THE . INTERNATIONAL ENCYCLOPEDIA OF SURGERY. VOL. VI. THE INTERNATIONAL ENCYCLOPAEDIA OP SURGERY A SYSTEMATIC TREATISE ON THE THEORY AND PRACTICE OF SURGERY BY AUTHORS OF VARIOUS HATIOUS EDITED BY JOHN ASHHURST, Jr., M.D. PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA, SURGEON TO THE PENNSYLVANIA HOSPITAL, ETC. ILLUSTRATED WITH CHROMO-LITHOGRAPHS AND WOOD-CUTS IX SIX VOLUMES VOL VI. REVISED EDITION NEW YORK WILLIAM WOOD & COMPANY 1888 Copyright : WILLIAM WOO,, & COMPANY, 1 8 8 7, Publishers' Printing Compant, 157 and 159 William Street, New York. COMPLETE ALPHABETICAL LIST OF THE CONTRIBUTORS TO THE * INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. D. Hayes Agnew, M.D., LL.H., Barton Professor of Surgery in the Uni- versity of Pennsylvania, Philadelphia. General Principles of Surgical Diagnosis. V ol. I. William Allingham, F.R.C.S., Surgeon to St. Mark’s Hospital, London. Injuries and Diseases of the Rectum. Vol. VI. Edmund Andrews, M.D., LL.D., Professor of Clinical Surgery in the Chicago Medical College, Surgeon to Mercy Hospital, Chicago. Injuries of the Joints. Vol. III. Thomas Annandale, F.R.C.S.E., Regius Professor of Clinical Surgery in the University of Edinburgh, and Senior Surgeon to the Edinburgh Royal Infirmary. Diseases of the Breast. Vol. V. John Ashhurst, Jr., M.D., Professor of Clinical Surgery in the University of Pennsylvania, Philadelphia. Amputations. Vol. I.; Excisions and Resectio?is. Vol. III.; Intestinal Obstruction. VOl. VI. Richard Harwell, F.R.C.S., Surgeon to Charing Cross Hospital, London. Aneurism. Vol. II.; Diseases of the Joints. Vol. III. *H. Poyes Bell, F.R.C.S., Surgeon to, and Demonstrator of Surgery at, King’s College Hospital, London. Injuries and Diseases of the Male Genital Organs. Vol. VI. Edward Bellamy, F.R.C.S., Fellow of King’s College, London ; Surgeon to the Charing Cross Hospital; Member of the Board of Examiners, Royal College of Surgeons of England. Injuries and Surgical Diseases of the Lymphatics. Vol. III. Edward II. Bennett, M.D., F.R.C.S.I., President of the Royal College of Sur- geons in Ireland ; Professor of Surgery in Trinity College, Dublin, Surgeon to Sir Patrick Dun’s Hospital, etc. Injuries of the Chest. Vol. V. *J. II. Btll, M.D., Surgeon and Brevet Lieutenant-Colonel, U. S. Army. Sabre and Bayonet Wounds ; Arrow Wounds. Vol. II. * Deceased. complete alphabetical list of the contributors John TT. Brinton, M.D., Professor of the Practice of Surgery and of Clinical Surgery in the Jefferson Medical College, Surgeon to St. Joseph’s Hos- pital, Philadelphia. Operative Surgery in General. Vol. I. Thomas Bryant, F.R.C.S., Surgeon to, and Lecturer on Surgery, at Guy’s Hospital, London. Wounds. Vol. II. Albert II. Buck, M.D., of New York. Injuries and Diseases of the Ear. Vol. IV. Henry Trentiiam Butlin, F.R.C.S., Assistant Surgeon to, and Demonstrator of Surgery at, St. Bartholomew’s Hospital, London. Scrofula and Tu- bercle. Vol. I.; Tumors. Vol. I. W. Watson Cheyne, M.B., F.R.C.S., Assistant Surgeon to King’s College Hospital, and Demonstrator of Surgery in King’s College, London. The Antiseptic Method of Treating Wounds. Vol. II. *Bennett A. Clements, M.D., Brevet Lieutenant-Colonel and Surgeon, IT. S. Army. Preparation of Military Surgeon for Field Duties; Apparatus Required ; Ambulances ; Duties in the Field. Vol. VI. J. Solis-Cohen, M.D., Professor of Diseases of the Throat and Chest in the Philadelphia Polyclinic, Honorary Professor of Laryngology in the Jef- ferson Medical College, Physician to the German Hospital, etc., Phila- delphia. Injuries and Diseases of the Air-passages. Vol. A".; Injuries and Diseases of the Oesophagus. Vol. VI. P. S. Conner, M.D., Professor of Surgery and Clinical Surgery in the Medi- cal College of Ohio, Cincinnati; Professor of Surgery in the Dartmouth Medical College, etc. Gunshot Wounds. Vol. II.; Injuries and Dis- eases of the Muscles, Tendons, and Fasciae. Vol. III. Edward Cowles, M.D., Superintendent of the McLean Asylum, Somerville, Massachusetts. Construction and, Organization of Hospitals. Vol. VI. Francis Delafield, M.D., Professor of Pathology and Practical Medicine in the College of Physicians and Surgeons, Medical Department of Co- lumbia College, New York. Pyaemia, and Allied, Conditions. Vol. T. Simon Duplay, M.D., Professor of Clinical Surgery in the Faculty of Medi- cine of Paris, Surgeon to the Lariboisiere Hospital, etc., Paris. Injuries and Diseases of the Urethra. Vol. VI. George E. Fenwick, M,D.,C.M., Professor of Surgery in McGill University, Surgeon to the