There is scarcely any equally limited area of the body in which as many

varied and widely different pathological conditions may be exemplified

as in the appendix and the space immediately around it. The mildest

degree of hyperemia or vascular engorgement, the most destructive form

of inflammation, with fulminating necrosis, may here be observed.

Moreover, conditions commencing under one type may quickly change and

the whole type of an attack may within a short time be merged from the

mildest into the most severe.

In _catarrhal or endo-appendicitis_ it is mainly the mucosa which

suffers. This may undergo merely a congestion, with increase of

discharge, and, so long as the outlet be not completely obstructed,

may be a purely temporary matter of but a few hours’ duration, or it

may extend over a few days. The purulent or more destructive forms may

commence in either of the coats of the appendix. It is no uncommon

thing to find a necrotic mucosa with a still unbroken serosa, or a

perforation of the outer coats and a hernial protrusion of the inner,

perhaps just ready to give way. In location and extent the _suppurative

and destructive process may also vary_. Whereas ordinarily the distal

portion, being less supplied with blood, will suffer first, it is not

uncommon to find perforation at the junction of the appendix with the

cecum, or even gangrene of a limited area of the cecal wall itself.

Again, at times, the trouble seems limited to accumulation of pus

within the appendix, _i. e._, an _empyema of the appendix_, without

great tendency to involve the structures adjoining, and an appendix

may be found containing a few drops of pus or distended almost to its

bursting point still free or but slightly attached by exudate. In the

milder cases there may be found strictures indicating the site of

previous lesions. Again, aside from pus, there may be more or less

fluid or semisolid fecal matter or dense concretions, in addition

to the possible foreign bodies whose presence has been elsewhere

considered. In the more subacute or chronic forms there will be found

relics of previous rather than active expressions of present trouble,

such as strictures, thickenings, contortions, old adhesions, sometimes

quite dense, and contained concretions, or other foreign bodies, or

one may find appendices shrivelled up or more or less obliterated

(appendicitis obliterans).

The role of the omentum has elsewhere been mentioned, but must be

alluded to again at this point, since it participates more or less in

almost every case of acute appendicitis. The moment the appendix is

acutely inflamed the omentum tends to shift itself over toward it and

finally around it, and it is not uncommon to find a gangrenous appendix

wrapped in a roll of this kindly disposed fatty apron. In fact this may

constitute the tumor which may have been already discovered and found

to be fixed or movable. The inner surface at least of the omentum thus

applied will nearly always have sacrificed itself and one has need

usually to remove a considerable area of gangrenous omentum, as well

as the appendix itself, feeling as he does it that he is necessarily

sacrificing the best friend that the incriminated appendix has had.

Aside from what may concern the appendix itself the two most serious

complicating local conditions are _abscess_ and _gangrene with

perforation_. Abscess is not necessarily the result of perforation, at

least at first, but may be due to infection by continuity, the sequence

of events being acute appendicitis, with exudation, fixation, and

adhesion of surrounding tissues, followed by pus formation, perhaps

first within the appendix and then perforating, or perhaps having

its origin in the infected exudate exterior to it. So long as this

process is localized by a protective barrier of surrounding lymph, with

intestinal adhesions and the assistance of the omentum, there is to be

dealt with a more or less complicated _peri-appendicular abscess_, such

as in the past was frequently seen and spoken of as _perityphlitic_.

Concerning the frequency of perityphlitic abscess in days gone by the

literature of the previous century will afford ample illustration,

but in spite of the surgical acumen and advice of Willard Parker, who

taught the profession how to deal with it, its proper explanation did

not come until the researches of Fitz, alluded to at the beginning of

this chapter. Even now it is perhaps not quite correct to say that

every typhlitic abscess, _i. e._, every collection of pus around the

typhlon or head of the large intestine, is of appendicular origin,

for the tendency has been to forget the possibility of phlegmonous

cellulitis about any part of the bowel without reference to the

appendix.

Such a peri-appendicular abscess may be small, containing but a few

drops of pus, or extensive, even to the degree of holding a pint or

more. The pus is usually offensive and sometimes one will find floating

in it shreds of tissue, or even a completely separated and sloughed-off

gangrenous appendix. According to the original location of the

appendix, and the disposition of the adjoining parts, such a collection

of pus may form a tumor in the iliac fossa, which may also fill the

pelvis, or may present in the loin, closely simulating a perinephritic

abscess.

It is unfortunate when the natural walling off process has failed and

we have to deal with a _spreading, generalized, septic peritonitis_.

A partial compromise between these conditions sometimes appears as a

widespread yet practically localized peritonitis, in which several

loops of bowel have become affixed, and, what is worse, infected to

such an extent that they are themselves breaking down, so that there

may be impending or actual gangrene of the intestine. Such a condition

bespeaks the intensity of the infection and the destructiveness of

the infectious process, and produces a condition which may appall

the operator. The result is not only acute obstruction of the bowel

but such a local condition that one scarcely knows where to begin

or terminate his operative efforts. It was in such a case as this

that I removed eight feet and nine inches of bowel, the last nine

inches including the colon, turning in both ends and making a lateral

anastomosis, because of multiple gangrenous patches, each of which

taken alone would have required a distinct and laborious intestinal

resection, it seeming better to remove the entire amount involved.

