinal canal. An incomplete
and direct hernia is often referred to as _bubonocele_. (Fig. 601.)

Holding the views above enunciated, regarding the congenital origin
of practically every inguinal hernia, it is necessary to pay less
attention to the distinctions insisted upon by the earlier authors
concerning the congenital, the infantile, or the encysted forms of
hernia, which depend upon the extent and degree of closure of the
vaginal process or the canal of Nuck, which is carried down with the
testis during its migration from the lower margin of the Wolffian
body, and which is normally obliterated at birth. Nevertheless these
conditions, however explained, are actually met during life and are
represented by the diagrams seen in Figs. 602, 603 and 604.

[Illustration: FIG. 601

Indirect inguinal hernia (bubonocele.) (Richardson.)]

[Illustration: FIG. 602

Congenital inguinal hernia.]

[Illustration: FIG. 603

Infantile or encysted hernia.]

[Illustration: FIG. 604

Hernia of the funicular process.]

In the female the canal of Nuck is a matter of minor importance,
containing only the round ligament. Nevertheless along it may proceed
an indirect inguinal hernia corresponding to that in the male.

The so-called _acquired indirect hernia_, according to the above
views, _would not occur were it not for the opportunity--as it were,
the temptation--already afforded by some deviation of the peritoneal
arrangement in this locality_. In these cases, however, the sac
appears to be new and is pushed along the inguinal canal anteriorly
to its normal contents. This may be the result of violent strain, or
of one which is apparently disproportionately small, but frequently
repeated.

_Direct inguinal hernia_ is generally an occurrence of adult life,
takes place commonly as the result of accident, is a direct protrusion
through the abdominal wall at the triangular weak spot, whose outer
limit is the deep epigastric artery, with the obliterated hypogastric
artery to the inner side and Poupart’s ligament below, _i. e._, the
so-called triangle of Hesselbach. This hernia appears always at the
external ring, from which it may descend and become scrotal.

[Illustration: FIG. 605

Scrotal hernia. (Richardson.)]

With complete or scrotal hernia there is usually little difficulty of
diagnosis (Fig. 605). An incomplete hernia, protruding at the external
ring, covered with considerable fat, and perhaps shifted a little in
position, is sometimes hard to distinguish from a hernia through the
femoral opening. The inguinal form escapes above Poupart’s ligament,
the femoral always below it, and Poupart’s ligament is to be located
by a line drawn from the anterior superior spine to the spine of the
pubis. The inguinal forms are usually nearer the middle line. If the
epigastric artery can be identified, either before or during operation,
the character of the hernia will be promptly demonstrated by its
relations to the neck of the sac.

Hernial protrusions give a familiar _impulse on coughing_ unless the
incarceration of an epiplocele may mask this feature. By it they are
to be distinguished from hydrocele, varicocele, aneurysm, undescended
testicle, and the like.

[Illustration: FIG. 606

Hernia of liver through congenital opening in the umbilicus.
(Richardson.)]

=Femoral Hernia.=--Femoral hernia is much more common in women than in
men, and constitutes about one-tenth of all cases. This form is also
nearly always congenital in the above sense, and is particularly liable
to strangulation. It escapes through the femoral ring into the femoral
canal, to the inner side of the femoral vein, and then, passing forward
through the femoral opening, finds its direction of least resistance
upward. In consequence a loop of bowel thus escaping from the abdomen
may first pass downward, then forward, and then upward, which will
illustrate the futility of the ordinary methods of taxis in the effort
to reduce it by manipulation. These hernias are usually small, hence
their greater danger. These cases have especially to be differentiated
from psoas abscess, from inguinal lymphatic enlargements, and tumors.
If the sac be entirely filled with omentum diagnosis is often difficult.