Montreal General Hospital, Montreal. Excision of the Knee-Joint. Vol. III. Frederic R. Fisher, F.R.C.S., Assistant Surgeon to the Victoria Hospital for Sick Children, London. Orthopaedic Surgery; The Treatment of Deformities. Vol. III. George Jackson Fisher, A.M., M.D., of Sing Sing, N. Y. A History of Surgery. Vol. VI. William S. Forbes, M.D., Professor of Anatomy in the Jefferson Medical College, Senior Surgeon to the Episcopal Hospital, Philadelphia. Hy- drophobia and Rabies, Glanders, Malignant Pustule. Vol. I. Sir J. A. Grant, M.D., M.R.C.P. Loud., F.R.C.S. Edin., Physician to the General Protestant Hospital, Ottawa. The Effects of Cold. Vol. I. Robert P. Harris, A.M.,M.D., of Philadelphia. The Caesarean Section and its Substitutes ; Laparotomy for Ruptured, Uterus and, for Extra-Uterine Fueiation. Vol. VI. * Deceased. TO THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. Reginald Harrison, F.R.C.S., Lecturer ou Clinical Surgery in the Victoria University, Surgeon to the Royal Infirmary, Liverpool. Injuries and Diseases of the Bladder and Prostate. Vol. VI. Christopher Heath, F.R.C.S., Holme Professor of Clinical Surgery in Uni- versity College, London, and Surgeon to University College Hospital. Injuries and Diseases of the Mouth, Fauces, Tongue, Palate, and Jaws. Vol. IV. William H. Hingston, M.I)., D.C.L., L.R.C.S.E., etc., Professor of Clinical Surgery in the Montreal School of Medicine, Surgeon to the IIotel-Dieu Hospital, Montreal. Lithotrity. Vol. V. *Joiin T. Hodgen, M.D., LL.D., Professor of Surgical Anatomy in the St. Louis Medical College, St. Louis. Ulcers. Vol. I. Joseph W. IIowe, M.D., Clinical Professor of Surgery in the Bellevue Hos- pital Medical College, New York. Diseases of the Cellular Tissue. Vol. III. William Hunt, M.D., Senior Surgeon to the Pennsylvania Hospital, Phila- delphia. Traumatic Delirium and Delirium Tremens. Vol. I. *Charles T. Hunter, M.D., Demonstrator of Anatomy in the University of Pennsylvania, Surgeon to the Episcopal Hospital, Philadelphia. Minor Surgery. Vol. I. Christopher Johnston, M.D., Emeritus Professor of Surgery in the Univer- sity of Maryland, Baltimore. Plastic Surgery. Vol. I. E. L. Keyes, A.M., M.D., Professor of Genito-Urinary Surgery in the Bellevue Hospital Medical College of New York, Consulting Surgeon to the Charity Hospital, Surgeon to Bellevue Hospital, to the Skin and Cancer Hospital, and to St. Elizabeth Hospital, New York. Urinary Calculus. Vol. V. Norman W. Kingsley, M.D.S., D.D.S., Late Professor of Dental Art and Mechanism in the New York College of Dentistry, New York. Surgery of the Teeth and Adjacent Parts. Vol. IV. Charles Carroll Lee, M.D., Surgeon to the Woman’s Hospital, Consulting Surgeon to the Charity Hospital, New York. Ovarian and, Uterine Tumors. Vol. VI. George M. Lefferts, M.A., M.D., Clinical Professor of Laryngoscopy and Diseases of the Throat in the College of Physicians and Surgeons, Medical Department of Columbia College, New York, Consulting Laryngoscopic Surgeon to St. Luke’s Hospital, etc. Diseases arid Injuries of the Nose and its Accessory Sinuses. Vol. IV. *John A. Lidell, A.M., M.D., Late Surgeon to Bellevue Hospital, also Late Surgeon U. S. Volunteers in charge of Stanton U. S. Army General Hospital, Inspector of the Medical and Hospital Department of the Army of the Potomac, etc. Injuries of Bloodvessels. Vol. II.; Injuries of the Back, including those of the Spinal Column, Spinal Membranes, and Spinal Cord. Vol. IV. Henry M. Lyman, A.M., M.D., Professor of Physiology and of Diseases of the Nervous System in the Rush Medical College, Chicago. Anaesthetics and, Anaesthesia. Vol. I. Hunter McGuire, M.D., Formerly Professor of Surgery in the Medical College of Virgina, Richmond. Contusions. Vol. II. * Deceased. COMPLETE ALPHABETICAL LIST OF THE CONTRIBUTORS Sir George H. B. Macleod, M.D., F.R.C.S. and F.R.S. Edin., Senior Sur- geon to, and Lecturer on Clinical Surgery at, the Western Infirmary ; Regius Professor of Surgery in the University of Glasgow ; Surgeon in Ordinary to II. M. the Queen, in Scotland. Injuries and Diseases of the Neck. Vol. V C. W. Mansell-Moullin, M.A., M.D. Oxon., F.R.C.S., Fellow of Pembroke College, Oxford ; Late Travelling Fellow, Univ. Oxon., Surgical Registrar to the London Hospital, London. Shock. Vol. I. Howard Marsh, F.R.C.S., Assistant Surgeon to St. Bartholomew’s Hospital, London. Abscesses. Vol. I. E. M. Moore, M.I)., Professor of the Principles and Practice of Surgery in the University of Buffalo. Gangrene and Gangrenous Disease. ALdl. I. Henry