This patient recovered and was well years after the operation. Still

other complications may disturb the surgeon’s calculations. Thus _fecal

fistula_ may have already occurred, or _suppurative thrombophlebitis_

may have already produced the beginnings or an _hepatic abscess_, while

septic expressions within the lungs, the heart, or elsewhere may have

also occurred. In addition to this general peritonitis, with all of its

terrors, may put a hopeless aspect upon the case.

=Treatment.=--Viewed in the above light it will be seen that

_appendicitis is essentially a surgical disease_, and that while mild

attacks may at times be successfully conducted to resolution, or tend

in that direction without treatment, the danger of spreading infection

with all its possible disasters is ever present, and even a mild case

is at no moment free from the danger of becoming acute. Considering

its widest relations, and believing in the greatest good to the

greatest number, the surgeon may easily maintain that, _save when it

is too late, it is never a mistake to operate_, providing operation be

properly performed. This, however, is sometimes out of the question,

and the laity occasionally assume responsibility for a decision against

the better judgment of the profession. We have to accept, then, the

fact that, no matter what the theory may be, we are not always allowed

to operate when we desire. Nevertheless if a universal rule could be

established it could be laid down in terms such as these, that more

lives would be saved by operating upon every case of appendicitis as

soon as the diagnosis has been made or even in the presence of good

reason for suspicion.

With conditions such as they are, and the fact that these cases are

usually first seen by general practitioners whose surgical judgment has

not been cultivated, and whose prejudices often actuate them, it may

be said that every case should be seen early by a surgeon, no layman

and no ordinary practitioner of small experience being in position to

assume responsibility for delay. It then remains for the judicious and

competent operator who may see such a case early, as thus advised, to

study it carefully in order to convince himself whether there be about

it good and sufficient reasons for not operating. The most honest

operator does not gainsay the possibility of mild cases recovering

without operation. He does, however, question by which course they run

greater risk.

The following may serve as a brief summary of conditions which justify

waiting:

1. When symptoms are mild and not increasing in severity;

2. When pain and tenderness are not pronounced and gradually subside;

3. When the pulse rate does not exceed 100;

4. When temperature is not rising nor showing abrupt changes,

especially if during the first thirty-six hours there have been no

rise. (Murphy states that if there has been no temperature during the

first thirty-six hours he begins to doubt the diagnosis.)

5. When the belly is not distending;

6. When rigidity is not increasing and there is no evidence of

peritonitis;

7. When nausea is not increasing;

8. When neither in facial expression nor elsewhere are there

evidences of septic infection;

9. When there is no perceptible tumor in the right iliac fossa.

Under the above conditions the conservative surgeon will be justified

in waiting; being prompt, however, to intervene, should there be change

for the worse in any one of the features specified. Even here it may

be said that with conditions all as favorable as above represented pus

may be present (in small quantity) and the whole picture may suddenly

change into one of local disaster.

Finally it may be summed up in these words: _When there is no doubt

as to the advisability of waiting, then wait; but in case of doubt

operate_, i. e., _give the patient the benefit of the doubt_, which he

in this way the more certainly obtains.

=Non-operative Treatment.=--While thus waiting in cases which justify

it, what should be done? Absolute rest in bed, even to the extent of

using bedpan instead of commode, is the first essential. The second

comprises abstention from all food, and practically the temporary

starvation of the patient, who may be allowed water in abundance and

nothing else. Altogether too much stress has been placed upon the

so-called starvation treatment as “saving patients from operation.”

Active therapeutic treatment is limited mainly to the use of cathartics

and of anodynes, according to reason therefor. On one hand it is

not advisable to rudely stir up the large intestine, one part of

whose structure is already involved in a serious and questionable

inflammatory process; on the other hand it is not for the general

welfare of the patient to permit him to continue with a condition of

coprostasis and the ever-increasing stercoremia which it encourages.

On the whole it would seem better to clean out the lower bowel at

the earliest possible moment, after which if the patient be properly

starved there will be less necessity for subsequent active catharsis.

The question of anodynes is one of equal importance. Those who bear

pain badly, or those who suffer intensely, will demand anodynes, which

every physician knows both help to mask the symptoms and interfere

with elimination; but such cases seem to be of themselves so violent

that the extreme expression of pain should of itself be regarded as

an indication for operation. It should be held, then, that cases

which demand opiates for relief of pain demand operation even more

strongly. In the mild cases, expectantly treated, the local application

of ice may be of some value. In effect these cases are to be treated

expectantly, and, while expectant treatment is a confession of weakness

or of ignorance, it may be unavoidable because early operation is

flatly refused.

=Indications for Operation.=--Sufficient reasons for not operating

being absent or having passed, the following may be considered among

the more urgent indications for immediate surgical attack:

1. Continued and especially increasing pain and tenderness;

2. A rapid pulse (110 or over) tending to increase in rapidity;

3. Any rapid change in the temperature, either a sudden rise or a

drop to the normal or subnormal, without corresponding improvement in

every other particular;

4. Increasing or widespread abdominal rigidity; when the right side

of the abdomen of a sensible and non-neurotic subject is rigid this

of itself should be sufficient to justify operation;

5. The appearance of tumor in the right iliac fossa;

6. Recurring and especially constant vomiting;

7. Any indication of septic infection, local or general.

Such are the indications by which the surgeon may say upon the instant

of their recognition that a given case requires immediate operation.