=Umbilical Hernia.=--Umbilical hernia is primarily permitted by failure
in obliteration of the opening at the navel for the omphalomesenteric
duct and for the urachus. Originally small, it may yet assume enormous
dimensions. Though actually of congenital origin, as just stated, it
may not be discovered until the later years of life. It occurs much
more commonly in females than males, and usually in connection with a
large deposit of fat in the abdomen, by which its existence, or, at
least, its limits and dimensions are masked. Through the umbilical
opening, which in the majority of cases is small, may escape other of
the abdominal viscera, as is shown in Fig. 606, illustrating hernia of
the liver. Fig. 607 illustrates the pendulous form which many of these
cases assume.

[Illustration: FIG. 607

Umbilical hernia of pendulous form. (Park.)]

An _infantile form_ (umbilical) is known, in which the actual
protrusion does not occur until the infant is several months old, and
which appears to be due to frequent strain, on a weak or incompletely
closed fenestrum, by coughing, crying, efforts to expel urine through a
strictured prepuce, and the like. These tumors at first are small and
always intestinal. It is often possible to so adjust a small pad over
these openings as to secure subsequent closure by natural processes.
On the other hand, the forms which come on in later life, acquired
during pregnancy, ascites, or in connection with excessive obesity,
assume sometimes relatively enormous size. Here the hernial contents
may be solely omental, but are usually at least partially intestinal.
Strangulation occurs in a large proportion of these instances and
incarceration is nearly always observed. Naturally, in consequence,
the patient complains of gastric disturbances, as well as of chronic
constipation, with frequent colicky attacks.[61]

  [61] A rare form of hernia into the umbilical cord has been described
  by Moran. It has been known as _hernia funiculi umbilicalis_, and has
  been held to be due to abnormal persistence of the vitelline duct,
  which holds the loop of intestine to which it was attached inside the
  abdominal wall, the intestine continuing to grow, the umbilical ring
  remaining open and the hernia thus enlarging. Occurring in this way
  it happens about the tenth week of fetal life. Such a hernia has no
  covering except the peritoneum and the amnion--_i. e._, is without
  muscle or skin covering. It would be probably first noted when the
  cord is about to be tied, when at its loop, as a translucent tumor,
  varying in size from that of a small cherry to a lemon, the cord
  being distended and assuming its own natural size only after it has
  left the hernial tumor. The bloodvessels will run on one side of the
  amniotic sac. Such sacs rupture easily, perhaps during crying efforts
  or even during parturition. The condition is serious, and when
  present no traction should be made on the cord. If easily reduced by
  taxis an antiseptic compress should be fastened over the opening.
  Should anything like strangulation occur operation is imperative and
  should be done immediately.

=Ventral Hernia.=--Ventral hernia is of two types--the _spontaneous_,
usually _epigastric_, which is an omental escape in the middle line
above the umbilicus, occurring most often in fat women, in whom it
is likely to be mistaken for a hernia of ordinary umbilical type. By
fixation of its contained intestine and omentum there is more or less
dragging upon the upper abdominal viscera, with consequent disturbance
of function.

=Postoperative Hernia.=--Postoperative hernia often also spoken
of as ventral, occurs through the cicatrix of the wound which has
permitted it, whether this be in the middle line or elsewhere. It is an
unfortunately frequent sequel of laparotomy wounds which have required
drainage, but occasionally occurs in perfectly clean wounds which have
closed satisfactorily in the first place, but which have subsequently
parted because of unsatisfactory methods of bringing together their
deeper portions. (See p. 778.) Consequently it should be sufficient
here to remind the reader that the more accurate the method of
approximating the margins, layer by layer, and effecting a complete and
perfect union between them individually the less the tendency to this
unpleasant sequel.

Postoperative hernia may be so small as to be kept under subjection
with some form of abdominal support, or it may call for operations for
radical cure, as do other cases. They are subject to the same dangers
of strangulation of their contents.