Morris, M.A. and M.B. Bond., F.R.C.S. Eng., Surgeon to, and Lecturer on Surgery at, the Middlesex Hospital, London. Injuries and Diseases of the Abdomen. Vol. V. Thomas George Morton, M.D., Surgeon to the Pennsylvania Hospital and to the Orthopaedic Hospital, Consulting Surgeon to the Jewish Hospital, etc., Philadelphia. The Effects of Heat. Vol. I. Charles B. Nancrede, M.D., Professor of General and Orthopaedic Surgery in the Philadelphia Polyclinic; Surgeon to the Episcopal Hospital and to St. Christopher’s Hospital, Philadelphia. Injuries and Diseases of the Bursce. Vol. III.; Injuries of the Head. Vol. V. M. Nicaise, M.I)., Professor Agrege in the Faculty of Medicine of Paris ; Surgeon to the Hospitals, Paris. Injuries and Diseases of Nerves. Vol. III. L. Ollier, ALL)., Professor of Clinical Surgery in the Faculty of Lyons. Inflammatory Affections of the Bones. Vol. III. John II. Packard, M.D., Surgeon to the Pennsylvania Hospital and to St. Joseph’s Hospital, Philadelphia. Poisoned Wounds. Vol. II.; Injuries of Bones. Vol. IV. Theophilus Parvin, M.D., Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, Philadelphia. Injuries and Diseases of the Female Genitals. Vol. VI. A. Poncet, Professor of Operative Surgery in the Faculty of Medicine of Lyons. Tumors of the Bones. Vol. III. C. Post, M.D., LL.D., Emeritus Professor of Clinical Surgery in the University of the City of New York; Consulting Surgeon to the New York Hospital, St. Luke’s Hospital, the Presbyterian Hospital, and the Woman’s State Hospital, New York. Injuries and Diseases of the Face, Cheeks, and Lips. Vol. IV. J. Lewis Smith, M.D., Clinical Professor of Diseases of Children in the Belle- vue Hospital Medical College, New York. Rachitis. Vol. I. Alfred Stille, M.D., LL.D., Emeritus Professor of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania, Philadelphia. Erysipelas. Vol. I. S. Stricker, M.D., Professor of Experimental and General Pathology in the University of Vienna. Disturbances of Nutrition; The Pathology of In- flammation. Vol. I. * Deceased. TO THE INTERNATIONAL ENCYCLOPEDIA OF SURGERY. IX F. R. Sturgis, M.D., Professor of Venereal Diseases in the University of the City of New York (Medical Department), Visiting Surgeon to the Third Venereal Division of Charity Hospital, Blackwell’s Island, etc., New York. Venereal Diseases: The Simple Venereal Ulcer or Chancroid. VOL. II. Frederick Treves, F.R.C.S., Assistant Surgeon to, and Lecturer on Anatomy at, the London Hospital. Malformations and, Diseases of the Spine. Vol. IV.; Malformations and Diseases of the Head. Vol. V. * William II. Van Buren, M.D., LL.D., Professor of the Principles and Prac- tice of Surgery in the Bellevue Hospital Medical College, New York. Inflammation. Vol. I. Arthur Van Harlingen, M.D., Professor of Diseases of the Skin in the Philadelphia Polyclinic, Consulting Physician to the Dispensary for Skin Diseases, Philadelphia. Venereal Diseases: Syphilis. Vol. II. A. Verneuil, M.D., Professor of Clinical Surgery in the Faculty .of Medi- cine, Paris. The Reciprocal Effects of Constitutional Conditions and Injuries. Vol. I. Eugene Vincent, M.D., Professor Agrege, Surgeon-in-Chief of the Hospital of La Charite, Lyons. Scrofulo-tuberculous and other Structural Diseases of Bones. Vol. III. Philip S. Wales, M.D., Surgeon-General of the United States Navy. Scurvy. Vol. I. H. R. Wharton, M.D., Lecturer on Surgical Diseases of Children and Instructor in Clinical Surgery in the University of Pennsylvania, Assistant Surgeon to the University Hospital, Surgeon to the Children’s Hospital, Philadelphia. Venereal Diseases: Bubon d'Emblee, Venereal Warts or Vegetations, Pseudo-venereal Affections, Venereal Diseases in the Lower Animals. Vol. II. James C. White, M.D., Professor of Dermatology in Harvard University. Surgical Diseases of the Skin and its Appendages. Vol. III. J. William White, M.D., Clinical Professor of Genito-Urinary Diseases in the Hospital of the University of Pennsylvania, Assistant Surgeon to the University Hospital, Surgeon to the Philadelphia Hospital, Phila- delphia. Venereal Diseases: Gonorrhoea,. Vol. II. E. Williams, M.D., Professor of Ophthalmology in Miami Medical College, Cincinnati. Injuries and, Diseases of the Eyes and, their Appendages. Vol. IV. John Wood, F.R.S., F.R.C.S., Professor of Surgery in King's College, and Senior Surgeon to King’s College Hospital, London. Hernia. Vol. VI. John A. Wyeth, M.D., Professor of Surgery in the New York Polyclinic, Surgeon to Mt. Sinai Hospital, New York. Surgical Diseases of the Vascular