Fortunate are both he and the patient if the case be seen early, when

these conditions have but lately shown themselves, and before it be too

late. It has been said that almost _every death from appendicitis means

the loss of a life that might have been saved_ and for which someone is

responsible, this responsibility being divisible among the patient, the

parents or family, and the general practitioner who first saw the case

and was tardy in recognizing its essential features. While patients die

after late operations the surgeon himself is rarely censurable, it not

being his fault that he was called in too late, and the patient dying

of the progress of the disease in spite of an operation and not because

of it.

_Operation for appendicitis_ may be one of the simplest and easiest

of the abdominal operations, especially when the acutely infectious

element be not present, or it may be one of the most trying and

difficult of all possible surgical procedures, taxing alike the

judgment of the experienced operator and the resources of the clinic.

Much will depend upon the time at which it is performed. If within the

first forty-eight hours the surgeon may expect to find but a small

amount of pus; if from the second to the fifth day, he may find a

well-marked collection, while later he may have not only localized

abscess but extensive complications. Again, he who operates between

attacks, during the interval or interim stage, will find conditions of

adhesion and results of old disease rather than its active products.

These operations should then be considered under these different

headings:

1. Early operations in acute cases, where there is little or no tumor;

2. Operations in cases where abscess is present;

3. Operations in cases of more or less peritoneal involvement, with

obstruction;

4. Interval operations.

Under the above headings conditions vary so widely that they can

scarcely be spoken of or described under the same name. The seat of the

disease should first be approached. Here there is wide range for choice

of location of incision and even the method of its performance. Some

prefer the outer border of the rectus, others go through the rectus

muscle proper by an incision parallel to its fibers, which when exposed

are separated, its sheath both anteriorly and posteriorly being divided

separately. Others go through the abdominal wall by incisions more or

less oblique, and made near the anterior superior spine, where are

found the different layers of the abdominal muscles arranged in proper

order, their fibers being disposed at right angles to each other. That

incision is best in each case which affords the shortest and easiest

route to the site of the lesion when it can be located. If tumor

be present it is ordinarily best to go in directly over it. In the

absence of tumor the point of greatest tenderness is the best guide.

The possibility of subsequent hernia at the site which is weakened by

operation should be taken into account. If it be possible to avoid

drainage hernia may usually be avoided. When drainage is necessary

hernia is sometimes unavoidable. The advantage of operation through

the rectus is that the muscle fibers can be separated without dividing

them. Incision here may, however, carry the operator so far from the

site of the appendix that he must necessarily disturb the interior

arrangement more than is advisable, and thus increase the danger of

infection. The oblique exterior incisions near the ilium always permit

of separation of the fibers of the external oblique. The deeper muscle

fibers which cross at nearly a right angle may sometimes be nicked

and widely separated by firm traction, as in the so-called “gridiron

method,” or they may require division. A short external incision is

desirable when it suffices for the purpose. Considerations of safety

(_i. e._, the better exposure and easier removal of the appendix) may

call in some instances for long incisions, and they should be made

sufficiently long for his purpose.

It will often happen that as the surgeon passes more deeply toward

the peritoneum he will find the tissues more or less edematous. This

is a reliable indication of the presence of pus beneath, and should

make him open the peritoneum with care and then use extreme caution

in his further manipulation, lest by separating recent adhesions he

permit pus to escape. The peritoneum being opened sufficiently the

finger is gently insinuated, and thus the first orientation concerning

internal conditions is obtained. With the exploring finger there should

be ascertained, first, the existence of any adhesions; second, their

location and relative firmness, and, third, in a general way, the

amount of surrounding disturbance. With an appendix placed anteriorly

we may thus come directly upon it, while when placed deeply and

posteriorly we may have much to do before reaching it. After the first

general exploration the next procedure should be to protect and wall

off the region involved from the rest of the abdominal cavity by strips

of gauze. These should be long and so secured that none may be lost

by being left within the abdomen. The introduction of gauze for this

purpose will sometimes increase depression and decrease blood pressure,

but it is a necessary procedure in nearly every instance. Moreover,

several strips may be needed, and the incision may have to be extended

to a limit of two or three inches, according as further exploration

reveals a more complicated situation. The fluid pus which may escape

should be gently removed with dry gauze, or, if present in considerable

amount, be carefully conducted toward the surface. Loops of bowel or

tissue bound together by lymph should be gently separated, as they

may easily tear, or since imprisoned between them there may be found

small collections of pus. If found gangrenous the situation is thereby

seriously complicated, and it is advisable not to restore such a loop

to the abdominal cavity.

The omentum, as already indicated, may serve as a valuable guide to

the location of the appendix, which may be found wrapped within it.