=Diaphragmatic Hernia.=--Diaphragmatic hernia may be _congenital_, as
when occurring through a defect in this partition, or _acquired_, as
when under stress or strain some of the abdominal contents are forced
into the thorax, either through natural openings or through a rent
or tear. Such escape may include but a small portion of bowel; in
congenital cases one-half the abdominal contents have been found within
the thorax. The left side seems more often involved than the right.
Serious wounds of the diaphragm may be followed by this condition.
Under these circumstances the thoracic viscera are more or less
displaced, and the heart may be pushed considerably out of place. In
cases with a history of violent accident the surgeon may more readily
suspect and recognize the condition than in congenital cases, where
anatomical relations have long been disturbed, but apparently more or
less adjusted or compensated.

=Pelvic Hernia.=--In the lower part of the pelvis, under rare
circumstances, hernial protrusions occur either through the
sacrosciatic foramina, in which case they are known as _gluteal_ or
_ischiatic_ (Fig. 608), or through the obturator foramen, when they
are known as _obturator_ hernias, the latter occurring more often in
stout women. Unless these constitute some form of recognizable tumor,
or produce acute obstruction by strangulation, they will pass quite
unrecognized. A _perineal_ form of hernia is also known, which occurs
in Douglas’ cul-de-sac, behind the bladder or uterus, the levator ani
muscle being more or less disturbed, and the protrusion occurring
somewhere between the labium and the anus. In such hernial sacs the
ovary has been found, as well as intestinal loops, and the so-called
_ovarian_ hernia includes some anatomical anomaly of this kind.

[Illustration: FIG. 608

Ischiatic hernia. (Richardson.)]

[Illustration: FIG. 609

Hernia into foramen of Winslow.]

=Lumbar Hernia.=--In so-called lumbar hernia, which is very rare, the
hernia escapes along the outer border of the quadratus lumborum muscle
into the triangle of Petit. Such a tumor, usually small, may be easily
mistaken for lipoma or for cold abscesses.

Other anomalous types of hernia may occur in connection with congenital
defects of the bones or the less dense structures of the pelvis proper.

=Retroperitoneal and Properitoneal Hernia.=--Retroperitoneal and
properitoneal hernia are types which seem to corroborate the views
already enunciated concerning the essentially congenital origin of
the ordinary forms. The former implies a protrusion into an internal
peritoneal pouch, and is usually found in the upper abdominal cavity
in the duodenojejunal fossa, although it may also occur lower down on
either side. It will not be recognized save by its effects, which will
usually be those of acute intestinal obstruction, and even then will
only be diagnosticated after the operation which the condition will
necessitate. Hernia through the foramen of Winslow has already been
mentioned in the chapter on the Small Intestines. (See Fig. 609.)

_Properitoneal hernia_ implies usually the existence of a double sac,
with a common opening, its inner portion lying between the peritoneum
and the abdominal musculature, while its outer portion takes the
usual position of the hernial sac, either the inguinal, the femoral,
or the umbilical form. It may be suspected when reduction which has
been apparently successful has later evidently failed. It occurs most
often in the inguinal region, where it is usually referred to as
_inguinoproperitoneal_ hernia, and where it was first recognized by
Parise, and later fully described by Krönlein. It may be with equal
propriety called _interstitial hernia_, and is often associated with
imperfect descent of the testicle, which perhaps has served to deflect
the descending hernia in an unusual direction. The properitoneal sac
is most often found between the internal ring and the anterior spine,
although it may be directed downward and inward toward the bladder,
or backward toward the iliac fossa. In size it is usually small as
compared with the external portions. Its existence may be suspected
when a patient with a hernia previously easily reducible suddenly
develops strangulation, which is apparently relieved by taxis, only to
recur a little later. So far as its radical treatment is concerned all
that is necessary is the extirpation of the extra sac, with perhaps
separate treatment of its neck, when dealing with the greater and more
completely filled pouch in front (Fig. 610).

[Illustration: FIG. 610

Properitoneal hernia. This illustrates also incomplete reduction of
hernia. (Richardson.)]