System. Vol. II. * Deceased. ALPHABETICAL LIST OE AUTHORS. (VOL. VI.) WILLIAM ALLINGHAM, JOHN ASH HURST, Jr., H. ROYES BELL, BENNETT A. CLEMENTS, J. SOLIS-COIIEN, EDWARD COWLES, SIMON DUPLAY, GEORGE JACKSON FISHER, ROBERT P. HARRIS, REGINALD HARRISON, CHARLES CARROLL LEE, THEOPHILUS PARVIN, JOHN WOOD. THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. ARTICLES CONTAINED IN THE SIXTH VOLUME. Injuries and Diseases of the (Esophagus. By J. Solis-Cohen, M.D., Professor of Diseases of the Throat and Chest in the Philadelphia Polyclinic, Honorary Professor of Laryngology in the Jefferson Medical College, Physician to the German Hospital, etc Page 1. Intestinal Obstruction. By John Asiihurst, Jr., M.D., Professor of Clin- ical Surgery in the University of Pennsylvania. Page 45. Injuries and Diseases of the Rectum. By William Allingham, F.R.C.S., Surgeon to St. Mark’s Hospital, London. Page 93. Hernia. By John Wood, F.R.S., F.R.C.S., Professor of Clinical Surgery in King’s College, and Senior Surgeon to King’s College Hospital, London. Page 145. Injuries and Diseases of the Bladder and Prostate. By Reginald Harrison, F.R.C.S., Lecturer on Clinical Surgery in the Victoria Uni- versity, Surgeon to the Royal Infirmary, Liverpool. Page 211. Injuries and Diseases of the Urethra. By Simon Duplay, M.D., Pro- fessor of Clinical Surgery in the Faculty of Medicine of Paris, Surgeon to the Lariboisiere Hospital, etc. Page 309. Injuries and Diseases of the Male Genital Organs. By H. Royes Bell, F.R.C.S., Surgeon to, and Demonstrator of Surgery at, King’s College Hospital, London. Page 415. THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. Injuries and Diseases of the Female Genitals. By Ttieophilus Parvin, M.I)., Professor of Obstetrics and Diseases of Women and Children in the Jefferson Medical College, Philadelphia. Page 553. The Cesarean Section and its Substitutes ; Laparotomy for Ruptured Uterus and for Extra-Uterine Fcetation. By Robert P. Harris, A.M., M.D., of Philadelphia. Page 649. Ovarian and Uterine Tumors. By Charles Carroll Lee, M.D., Surgeon to the Woman’s Hospital, Consulting Surgeon to the Charity Hospital, New York. Page 679 APPENDIX. Construction and Organization of Hospitals. By Edward Cowles, M.D., Superintendent of the McLean Asylum, Somerville, Massachusetts. Page 733. Preparation of Military Surgeons for Field Duties ; Apparatus Re- quired; Ambulances; Duties in the Field. By Bennett A. Clem- ents, M.D., Brevet Lieutenant-Colonel and Surgeon, U. S. Army. Page 764. A History of Surgery. By George Jackson Fisher, A.M., M.D., of Sing Sing, New York. Page 790. CONTENTS. PAGE Contributors to the International Encyclopaedia of Surgery . v Alphabetical List of Authors in Yol. VI. . . . x List of Articles in Yol. YI. . . . . . . xi List of Illustrations . ..... xxxi INJURIES AND DISEASES OF THE (ESOPHAGUS. By J. SOLIS-COHEN, M.D., PROFESSOR OF DISEASES OF THE THROAT AND CHEST IN THE PHILADELPHIA POLYCLINIC, HONORARY PROFESSOR OF LARYNGOLOGY IN THE JEFFERSON MEDICAL COLLEGE, PHYSICIAN TO THE GERMAN HOSPITAL, ETC. Wounds and ruptures of the oesophagus ..... 1 Wounds of the oesophagus ...... 1 Wounds from without ...... 2 Wounds of internal origin ...... 2 Symptoms and diagnosis of oesophageal wounds ... 3 Prognosis of oesophageal wounds ..... 4 Treatment of oesophageal wounds . . . . ' . 5 Ruptures of the oesophagus ...... 6 Foreign bodies in the oesophagus ...... 7 Points of lodgment . . . .... 9 Effects, immediate and consecutive ..... 9 Symptoms and diagnosis . . . . . .10 Prognosis . . . . . . . .12 Treatment . . . . . . . .14 Malformations of the oesophagus . . . . . .19 Morbid growths of the oesophagus ...... 20 Benign growths ........ 20 Malign growths ........ 23 Stricture of the oesophagus ... .... 26 Coarctation stricture or extraneous stenosis . . . .28 Spasm and paralysis of the oesophagus . .... 28 Spasm of the oesophagus or oesophagismus . . . .28 Paralysis of the oesophagus . . ... . .29 XIV CONTENTS. PAGE Dilatation and sacculation of the oesophagus .... .29 QEsophagocele ........ 29 Etiology and symptoms of dilated oesophagus . . . .32 Diagnosis, prognosis, and treatment . . . . .33 (Esophageal instruments ... .... 34 Introduction of stomach-tube ...... 34 Bougies and dilators ....... 34 Operations on the oesophagus ....... 35 (Esopliagotomy and oesophagectomy . . . . .35 External oesophagotomy ...... 36 Internal oesophagotomy . . . . .38 Combined oesophagotomy ...... 38 Gastrotomic dilatation of the oesophagus . . . . .39 (Esophagectomy ........ 39 Gastrostomy and enterostomy ....... 