It should be handled with great caution, while, at the same time,

it is made to reveal the desired information. When the omentum is

infiltrated, contorted, and adherent we may be sure of finding pus

concealed within the cavity which it helps to wall off. That which is

already gangrenous should be removed, with use of sutures in such a way

that there shall be no subsequent bleeding. It may be found easily,

or not until many other details have been mastered. The involved

appendix, when found, may be in one of the conditions described above,

all of which demand its removal save those where this has been already

accomplished by violence of the disease, in which case the opening in

the cecum may have to be closed, or one may employ it for the purpose

of an artificial anus. The appendix is often so hard to find that any

reliable guide will be welcomed. Such a guide may be found, first, in

the location and relation of the omentum, and, secondly, in the cecum

if this can be exposed, or in either one of its firm, longitudinal,

white tissue bands, which, leading down on either side of the colon,

meet and blend at the point of origin of the appendix. Either of these

followed in the right direction leads to this spot. Conditions may

be such, however, as to obscure both of these guides, and then the

colon should be followed downward toward the ileocecal valve, or the

small intestine up toward it, in the belief that in this vicinity, and

probably in the centre of the tumor, the appendix will be found. What

the surgeon shall next do depends on the details of each case. He has

not only to remove the diseased appendix, but to ligate and separate

from it its mesentery; furthermore to separate either or both of these

from surrounding tissues or organs, _e. g._, the wall of the pelvis,

the ovary, the bladder, the retroperitoneal tissue above the sacrum,

or from the lateral or anterior abdominal wall. This separation may

be easy, or in its performance the tube may rupture and both pus and

fecal matter escape; or perforation may have already occurred and the

operator will be conducted into a cavity containing matter, pus and

fecal mixed, in which perhaps fecal concretions of considerable size

will be found loose. He is fortunate who, finding a condition of this

kind, finds at the same time that he is still within a circumscribed

cavity. This he should respect, and, while endeavoring to clean it

thoroughly and drain it, he will avoid doing further harm by breaking

down its walls.

Another condition which may arise after the peritoneum is opened is

that of escape of a quantity of seropurulent fluid or of almost clear

pus which is free within the abdominal cavity. There may be little or

much of this. When present it should be removed by gentle sponging

before the gauze packing is introduced. Some operators are inclined

to irrigate freely and endeavor to wash out all this contained fluid.

Others are opposed to this method and believe that gentle dry sponging

is preferable. When the appendix is found free and movable, and when

the tissues in previous contact with it are free from evidences of

destructive infection (as, for instance, when peritoneal surfaces have

not lost all their glimmer or sheen), one should carefully remove it,

cauterizing its stump, burying it beneath the surrounding peritoneum,

and close the abdomen without drainage. In spite, however, of the

assertions and actions of some operators, I believe it to be the wisest

rule to lay down for general application that it is safer to drain in

every case where free pus or breaking down exudate is discovered.

The _question of drainage_ thus raised is as important as any connected

with this subject. When and how shall one drain is a question upon

which hundreds of pages have been written by various operators, and one

which, while settled for individuals, can hardly be settled for the

profession at large by any brief statement. Inefficient drainage is

almost as bad as none. Efficient drainage may call for the insertion

of a tube into the depths of the pelvis, even for counteropening in

the cul-de-sac, or for additional opening in the loin, or for the

employment of two or three tubes and drains of various kinds. A large

tube loosely packed with gauze, perhaps split through its length and

abundantly provided with openings, is probably the most effectual drain

for most purposes. The cigarette drain, of gauze wrapped in oiled silk,

or a few folds of oiled silk loosely tied together, along which fluid

may percolate, may be sufficient for cases of lesser extent. Large foul

cavities are better left more widely open, and abundantly drained with

gauze packing, in spite of the humorous stigma which has been cast

upon some of these methods by Morris with his expression “committing

taxidermy upon patients.” The depressing reflex influence of such

packing being readily conceded it may be regarded as the lesser of two

evils.

Another almost equally important question is that of _treatment of the

peritoneal cavity_ when involved. Here methods and opinions have varied

widely. A peritoneal cavity once inflamed cannot be made absolutely

clean in any way, and much reliance should be placed on the properties

of the membrane itself, which, to a large extent, should act as its own

scavenger. When, however, by removing the parts evidently diseased we

have taken away the main source of infection we may feel like relying

upon the natural protective forces of the human body; still even here

opinions differ. Thus some would flush the abdomen with hot saline

solution and even leave some portion of it there, closing the external

wound, while others would carefully avoid the introduction of anything

by which infectious material may be spread; and while each method has

much to justify it one is scarcely found preferable to the other. I

believe, however, in thoroughly cleaning out any distinct abscess

cavity, and if the pelvis be such then I would irrigate it. I would

also thoroughly drain it.

The attention of the reader is here directed to the general

considerations found earlier in this work concerning the general

technique of abdominal operations, and the matters of drainage and

after-care, it being scarcely necessary to reiterate what has been

there said regarding the general use of saline solution locally and by

the rectum, the advantage of the Fowler position, or of Murphy’s method

of slow and gentle introduction of saline solution into the rectum,

providing for its continuous absorption, etc.

The possibility of appendicitis leading to general peritonitis, this

to acute obstruction of the bowel, and this possibly even to multiple

gangrene, has been mentioned. What should best be done under these

circumstances must depend upon the patient and upon the surroundings.

With a patient too much reduced to justify any prolonged operation the

surgeon would probably content himself with evacuation of pus which may

be readily reached, and then perhaps by the formation of an artificial

anus. Cases which will justify such extensive operation as that above

reported by myself in this connection, where it was possible to

successfully remove nearly nine feet of intestine, will be exceedingly

rare, as well as impracticable in the ordinary private house.

A condition perhaps a little less serious but always perplexing is that

of _gangrene of a limited area of cecum_ around a gangrenous appendix.