=Littre’s or Richter’s Hernia.=--These terms have reference to
strangulation of intestine in which, nevertheless, the entire lumen
of the bowel is not completely involved, rather only a small area,
which soon becomes sacculated, or perhaps by a diverticulum becoming
involved in the occlusive and later gangrenous process. These forms
are most frequently seen in women and at the femoral ring. They are
peculiarly dangerous in that they produce symptoms which do not include
those of total and acute bowel obstruction, and hence are often allowed
to go unoperated until gangrene has already occurred. These forms,
then, will produce signs and symptoms of partial strangulation, with
incarceration, followed after hours or perhaps days by those of local
cellulitis, with perhaps necrosis; conditions which when opened may
expose gangrenous bowel and promptly become fecal fistulas.

=Treatment of Hernia.=--Hernia is treated for three different purposes:
for the _relief of strangulation_, _i. e._, as an emergency, for
_palliation_, or for _radical cure_, according to the nature of the
case and the wishes of the patient.

_The relief of strangulated hernia_ becomes a measure of instant
importance so soon as the condition is recognized, mortality being due
to delay, practically every case being curable could it be recognized
and operated promptly. The symptoms of strangulation, as repeatedly
indicated, are those of acute obstruction of the bowel, including
fecal vomiting with meteorism, and the local indications which may be
trifling, as in very small hernial protrusions, or unmistakable, as in
large hernial masses. The indication in every instance is to restore
the occluded bowel to the abdominal cavity. Occasionally this may be
effected by the method of _manipulation_ or by _taxis_, which should
never be thought of save at the very outset, and which may be aided by
the local use of cold, or especially by the Trendelenburg position,
which may be exaggerated. Under these circumstances, as Richardson has
said, minutes are precious and delay adds materially to the danger, so
that usually all non-operative methods are to be condemned.

[Illustration: PLATE LIV

Strangulated Right Inguinal Hernia. (Richardson.)

The sac has been opened and its edges are drawn apart by means of
forceps. The inguinal canal and spermatic cord have been dissected.]

=Taxis.=--The principal danger in connection with taxis is that of
doing harm to the occluded bowel by rough manipulation. The method
includes a coaxing pressure in the proper direction, with more or less
compression of the external mass, the effort being to gently persuade
it back into the abdominal cavity. In this effort the temptation,
especially among the inexperienced, is to use too much force, by which
extravasation is produced, exudate increased, and the local condition
in every way made worse. That which is possible during the first hour
after strangulation has occurred may be impossible a little later, when
edema and exudate have distorted the parts or cemented them together.
The effort should not be prolonged, but rather very brief, and if after
a very few moments no gain be made it should be discontinued.

_Reduction “en bloc”_ is an unusual but ever-present danger. It implies
forcing back the peritoneal sac as well as its contained intestine
unreduced, so that while the external tumor is dissipated the actual
condition of strangulation is not influenced. Its effect would be in
no way to diminish the danger of the condition, but rather to more
seriously menace the patient, under the supposition that reduction had
been accomplished satisfactorily.

Two or three axioms in the treatment of strangulated hernia are
imperative:

_Very little time, if any, should be wasted in manipulation or taxis._

_Taxis failing or there remaining any suspicion of reduction en bloc,
open operation is imperative._

_The time to operate is just after the diagnosis has been made and
the condition recognized. Every hour of delay increases danger of
obstruction and of gangrene._

_Operations for strangulated hernia_ should thus always be done early
and before much exudate or local disturbance has occurred, as when thus
performed they may be combined with measures for radical cure, which
are hardly to be thought of when infection has occurred. (See Plate
LIV.)