40 Gastrostomy ........ 40 Enterostomy ........ 43 INTESTINAL OBSTRUCTION. By JOHN ASHHURST, Jr., M.D., PROFESSOR OF CLINICAL SURGERY IN THE UNIVERSITY OF PENNSYLVANIA. Intestinal obstruction ........ 45 Acute intestinal obstruction ....... 46 Congenital malformations . . ' . . . . .46 Impaction of foreign bodies, gall-stones, enterolites, etc. . . .46 Intussusception or invagination ...... 47 Volvulus ......... 49 Internal strangulation ....... 49 Enteritis and peritonitis ....... 50 Chronic intestinal obstruction . . . . . . .51 Fecal accumulations . . . . . . .51 Stricture of the bowel . . . . . . .51 Chronic invagination ....... 52 Traumatic changes . . . . . . .52 Chronic peritonitis ....... 53 Pressure external to bowel ...... 53 Symptoms of intestinal obstruction ...... 53 Symptoms of acute obstruction ...... 53 Symptoms of chronic obstruction ...... 56 Diagnosis of intestinal obstruction ...... 56 Differential diagnosis in acute obstruction . . . .57 Differential diagnosis in chronic obstruction . . . .58 Diagnosis as regards seat of obstruction . . . . .59 CONTENTS. Prognosis of intestinal obstruction ...... 59 Prognosis of acute obstruction ...... 59 Prognosis of chronic obstruction ...... 60 Treatment of intestinal obstruction ...... 60 Treatment of acute obstruction ...... 60 Treatment of obstruction by foreign bodies, gall-stones, enterolites, etc. 63 Treatment of acute intussusception . . . . .63 Treatment of volvulus ...... 63 Treatment of internal strangulation . . . . .64 Treatment of chronic obstruction ...... 64 Operative treatment of intestinal obstruction . . . . .65 Paracentesis or puncture of the bowel ..... 65 Enterocentesis . . . . . . .65 Laparotomy ........ 65 Mode of performing laparotomy . . . . .67 Analysis of 346 cases of laparotomy for intestinal obstruction . 69 Tables of cases of laparotomy for intestinal obstruction . . 70 Enterotomy ........ 77 Colotomy ......... 77 Callisen’s or Amussat’s operation . . . . .78 Littre’s operation ....... 78 Tables of cases of colotomy ...... 80 Analysis of 351 cases of colotomy . . . . .87 Enterectomy ........ 87 Colectomy ......... 88 Table of cases of resection of the bowel . . . .89 INJURIES AND DISEASES OF THE RECTUM. By WILLIAM ALLINGHAM, F.R.C.S., SURGEON TO ST. MARK’S HOSPITAL, LONDON. Anatomy and physiology of the rectum ...... 93 Muscular coat . . . . . . . .93 Submucous connective tissue ...... 94 Mucous membrane ........ 94 Muscles of rectum and anus ...... 95 Vessels of rectum and anus ...... 96 Nerves . . . ... . . . .96 Lymphatics ........ 97 Relations of rectum ....... 97 Malformations of rectum and anus ... . . . .97 Injuries of the rectum ........ 99 Wounds of the rectum ....... 99 Foreign bodies in the rectum . . . . . .100 XVI CONTENTS. Fistula in ano ......... 100 Causes of fistula in ano . . . . . . .100 Course of fistula in ano . . . . . . .101 Treatment of fistula in ano . . . . . .104 Fistula in conjunction with phthisis . . „ . . 108 Fissure and painful ulcer of rectum . . . . . .108 Proctitis . . . . . . . . .112 Ulceration and stricture of the rectum . . . . . .113 Cancer of the rectum . . . . . . . .120 Hemorrhoids . . . . . , , . . 126 External hemorrhoids . . . 0 . . .126 Internal hemorrhoids . . . . „ . .128 Excision of hemorrhoids . . . . . .131 Clamp-and-cautery method ...... 132 Dilatation of anal sphincter . . . . . .133 Treatment by ligature . . . . . .133 Complications of internal hemorrhoids . . . . .135 Treatment of hemorrhage after operations for hemorrhoids . .136 Procidentia and prolapsus of rectum . . . . . .137 Pruritus ani ......... 139 Polypus of rectum . . . . . . . .140 Impaction of feces . . . . . . . .142 Neuralgia of rectum and irritable rectum . . . . .143 Inflammation of the rectal pouches . . . . . .144 Recto-vesical and recto-urethral fistula . . . . . .144 HERNIA. By JOHN WOOD, F.R.S., F.R.C.S., PROFESSOR OF CLINICAL SURGERY IN KING’S COLLEGE, AND SENIOR SURGEON TO KING’S COLLEGE HOSPITAL, LONDON. Hernia in general . . . . . . . .145 General causes of hernia . . . . . . .146 General signs of hernia . . . . . . . .147 Reducible hernia . . . . . . . .14!) Irreducible hernia . . . . . . , .149 Incarcerated and infarcted hernia . . . . . .150 Strangulated hernia . . . . . . . .150 General symptoms of strangulation . . . . .151 General diagnosis and treatment of strangulated hernia . . . 153 Inguinal hernia . . . . . . . .156 Parts involved in inguinal hernia . . . . . .156 Coverings of inguinal hernia . . . . . .160 Diagnosis of strangulated inguinal hernia . . . . .163 Operation for strangulated inguinal hernia . . . . .164 CONTENTS. PAGE Inguinal hernia— Diagnosis of inguinal hernia when not strangulated . . . 