To remove the appendix alone in this condition is to accomplish

nothing, while to meet the indication may require the exsection of

a small area of cecal wall or the resection of the entire cecum, or

perhaps in cases of limited extent the enfolding of the gangrenous area

and the suture of its edges in such a manner that when it sloughs it

may slough into the bowel cavity.

When the surgeon sees a case of peri-appendicular (the old

perityphlitic) abscess late, and after it is easily recognized, he

should operate according to the local indication, making incision

perhaps short and placing it at a point where pus will apparently be

most easily reached and best drained. Most of these instances present

rather on the side or even in the loin behind the colon, and here a

posterior incision might be sufficient. This may here be more liberal,

since there is little danger of postoperative hernia, while through

it one may possibly expose the cecum freely and often reach even the

appendix itself. In making this opening it is well, if possible, to

separate the fibers of the transversalis by blunt dissection. Here, as

in all of the other incisions made toward the outer side of the body,

the opening should be made, if possible, obliquely and parallel to the

branches of the iliohypogastric nerves, which are thereby avoided and

loss of sensation thus prevented. In fact this posterior method is

sometimes even more rapid, and preferable in exceedingly fat patients,

while it will always cause less shock and abdominal distress than

does an anterior section; moreover, drainage takes place in the most

desirable direction.

_Fecal fistula_ is sometimes the immediate and unavoidable, sometimes a

more or less delayed and apparently inevitable, result or complication

of some of these operations. In the former instance it will be

because of more or less gangrene or the necessity for an immediate

enterostomy. In the latter case it results from conditions which are

concealed, but may be imagined, comprising the giving way of tissues

already compromised or else being a continuation of the ulcerative

or gangrenous process. These complications are always unpleasant and

untoward, though they rarely reflect upon the method or judgment of

the operator, being essentially inevitable. If only the fecal outflow

escape externally the condition may be regarded as inconvenient and

temporary. Only in those instances in which the peritoneal cavity is

contaminated does septic peritonitis ensue. The majority of these

fecal fistulas close spontaneously by granulation tissue. Sometimes

closure is rapid, sometimes delayed, in which latter case it may be

stimulated by the use of silver nitrate, as already indicated above.

In a few instances the condition is so extensive or so permanent as

to justify or require further operation, which may be in the nature

of a curettement of the fistulous tract, a slight plastic procedure,

including a buttonhole suture about the opening, or possibly a complete

intestinal resection. I have seen small, fistulous tracts discharge

occasionally, even for years, and then finally close spontaneously, and

have far oftener seen some form of spontaneous closure than necessity

for operative intervention. The danger of infection around any such

fistulous tract is ever present, and when it has occurred the fact will

be made known by increase of edematous granulations, with swelling and

tendency to breaking down. In every such case active cauterization,

or, better still, the use of the curette, will be required.

A _tuberculous form of chronic appendicitis_, as well as tuberculous

infection of a subacute exudate, is possible, the case being converted

into one of greater chronicity, with more or less mild but constant

septic features (hectic). In any event, so soon as the tuberculous

element can be recognized radical measures should be instituted.

[Illustration: FIG. 583

Omentum being gently lifted in order to uncover the appendix enclosed

with its fold. (Lejars.)]

[Illustration: FIG. 584

Appendix delivered from the abdominal cavity and brought to view.

(Lejars.)]

[Illustration: FIG. 585

Separation of the meso-appendix. (Gosset.)]

=Operation for Chronic or Recurring Appendicitis; Internal

Operations.=--Other things being equal the most favorable time at which

to remove the appendix is that when pathological processes are least

active. If, therefore, there be a choice the interval of quiescence

rather than the stage of active infection would be chosen. Interval

operations, so called, are usually comparatively simple, both in

principle and technique. There are times, however, when it is difficult

to find a partially obliterated appendix which has been covered up in

thickened peritoneum or partially organized exudate. In such a case

considerable blunt dissection or separation may have to be done before

it can be removed. In those instances is this particularly true where

it had originally a retroperitoneal location, and at no time a free or

movable position. When difficult of recognition we may be unerringly

led to it if we but follow the bands of white fibrous tissue on either

side of the cecum to their junction.

The opening by which the appendix should, under these circumstances,

be reached may again be made at the point of election, and should best

be located over the area of greatest tenderness. Whatever incision is

selected we should endeavor to separate muscle bundles as much and

incise as little as possible. The appendix being delivered through

the wound, either before or after ligation of its mesentery, and being

thus completely isolated, is removed close to the large intestine,

its base being tied and its structure being seized within the blades

of a forceps in such a way that none of its contents may escape. The

scissors with which it is divided are contaminated by its contents and

should not be used again until cleansed. The stump on the proximal side

may be touched with the actual cautery, or scraped and then cauterized

with pure carbolic acid or formalin solution in order to thoroughly

disinfect it. Subsequent treatment of this stump differs with different

operators. Some are satisfied to leave it thus cauterized, while others

cover it with the adjoining peritoneum, which is brought together over

the stump end by either a purse-string or a continuous suture. Yet

others have been satisfied to invert the ends of the stump into the

cecum and thus leave it with or without further protection. It seems to

make really very little difference how the stump is treated, providing

only it be disinfected and prevented from leaking. Nevertheless it

would appear preferable to give it at least a peritoneal covering to

prevent adhesions (Figs. 583 to 588).