Strangulated hernia, then, being always a dire emergency, is in
nearly every instance best treated by _herniotomy_, whose principles
are the same, no matter whether applied to inguinal, femoral, or
umbilical hernia. By a suitably planned incision the sac is exposed.
In the inguinal region this follows the general direction of the
cord and inguinal canal. In the femoral region it is best to raise
a flap, while in umbilical hernia, although the first incision may
be in the middle line, it will usually be found necessary to make an
elliptical excision of the overlying skin, in order that both it and
the sac may be removed. Under conditions of long existent hernia, plus
strangulation, the original anatomical conditions are much altered,
and it is not necessary to waste time in the endeavor to recognize
the various coverings of the sac. One cuts directly down upon it
with such care that he may recognize it as he comes upon it, usually
by its color and by the sensation of proximity to its strangulated
contents. This is ordinarily not a difficult matter; all bleeding
vessels should be secured before the sac is finally opened. Final and
complete identification may be made by finding that the sac itself may
be pinched up between the fingers or forceps, while the underlying
contents slip away. Only when parts are bound together in exudate will
there be difficulty in this regard. The surgeon should still proceed
with caution, although the sac will usually contain sufficient fluid
of transudation to protect against injury to the enclosed bowel.
Nevertheless the greatest care should be observed not to wound the
intestine, which sometimes lies very closely under the skin, especially
in the middle line of an umbilical hernia, although there may be
masses of fat on either side of it. Sometimes the sac distended with
discolored fluid is itself mistaken for the bowel. Error can usually be
avoided by following it upward and identifying its continuity with the
surrounding tissues.

When opened its contained fluid may be found quite clear,
blood-stained, purulent, extremely offensive, or even fecal, according
to the relative age of the condition and the degree and results of
strangulation. Under all circumstances it is advisable to disinfect the
sac and its contents before endeavoring to release them. This may be
done with dilute peroxide of hydrogen or with any ordinary irrigating
fluid.

Within the sac, when thus identified and opened, may be imprisoned
omentum or bowel, or both, in any degree of preservation from that
which is almost normal, and with circulation but slightly disturbed,
to that which is absolutely gangrenous. Congested bowel will nearly
always be more or less discolored. So long as it is dusky or even
almost black, _but has not lost its luster_, it may probably be safely
returned to the abdominal cavity; but if green or if luster be gone,
or if the contained fluid be distinctly putrefactive, then serious
doubt as to its viability will arise. In case of actual perforation,
gangrene, or fecal abscess there will be no doubt as to the danger of
returning such bowel, and other measures should be adopted.

The _viability_ of the bowel having been determined and the sac
disinfected the location and degree of tightness of the constricting
ring should now be determined. In inguinal hernia the constriction may
occur either at the external or internal ring; in femoral hernia it
is usually at the femoral ring; in umbilical hernia, at some portion
of the umbilical opening; while in all three forms constriction may
occur within the sac itself and with little reference to the ordinary
hernial outlets; all of which needs to be clearly kept in mind. This
identification is usually done with the tip of the little finger,
gently insinuated and used as a probe. The operator who is sure of his
methods does not necessarily need to expose the constricting ring in
order to nick it or divide it, but he who is not as proficient should
extend and deepen his incision until the parts are clearly exposed, so
that he may be sure of not doing more harm than good.

Ordinarily it is necessary only to nick at one or two points the margin
of the ring, which will feel much like a wire loop, and then to use
the finger as a dilator, stretching and perhaps tearing, _i. e._,
making the knife do as little and the finger as much work as possible,
in order to so loosen up the constricted canal that by gentle taxis
or manipulation reduction can now be accomplished. The text-books on
anatomy give minute descriptions of the relations of these hernial
outlets to important bloodvessels, with which even the student should
be perfectly familiar. Nevertheless by following the subjoined rule,
and never departing from the principle thereby indicated, the operator
may safely proceed in practically every instance. _This is to cut in
the direction of the patient’s nose._ The knife used for this purpose
is ordinarily the _herniotome_, _i. e._, a blunt, slightly curved
bistoury, with but a small exposed cutting blade, whose dull point is
passed along the finger until the constriction is reached, and then, by
the sense of touch, beneath and beyond it, until the wire edge of the
ring rests upon the cutting part. The handle is then turned until this
edge points upward and is moved with a gentle sawing action always in
the above-specified direction, until the peculiar resistance is felt
to have yielded. It may then be turned a little and another nick be
similarly made. These nicks should not be more than one-quarter of an
inch deep, after which the knife is withdrawn and the finger now made
to dilate and tear. With these precautions there is very little danger
of dividing an anomalously placed vessel.