165 Radical cure of inguinal hernia . . . . . .167 Crural or femoral hernia . . . . . . .183 Diagnosis of strangulated crural hernia . . . . .187 Operation for strangulated crural hernia . . . . .188 Diagnosis of unstrangulated crural hernia . . . . .189 Operation for the radical cure of crural hernia .... 189 Umbilical hernia . . . . . . . .193 Diagnosis and treatment of umbilical hernia . . . • .196 Operation for strangulated umbilical hernia . . . .197 Ventral hernia . . . ... . . . .201 Obturator or thyroid hernia . . . . . . .201 Ischiatic hernia . ........ 202 Perineal, vaginal, and pudendal herniae ...... 202 Diaphragmatic hernia ........ 202 Trusses ......... 203 Trusses for inguinal hernia ...... 205 Trusses for crural hernia . ...... 207 Trusses for umbilical hernia. . . . . . . 207 INJURIES AND DISEASES OF THE BLADDER AND PROSTATE. By REGINALD HARRISON, F.R.C.S., LECTURER ON CLINICAL SURGERY IN THE VICTORIA UNIVERSITY, SURGEON TO THE ROYAL INFIRMARY, LIVERPOOL. Wounds of the bladder . . . . . . . .211 Rupture of the bladder . . . . . . . .214 Foreign bodies in the bladder . . . . . . .219 Malformations and malpositions of the bladder ..... 222 Complete absence of bladder . . . . . . 222 Two-cavity bladders . . . . . , .223 Exstrophy or extroversion of bladder ..... 223 Patent urachus ........ 227 Hernia of bladder ........ 227 Inversion of bladder . . . . . . .228 Cystitis ....... . 229 Ulceration of the bladder ....... 238 Hypertrophy and atrophy of the bladder ..... 239 Sacculated bladder . . . . , . . .241 Tumors of the bladder . . . . . . . .243 Tubercle of the bladder . . . . . , .251 Bar at neck of bladder ........ 253 Fissure of the bladder . . . . . . , .254 Irritable bladder . . . , . . . .255 xviii CONTENTS. PAGE Injuries of the prostate . . . . . . . .258 Prostatitis and prostatic abscess . . . . . . .260 Prostatorrhoea . . . . . . . .263 Prostatic irritation . . . . . . .263 Hypertrophy of the prostate . . . . . . .264 Atrophy of the prostate . . . • . . .275 Tumors and cancer of the prostate . . . . .276 Fibromas, prostatic tumors, or adenomas . . . . .276 Malignant tumors . • . . . . . .277 Tubercle of the prostate . . . . . . .279 Cysts of the prostate ........ 280 Prostatic calculus ........ 280 Haematuria ......... 282 Retention and incontinence of urine ; paralysis and atony ; spasm and neuralgia of the bladder ....... 287 Retention of urine ....... 287 Incontinence of urine ....... 293 Paralysis and atony of the bladder ..... 295 Spasm of the bladder ....... 296 Neuralgia of the bladder ....... 297 Puncture of the bladder ....... 298 Tapping the bladder above the pubis ..... 298 Subpubic operation ....... 300 Puncture through symphysis pubis ..... 300 Tapping the bladder from the perineum ..... 300 Puncture from the rectum ...... 305 Appendix ........ . 307 Prostatotomy ........ 307 Rupture of prostate and bladder ...... 308 INJURIES AND DISEASES OF THE URETHRA. By SIMON DUPLAY, M.D., PROFESSOR OF CLINICAL SURGERY IN THE FACULTY OF MEDICINE OF PARIS, SURGEON TO THE LA RIB OISI ERE HOSPITAL, ETC. (Translated by CHARLES W. DULLES, M.D., Surgeon for Out-patients to the Hospital of the University of Pennsylvania, and to the Presbyterian Hospital in Philadelphia.) Exploration of the urethra and bladder ..... 309 Direct inspection, etc. ....... 309 Exploration of urethra ....... 309 Exploration of bladder . . . . . . .310 Exploratory sounding ....... 310 Evacuatory catheterization . . . . . .313 Endcfecopy ........ 318 CONTEXTS, PAGE Traumatic lesions of urethra . . . . . . .318 Traumatic lesions of urethra produced from without inwards . . 318 Wounds of urethra ....... 319 Contused wounds : ruptures and lacerations . . . .319 Traumatic lesions of urethra produced from within outwards (false passages) 329 Foreign bodies in urethra . . . . . . .331 Foreign bodies coming from bladder . . . . .331 Foreign bodies formed in situ ...... 335 Foreign bodies introduced through meatus .... 337 Vital and organic lesions of urethra . . . . . . 339 Inflammation of urethra or urethritis ..... 339 Stricture of urethra ....... 339 Etiology and pathogenesis ...... 340 Pathological anatomy . . . . . .341 Symptomatology and diagnosis ..... 347 Complications ....... 350 Prognosis ........ 352 Treatment ........ 352 Cauterization . . . • . • .352 Dilatation ....... 353 Inflammatory dilatation ..... 353 Mechanical dilatation ..... 