[Illustration: FIG. 586

The base of the appendix is tied with silk. The meso-appendix is being

tied in sections with the Cleveland needle. (Richardson.)]

[Illustration: FIG. 587

Appendix surrounded with ligature at its base, after its isolation from

its mesentery. Purse-string suture in place. (Gosset.)]

[Illustration: FIG. 588

Complete detachment of appendix. (Gosset.)]

In the subsequent closure of the external wound drainage is not made,

there having been no pus to call for it; while the more perfectly the

wound layers be closed, each with a row of chromicized catgut sutures,

the peritoneal incision being first carefully approximated and over

it the muscle and aponeurotic layers, each by itself, the less the

tendency to subsequent postoperative hernia. On general principles,

also, the shorter the incision the less the danger of this undesirable

event. Nevertheless other considerations should not be sacrificed to

shortness and beauty of the cutaneous scar.

The essentials of after-treatment of these cases have been already

summarized in the previous section, and to these little exception may

be taken in cases such as those above described. Every precaution

should be taken to prevent vomiting, as every muscular effort involved

in the act tends to disturb a freshly sutured wound. While violent

muscular efforts of defecation are also to be deprecated, there is

perhaps as much or more to be dreaded from the abdominal distention

which may result from inattention to free intestinal elimination.

Until the bowels have been moved it is best to restrain the diet to

the simplest fluid nourishment. So soon as elimination becomes free

more liberality in diet may be allowed. There is the same liability to

and danger from other possible complications, such as postanesthetic

pneumonia, anuria, or lack of expulsive power of the bladder, which

requires the use of the catheter, in these as in other abdominal cases.

Principles of treatment, however, do not vary, and the reader is

referred to the previous section already indicated.

_Paratyphlitic abscesses_ are to be distinguished from perityphlitic

or peri-appendicular abscesses in that they arise from a phlegmonous

process in the cellular tissue around the colon not due to

intra-appendicular infection. In consequence of such a cellulitis

more or less considerable collections of pus may form, which are most

likely to present either in the loin or just in front of the cecum,

which may burrow either upward or downward, or appear elsewhere. They

are mentioned here, not because they are to be differently treated or

surgically regarded, but because it is worth while to remember that

here about the cecum and ascending colon, as on the left side, such

pericolic abscesses may form without reference to the appendix.

CHAPTER L.

THE LARGE INTESTINES AND THE RECTUM.

ANOMALIES OF THE LARGE INTESTINE.

The more common _congenital anomalies_ of the various divisions of

the colon have to do mainly with the presence of _diverticula_ and

_atresiæ_, or possibly total _absence_, due to defects in development.

Diverticula are much the more common. Some degree of constriction is

not particularly infrequent, but complete absence of even a section of

the colon is an extremely rare anomaly.

The _acquired anomalies_ have to do with disease processes or results

of injury. _Displacements_ may be the result of old adhesions and

distortions; of _chronic constipation_, _i. e._, fecal impaction and

resulting overloading, with sagging, stretching, and complete change

in shape and position; with displacement due to enlargement of other

organs, _e. g._, the liver, stomach, spleen, uterus, or, in milder

degree, with the gradual but inevitable and chronic results of tight

lacing. The causes which produce a gradual _enteroptosis of the

transverse colon_ are not supposed to concern the surgeon, yet the

condition may precipitate acute obstruction which will necessitate his

urgent participation in its final treatment.

There are no diseases peculiar to the large which do not also concern

the small intestine, and no surgical diseases peculiar to it which

have not been considered in the foregoing pages. It is not, therefore,

necessary to make even a brief summary of the surgical diseases

peculiar to the large intestine. Of well-known lesions, however,

in this location there is perhaps a little worth emphasis in this

place. The most serious surgical conditions of the large bowel, aside

from the acutely obstructive, are those pertaining to expressions of

tuberculosis, syphilis, actinomycosis, dysentery in one or other of

its tropical forms, and cancer. There is a condition also of either

acute or chronic _colitis_ or mucocolitis which may assume such extreme

degree as to necessitate a colostomy made at the cecum (appendicostomy)

for the purpose of more perfect irrigation and physiological rest.

The amount of suffering, as well as of toxemia, which may proceed

from a seriously inflamed colonic mucosa, must be at least once seen

in order to be fully appreciated. Such a condition is characterized

by local and general suffering, with septic and copremic symptoms, as

well as by tenesmus and the passage of numerous small or larger and

more infrequent amounts of blood-stained mucus, sometimes of almost

pure blood. As an illustration if one recall what may be seen in case

of a violently inflamed conjunctiva or pharyngeal mucous membrane,

and realize that this condition is duplicated through a large portion

of the colon, a more vivid picture of what it actually represents

can be afforded. When exposed to inspection, as it may be when the

rectum and the sigmoid are involved, it will be found to bleed at the

slightest touch and to freely discharge large quantities of thick

mucus. While such a colitis is usually treated by non-operative methods

an anesthetic is sometimes required for its more perfect diagnosis and

recognition, as well as for such local applications as can scarcely be

made without it.

TUBERCULOUS AND SYPHILITIC ULCERATIONS OF THE COLON.