Dilatation of the ring being now sufficient it is well to pull the
hernial mass a little downward, in order that the condition of the
bowel at the point of constriction may be exactly noted. It should
therefore be gently coaxed into the wound, once more subjected to
inspection, and then to disinfection. The surgeon should now determine
what to do both with the bowel and the omentum. Omentum which is
covered with exudate or darkly discolored, or surrounded by offensive
material, should be first liberated, then ligated, above the original
point of constriction, and the undesirable part removed, the stump
being returned to the abdominal cavity. The bowel, if decided by above
indications to be viable, may then be gently coaxed back if handled
with care.

But gut which has perforated, or is so compromised as to be threatening
gangrene, should _not be returned_ into the abdominal cavity, but
treated by resection, or by fixation and the formation of an artificial
anus, decision depending both upon the condition of the patient and of
the bowel. Some of these cases are too nearly moribund when operated to
justify such procedures as resection, and are suffering too profoundly
from the consequences of obstruction to make it advisable to do more
than open the bowel for its immediate relief. Artificial anus is,
therefore, the inevitable necessity in some forms of strangulation.
When the bowel is gangrenous it is not necessary even to endeavor to
draw it farther down into the sac, but it may be simply opened _in
situ_.

_Intestinal resection and suture_ instituted under these circumstances
are essentially the same as those already described in the chapter on
the Small Intestines. With the formation of an artificial anus there
results the inevitable fecal fistula which will require subsequent
operation, probably secondary resection.

In non-septic and favorable cases, the reduction having been
accomplished, the operator then may proceed to extirpation of the sac
and the closure of the hernial outlet, _i. e._, operate for radical
cure, this being a modern extension and addition to the old operation
for relief.

If obstructive symptoms should persist after operation the possibility
of twisting of the intestine, or a possible reduction _en bloc_,
may be feared, which is not likely to occur if the open part of the
operating have been done thoroughly.

Clean cases of strangulation may be closed without drainage. In case of
doubt, however, it is advisable to provide at least a capillary drain,
while every case known to have been contaminated should be perfectly
drained.

[Illustration: FIG. 611

Bassini’s operation. Ligation of the sac by means of a purse-string
suture passed through the internal surface of its neck. The cord is
drawn to one side. The aponeurosis of the external oblique is drawn
apart with forceps. (Richardson.)]

[Illustration: FIG. 612

Bassini’s operation. Suture of the conjoined tendon to the internal
surface of Poupart’s ligament. Fortification of the posterior surface
of the canal. (Richardson.)]

=Radical Cure of Hernia.=--From the earliest times rude and crude
methods of endeavoring to effect a radical cure of hernia have been in
vogue. While sometimes effective they have always been dangerous and
always clumsy. Not until the antiseptic method was introduced could
they be regarded as in any way safe or reliable. With the introduction
of Listerism it became practicable to do this work, upon principles
simple in character and ordinarily easy of performance, which may be
summed up in the formula: _Isolation and obliteration of the hernial
sac, with permanent closure of the hernial outlet._ Easy as such
description may sound it has been found more or less difficult in
practice, and numerous methods, apparently both simple and ingenious,
have proved defective and have called for the most pronounced
modification. Considerable space could be devoted to operations for
radical cure, but the intent here shall be to simplify the subject
as well as the method, and consequently but two or three will be
described. Suffice it to say that while all are based on the same
principle they vary somewhat in detail, and that some of these details
have to be adapted to the special requirements of individual cases.