355 Urethrotomy ....... 358 Internal urethrotomy ..... 359 External urethrotomy ..... 360 General indications relative to treatment of strictures; choice of method 361 Spasm of urethra ; spasmodic stricture ..... 362 Idiopathic spasm and contracture ..... 363 Etiology . . . . . . . 363 Symptomatology . . . . . . 364 Diagnosis . . . . . . .365 Prognosis ....... 366 Treatment ....... 367 Symptomatic spasm and contracture ..... 368 Urinary pouches ........ 369 Urinary abscesses . . . . . . . .370 Tumors and neoplasms of urethra . . . . . .372 Vices of conformation of urethra . . . . . .372 Congenital strictures . . . . . . .372 Occlusions of urethra . . . . . . .373 Congenital urinary pouches . . . . . .373 Abnormal openings of urethra, etc. . . . . .374 Hypospadia . . . . . . . .375 Etiology and pathogenesis . . . . . .375 Pathological anatomy . . . . . .376 Balanic or glandular hypospadia . . . .376 Penile hypospadia . . . . . .377 Scrotal and perineo-scrotal hypospadia . . . .378 XX CONTENTS. PAGE Vices of conformation of urethra— Functional disturbances . . . • • .379 Diagnosis of hypospadia . . . . . .379 Prognosis of hypospadia ...... 380 Treatment of hypospadia . . . . . . ■ 380 Epispadia ....... . 384 Etiology and pathogenesis ...... 384 Functional disturbances ...... 386 Complications ....... 387 Treatment ........ 387 Conditions which may complicate diseases of urethra .... 390 Urinary infiltration ....... 390 Urinary fistulae ........ 393 Urethro-rectal fistulas ...... 393 Urethro-perineo-scrotal fistulae ..... 397 Urethro-penile fistulae ...... 401 Treatment by cauterization . . . ' . . 403 Urethrorraphy ....... 403 Urethroplasty ....... 404 Urinary fever ........ 405 Acute form of urinary fever ...... 406 Chronic form of urinary fever ..... 409 Etiology of urinary fever ...... 409 Pathogenesis of urinary fever . . . . .410 Treatment of urinary fever . • . . . .412 INJURIES AND DISEASES OF THE MALE GENITAL ORGANS. By H. ROYES BELL, F.R.C.S., SURGEON TO, AND DEMONSTRATOR OF SURGERY AT, KING’S COLLEGE HOSPITAL, LONDON. Injuries and diseases of the penis ...... 415 Wounds of the penis ....... 415 Fracture and luxation of the penis . . . . .417 Foreign bodies in urethra . . . . . . .419 Preputial calculi . . . . . . . .419 Balanitis and posthitis ....... 419 Inflammation of the penis ....... 420 Abscess of the penis ....... 420 Gangrene of the penis ....... 420 Erysipelas of the penis . ...... 421 Herpes praeputialis ....... 422 Congenital defects of penis ...... 422 CONTENTS. XXI PAGE Injuries and diseases of the penis— Phimosis and paraphimosis . . . . . .424 Tumors of the penis ....... 428 Amputation of the penis ....... 432 Affections of the scrotum ....... 435 Contusions and wounds of the scrotum ..... 435 Cutaneous eruptions ....... 435 (Edema of the scrotum ....... 435 Mortification of the scrotum ...... 436 Pneumatocele of the scrotum ...... 437 Syphilitic induration ....... 437 Elephantiasis of the scrotum ...... 437 Lymph-scrotum ........ 439 Tumors of the scrotum ....... 440 Malignant disease of the scrotum ..... 442 Cleft scrotum . ...... 445 Hydrocele ......... 446 Common vaginal hydrocele ...... 446 Nature of fluid ........ 447 Symptoms . . . . . . . . 450 Treatment ........ 452 Radical cure ....... 453 Inguinal hydrocele ....... 457 Congenital hydrocele ....... 457 Encysted hydrocele of the testicle ..... 458 Diffused hydrocele of the cord ...... 460 Encysted hydrocele of the cord . . . . . .461 Congenital hydrocele of the cord ...... 462 General remarks on the diagnosis of hydrocele . . . 462 Complications of hydrocele ...... 463 Hydrocele of hernial sac ....... 464 Haematocele ......... 465 Haematocele of the tunica vaginalis . 465 Encysted haematocele of testicle ...... 468 Haematocele of spermatic cord ...... 468 Intra-testicular haematocele ...... 469 Varicocele ......... 469 Anatomy of varicocele . . . . . . .470 Diagnosis of varicocele . . . . . . .472 Treatment of variccrcele . . . . . . *472 Radical cure of varicocele . . . . . .473 Anomalies of the testicle . . . . . . .479 Anomalies in number of testicles . . * . . . .479 Imperfect transition of testicle ...... 480 Retracted testis . . . . . . . .485 Inversion and reversion of testis ...... 485 Hypertrophy and atrophy of testicle ..... 486 Affections of vas deferens, vesiculae seminales, and ejaculatory duct . . 488 Affections of vas deferens ....... 488 XXII CONTENTS. PAGE Affections of vas deferens, vesiculae seminales, and ejaculatory duct— Inflammation of vesiculae seminales ..... 488 Affections of ejaculatory duct ...... 