Tuberculous and syphilitic ulcerations of the colon may be localized

and relatively insignificant, or numerous, disseminated, extensive,

and serious. In extreme cases of this kind the entire colonic mucosa

will be involved and the amount of distress thus occasioned be scarcely

controllable. These are the cases which, failing to yield to ordinary

therapeutic measures, justify colostomy at the cecum, for the purpose

of temporary exclusion of the large intestine and its physiological

rest, as well as its more perfect local treatment by the irrigation and

suitable local applications thus permitted.

STRICTURES OF THE LARGE INTESTINE.

Strictures of the large bowel have the same etiology as those of the

small bowel, and are to be recognized by the same general indications,

of which increasing obstipation, perhaps with alternating attacks of

diarrhea and increasing difficulty in evacuation, are unmistakable

features. The nature of a stricture is not always to be foretold before

the exploration which it will necessitate. No stricture of the large

intestine which is above easy reach from the anus can be successfully

treated by any save operative methods, _i. e._, by abdominal section

and proper attention to whatever may be thereby revealed. Thus at one

time bands may be divided or some external mass removed by pressing

upon the bowel (_e. g._, a uterine myoma), or there may be found an

associated tumor, malignant or benign, whose complete removal is both

possible and permissible, or at other times a malignant stricture so

complicated that only an entero-anastomosis, for temporary relief, can

be effected.

CANCER OF THE LARGE INTESTINE.

Cancer of the large intestine spares no part of its length or lumen.

Primary _cancer of the cecum_ may commence in the region of the

appendix, and has frequently been mistaken for a chronic appendicitis.

If the transverse bowel be involved there may be more or less sagging

or fixation, while at the flexures obstruction is more easily produced.

Such growths in time become sufficiently prominent to be easily

recognized from without, but then they have usually gone beyond the

time when radical operation can hold out much promise. In the large,

as in the small, intestine radical operations are, however, often

successful, and always in proportion as they are made early and

thoroughly. When extirpation is impossible anastomosis will offer a

temporary substitute (Fig. 589).

[Illustration: FIG. 589

Cancer of cecum, showing ulcerating growth protruding interiorly and

obstructing. (Dr. E. A. Smith.)]

OBSTRUCTION OF THE LARGE INTESTINE.

Chronic obstruction of the large bowel is usually due to one of the

causes above considered. Acute obstruction of the colon is the result

either of precipitation of an acute condition upon the base of an old

chronic trouble, of invagination, of volvulus, or possibly of one

of the other mechanical contortions not included in either of these

expressions.

_Intussusception_ is most likely to occur either at the ileocecal

valve or in the region of the sigmoid. _Volvulus_ is more common in

the latter region. It is here due to relaxation of natural ligamentous

supports, to overloading and stretching, or is possibly permitted

by some congenital condition. Volvulus in this section having once

occurred the patient is liable to its subsequent recurrence. So well

known now is this fact that surgeons have endeavored to take special

precautions against it, which unfortunately have not been brilliantly

successful. It has been suggested, for example, to anchor the sigmoid

to the anterior abdominal wall, or to resect a portion of it, to

anastomose it with the cecum, as well as to reef the mesosigmoid.

Desirable as such operative relief may be, all of these methods present

inherent objections, while those which include absolute fixation of

the sigmoid perhaps predispose it to subsequent obstruction from other

causes. At present it would appear that a _sigmoidopexy_ is probably

the best procedure, in order to prevent local recurrence, in a sigmoid

volvulus which has once been exposed by operation, care being taken to

fasten it well up to its outer side, as well as posteriorly, in order

that there may be no vacant spaces in these directions.

THE RECTUM.

GENERAL CONSIDERATIONS.

The rectum was for too long a time relegated to the care and almost

sole interest of the itinerant charlatan, or the somewhat ambitious,

though scarcely more honest, specialist, who preyed alike upon the

suffering and ignorance of patients, until the practice of rectal

surgery was almost a mark of disgrace. From this unfortunate condition

it was rescued by the organized effort of honest men, until now, in the

light of their researches, the rectum has been shown to be both the

site of numerous, easily discernible, and serious, alike mysterious

and reflex lesions, all deserving careful study. The connection

between the sensory nerves with which its terminal inch and a half are

freely endowed and the vasomotor nerves throughout the body is easily

shown by their influence, for instance, upon the respiration and the

circulation, and in these respects some important lessons have been

learned from the charlatans. We have learned, for example, that general

vasomotor spasm, with its evidence in coldness of the extremities and

pallor of the surface, may often be overcome by so simple a measure as

stretching the sphincter; while to cure lesions which produce more or

less sphincteric spasm is to frequently restore general circulatory

tone. Again, what may be accomplished in stimulating respiration by

dilatation of the sphincter has been shown to be of the greatest value

in patients breathing badly under an anesthetic.

The “orificialists,” then, while making absurd and impossible claims,

have nevertheless taught us considerable concerning the value of

recognizing the importance of sphincteric spasm. Their claims

concerning so-called “pockets” and “papillæ” are untenable and absurd,

and the expression which they have taught many of the laity that they

are sufferers from “rectal pathology” indicates alike their ignorance

of good English and good surgery. That papillæ do become, under certain

circumstances, exquisitely sensitive and are occasionally in need of

the cautery or the scissors, as well as of the general relief afforded

by stretching the sphincter, is undoubtedly sometimes true.