With increase in experience has come enlarged confidence in the
operation, and it is now regarded as justifiable in nearly every
instance among individuals otherwise in good condition. It has a double
purpose--namely, the avoidance of the danger of sudden strangulation
and the riddance of necessity for wearing trusses, or suffering the
discomforts of hernia without any mechanical control. Some modern
methods include the utilization of some portion or all of the sac,
while in others it is entirely cut away. Consequently some operators
have endeavored to utilize such portion of the sac as could be made
available for either purpose, either as plug or suture material.

The _method of Bassini_ for relief of inguinal hernia, more or less
modified to meet individual demands, seems to have become of late years
the most popular and widely adopted. The incision is made over the most
prominent part of the tumor, extending as far downward upon the scrotum
as necessary, and upward to near the anterior superior spine. Through
it the external ring, with its pillars, is exposed, and then the sac,
by a dissection long and sufficiently wide to fully reveal it. The
exposure is made more complete by dissection of the aponeurosis of the
external oblique from the level of the external ring upward and outward
for an inch or so above the external ring. By seizing the edges of
the aponeurosis on each side with forceps and retracting there is now
afforded an excellent view of the hernia proper. (See Fig. 611.)

[Illustration: FIG. 613

Park’s method of utilization of sac, showing its isolation and one way
of employment in making the suture further represented in Fig. 614.]

By careful dissection the sac and cord are identified and isolated,
while the sac is opened and its edges held apart by forceps, after
which it is carefully separated from the other structures of the cord.
After thus isolating the sac, and with the least possible disturbance
of the cord and of the testicle, it is ligated as high as the internal
ring, or, if possible, higher yet. This leaves the cord uninjured; its
size should next be reduced by cutting away all superfluous tissue.
Some operators remove all the veins, but this seems unpromising and
dangerous.

[Illustration: FIG. 614

Park’s operation. Continuous suture made with a long thin sac.]

By all this dissection and reduction the inguinal canal has been
temporarily, cleared, and the sac having been elevated, ligated, and
cut away it becomes now a question of what to do with the cord. The
lower surfaces of the external oblique and of Poupart’s ligament are
next freed, the edge of the internal oblique, of the transversalis with
its fascia, the outer border of the rectus and the conjoined tendon
being all exposed to view by whatever dissection may be required, all
fat and areolar tissue being removed. The cord is finally disposed
of by holding it out of the way, usually by a loop of gauze, while
the deep layer of the external oblique and the external portion of
Poupart’s ligament are sewed to the muscle edges of the internal
oblique and transversalis, as appears in Fig. 612, by a line of sutures
which include the conjoined tendon, at the lower angle of the wound,
which should be affixed to the outer border of the rectus. In the
deeper portion of every such wound there is danger of injury to the
external iliac vessels as well as to the epigastric. For the escape of
the cord, and to avoid its undue constriction, an opening should be
left for it, _i. e._, a new _internal_ ring, adapted for the purpose
and not too small. This is made by not suturing the upper part of the
wound. The cord being afforded this exit is now dropped, and the edges
of the external oblique are brought together over it, the sutures
extending well downward, but being omitted at the lower portion, where
a new _external_ ring is thus left, only not of its original size, but
sufficiently large to accommodate the cord.

Such are the essentials of the Bassini method, which has been modified
by Halsted in such a way that the cord, reduced as much as possible,
usually by removal of most of its veins, is now not left within the
inguinal canal, but transplanted entirely outside of the external
oblique, escaping at the upper part of the incision and requiring no
further accommodation in its course toward the testicle. In children,
or even in adults with very small veins, he does not so reduce the
cord. After isolation, opening and transfixion of the upper end of the
sac, and its secure ligation, he drops the stump back into the abdomen.
The muscular and tendinous layers of the ring and abdomen are united
also, by layers, with quilted sutures.

[Illustration: FIG. 615

Park’s method. Shoelace suture made with a sac split into two strips.]