The itinerant “pile-drivers” and charlatans of their class have done

more harm than good, and yet even from them the honest practitioner

has learned that “it pays” often to give attention to the rectum. As

a source of various disturbing and particularly distressing reflexes

there is scarcely any portion of the body of equivalent area which

can furnish so many. The relief to mental conditions, amounting often

to pronounced melancholia, which follows cure of rectal lesions, is

often astonishing, all of which shows that the rectum is well worth the

attention of the scientist, and especially of investigation in every

case where the slightest complaint is made.

All of which properly leads up to the subject of _rectal examination

and how to make it complete_. Much can be learned here by use of the

educated finger, as well as in the vagina, and the surgeon should

cultivate that tactile sense which will orient him so soon as the

finger-tip comes in contact with a morbid or diseased surface. In this

way it is possible to detect ulcers which are within reach by the

finger alone, without having to use the speculum, at least to make a

diagnosis sufficient to indicate what further procedure is required.

The rectum and lower bowel should be thoroughly emptied. It is safe to

assume that exquisite sensibility and pronounced sphincteric spasm are

the result of morbid conditions. The use of a local anesthetic will

in many instances be sufficient to permit at least of a preliminary

digital examination, the suggestive characteristics especially sought

being the general size of the rectal tube, infiltration or fixation of

its walls, and the presence of stricture, tumor, or other impediment

to insertion of the finger, including pronounced spasm at the anus.

The presence of bloody mucus or pus should also be noted. In addition

the rectal surroundings should be examined and the presence of any

phlegmon, fistula, sinus or other evidence of present or past disease,

including old scar, either of ulcer or incision, should be noted. The

degree of pain as well as of hypersensitiveness produced should also be

noted. With tact and gentleness satisfactory knowledge of the condition

of the parts within reach may be obtained.

A rectal bougie may be used should suggestions of the presence of

stricture be present. Rectal bougies are usually made of soft rubber of

various sizes, with tips variously shaped, of which the tapering and

conical are the most useful. One of these may be anointed and gently

introduced, the endeavor being to guide it first in the middle line

along the course of the rectum and then gently toward the left as the

rectum swerves in this direction as it comes down from above. With

such a bougie the presence of a stricture beyond reach of the finger

may be detected. When recognized its nature is, however, still left

in doubt, to be decided by the history or other features of the case.

There is never excuse for roughness in handling a rectal bougie, since

perforation or serious injury might result.

The next method of more complete examination of the rectum is through

one of the various forms of specula, from the so-called rectal

speculum, with its blades only a couple of inches long, to the more

formidable proctoscope or sigmoidoscope, with their possibilities or

artificial illumination, etc. According to the nature of the lesion

and the sensibility of the surface exposed various specula may be

used, with or without an anesthetic. For the majority of purposes

local anesthesia is sufficient. One will furthermore often need the

aid of position. The ordinary digital examination may be made with

the patient upon the side or back. When an ordinary speculum is used

a position corresponding to Sims’ for gynecological work is far

preferable. For more thorough work when the long, tubular instruments

are used, the knee-chest position is necessary. The specialists have

devised certain elaborate chairs, instruments, and methods by which

exceedingly complete and satisfactory exposures of twelve or fifteen

inches of rectal and colonic mucosa can be made. What is written

here, however, is not for their purposes, but rather for those of the

general practitioner, who must work with ordinary means and methods.

The knee-chest position, for instance, can be assumed upon the ordinary

table or it may be facilitated by certain additions made to a regular

operating table. With all these facilities and the peculiar skill which

specialization produces it is possible to make striking demonstrations

of the valvular arrangement of the rectal mucosa, and of the varying

degrees of obstruction which mucous folds or cicatrices may produce,

as well as to successfully dilate or divide them. In the hands of a

limited number of skilled surgeons local treatment of obstipation, as

well as of various other conditions of the sigmoid or upper rectum,

has become extremely satisfactory. These are, however, in the writer’s

estimation, methods and procedures which are scarcely within the domain

of the general practitioner or even the general surgeon, as they

require a degree of peculiar facility and an amount of time which can

scarcely be expected of him. Therefore the conditions and methods of

treatment here considered will be limited to those intended for general

use.

CONGENITAL DEFECTS AND MALFORMATIONS OF THE RECTUM AND ANUS.

The lowermost portions of the intestinal tube are by far the most

common sites of congenital anomalies and defects. These rarely occur in

the direction of excess, rather of atresia or entire deficiency. The

lower end of the alimentary tube is differentiated from the balance

of the original neurenteric canal, and connected with the exterior,

in ways similar to those followed at its upper extremity. The canal

itself should early become obliterated at a point whose site is marked

by that small collection of lymphoid tissue known as the _coccygeal_

or _Luschka’s body_, corresponding in this respect and location to

the pituitary body at its other extremity. The rudimentary rectum is

then connected with the surface by the formation of a depression and

disappearance of tissue in just the same way that the mouth is formed,

and as about the mouth we find atresia or incomplete communication,

so we may find the same condition in various expressions about the

termination of the rectum. Moreover, there may occur also more or

less arrest or abnormal development of the tissues which eventually

shut off the rectum from the genito-urinary tract. In consequence,

we have various degrees of rectal _atresia_, and, finally, actual

_imperforation_. Beyond this we may more rarely meet with complete

absence of the rectum, and even of some portion or of nearly all of the

entire large intestine. In one case under my observation this entire

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.