In these as in many other methods, much, practically everything,
depends upon the certainty and durability of the sutures used for
disposal of the inguinal canal. For some years surgeons used silver
wire, which has now been abandoned. The choice now seems to depend on
_silk_, thoroughly and freshly boiled, or _animal sutures_, such as
kangaroo or reindeer tendon. McArthur suggested to dissect off a strip
from the margin of the opening in the external oblique, or from the
aponeurosis, and to use this strip of the patient’s own tissue for
suture material. I have modified this method, as will be described
later. Kocher devised a method of isolation of the sac, without such
complete emptying of the inguinal canal, the sac being drawn up through
the canal, then through the internal ring, and finally through an
opening in the external oblique, over the internal ring, where it was
twisted and fastened, after which the external portion was removed.

My own preference in operations for radical cure has been, until
recently, an exposure similar to that of Bassini’s, with complete
isolation of the sac, which is separated up to the level of the
internal ring or even higher. At this point it is drawn out through an
incision made in the external aponeurosis, twisted and fastened. The
inguinal canal is then closed, its deeper layers by a shoelace suture
of tendon, threaded into two stout curved needles, by which the deeper
margins of the canal are brought accurately together. Sometimes I have
transplanted the cord and again have dropped it back, the layer of
shoelace sutures closing the external aponeurosis over it. It has not
seemed to me to make any difference which method was adopted, and I
have practically never seen any atrophy or permanent disturbance of the
testicle.

More recently it has occurred to me to utilize the sac itself for
suture material, and this is the method which I now adopt in those
cases that permit of it.

Figs. 613 to 616 show the method of thus utilizing the sac. A long thin
sac may be twisted into a cord and used as an over-and-over suture, by
which the margins of the canal are brought together. If found thick
and unwieldy it may be trimmed down into a single suture, or it may be
_split_, with more or less trimming, into two portions, by which the
canal is then braided together or closed with a shoelace suture, the
ends being tied or fastened at the lower portion. Fig. 616 shows how a
short sac not otherwise available can be lengthened and made sufficient
for the purpose.

[Illustration: FIG. 616

Park’s method. A short sac is so divided as to be elongated
sufficiently for use as a suture.]

This again is utilization of the patient’s own tissue, he himself
furnishing his own animal ligature, which, being fresh and sterile, may
be regarded as reliable. The method, furthermore, has this advantage,
that there is reason to believe that tissue so utilized becomes
organized, in time, and that the union becomes more reliable rather
than otherwise. At all events in a considerable number of cases it
has yielded satisfactory results, and in no case has it caused any
disappointment.

[Illustration: FIG. 617

Radical cure of femoral hernia. Dissection of the saphenous opening.
The sac of the hernia has been tied. (Richardson.)]

[Illustration: FIG. 618

Radical cure of femoral hernia, showing method of application of
purse-string ligature to close saphenous opening. (Richardson.)]

[Illustration: FIG. 619

Radical cure of femoral hernia. Sutures applied to pectineal fascia,
fascia lata, and Poupart’s ligament. (Richardson.)]

[Illustration: FIG. 620

Obliteration of the femoral opening by purse-string suture. (Coley.)]

_Recurrence_ after these operations occurs less and less frequently
as operators gain in experience and technique is improved. At all
events the procedure has now become standard and disappointments are
relatively rare. It is useless to quote statistics of individuals, for
they necessarily differ. In general, however, it is probable that from
90 to 96 per cent. of cases properly operated suffer no recurrence.

_In the female_ inguinal hernia is treated in practically the same way,
conditions being simplified by the absence of necessity for making any
provision for the blood supply of the testicle or cord. The canal and
rings may, therefore, in the female be absolutely closed.

_Femoral hernia_ is radically treated on the same general principles,
but with greater difficulty, as anatomical conditions are less
favorable. A flap is raised below Poupart’s ligament, with its centre
over the tumor, and the sac exposed and completely dissected, then
opened, as in inguinal hernia. Its contents being reduced obliteration
of the sac and its utilization, if possible, are in order. It is rarely