489 Spermatocele ......... 489 Neuroses of the testicle ....... 490 Injuries of the testicle . . . . . . . .491 Orchitis . . . . . . . . .491 Acute orchitis . . . . . . . .491 Spontaneous gangrene of testicle ..... 494 Encysted abscess of testis ...... 494 Inflammatory atrophy of testis ..... 494 Special varieties of orchitis ...... 495 Diagnosis and prognosis of orchitis ..... 497 Treatment of orchitis ...... 498 Chronic orchitis ........ 500 Syphilitic sarcocele or syphilitic orchitis . . . . .501 Syphilitic epididymitis ...... 503 Benign fungus of the testicle ...... 504 Tuberculous and scrofulous disease of the testis .... 506 Diagnosis . . . . . . . . .511 Prognosis and treatment . . . . . . .512 Cystic disease of testis . . . . . . .513 Dermoid cysts in testicle and scrotum ...... 515 Solid tumor of the testis ....... 516 Enchondroma of the testis . . . . . .516 Fibrous tumors of the testis . . . . . .518 Fibro-plastic tumors of the testis . . . . . .519 Calcareous matter in epididymis . . . . . .519 Carcinoma of testis . . . . . . .519 Sarcoma of testis ........ 522 Lymphadenoma of testis ....... 524 Epithelioma of testis ....... 524 Excision of the testis ........ 524 Entozoa in testicle and scrotum ...... 526 Functional disorders of male genital organs . . . . .526 Spermatorrhoea: nocturnal and diurnal pollutions .... 526 Etiology of spermatorrhoea ...... 530 Pathological anatomy and symptoms ..... 533 Diagnosis ........ 534 Prognosis and treatment ... . 535 Impotence and sterility ....... 540 Impotence ....•••• 540 Prognosis . ' . • • * * .543 Treatment ....... 544 Sterility 544 Azoospermia ....... 545 Satyriasis . . • • • • • • .546 Priapism 548 Description of plates . • • • • « • • 551 CONTENTS. INJURIES AND DISEASES OF THE FEMALE GENITALS. By THEOPHILUS PARVIN, M.D., rROFESSOR OF OBSTETRICS ANI) DISEASES OF WOMEN AND CHILDREN IN THE JEFFERSON MEDICAL COLLEGE, PHILADELPHIA. PAGE Modes of exploration ........ 553 Touch and sight ........ 553 Table for examination ; general preparations; position of patient . 554 Vaginal touch ........ 555 Rectal touch ........ 556 Vesical touch ........ 557 External touch or abdominal palpation ..... 557 Combined examination ....... 558 Mediate touch or examination with uterine sound or probe . . 559 Visual examination . . . . . . .561 Examination with speculum . . . 561 Mensuration, auscultation, and percussion . 563 Dilatation of cervical canal ...... 564 Curette and exploring needle ...... 565 Ruptures and wounds of the vagina ...... 565 Wounds of the pregnant uterus . . . . . .566 Lacerations of cervix uteri; tracheloplasty ..... 568 Diagnosis of lacerated cervix ...... 570 Indications for tracheloplasty ...... 570 Preparatory treatment . . . . . . .571 Operation . . . . . . . . .571 After-treatment ........ 574 Accidents during and after operation . . . . .574 Tears of the perineum . . . . . . . .575 Varieties ......... 576 Treatment ......... 576 Perineorraphy . . . . . . .576 Perineoplasty ........ 578 Traumatism involving genital zone in pregnancy .... 585 Foreign bodies in vagina ....... 585 Genital atresia ......... 538 Vulvar atresia ........ 588 Imperforate hymen ....... 588 Absence or rudimentary condition of vagina .... 539 Complex atresia . . . . . . . .591 Accidental genital atresia . . . . . .. .591 Double vagina ......... 592 Hydrocele muliebris . . . . . . . .592 XXIV CONTENTS. PAGE Vulvar and vaginal fissures ....... 593 Noma pudendi ......... 593 Lupus .......... 594 Idephantiasis of the vulva ....... 595 Tumors of the vulva ........ 597 Cysts of the vulva ....... 597 Lipomata of the vulva ....... 598 Fibromata of the vulva ....... 599 Warty tumors or vegetations of the vulva ..... 599 Hsematoma of the vulva ....... 600 Cancer of the vulva ....... 601 Vaginal tumors ........ 602 Cystic tumors of vagina . . . . . . . 602 Fibroids of vagina ....... 604 Cancer of vagina ........ 604 Sarcoma of vagina ....... 604 Mucous polypi of vagina ....... 605 Haematoma of vagina ....... 605 Uro-genital fistulas ........ 605 Etiology of uro-genital fistulae ...... 606 Symptoms and diagnosis ....... 607 Complications ........ 608 Treatment . . . . . . . 608 Special methods necessary in different varieties of fistulae . . 613 Recto-vaginal fistulae . . . . . . . .613 Diseases of the cervix uteri ....... 615 Ulceration of cervix . . . . . . .615 Hypertrophy of cervix . . . . . . *617 Fibroid tumors of cervix ....... 618 Polypi of cervix . . . . . . . *619 Malignant disease of cervix . . . . . -619 Sarcoma of cervix . . . . . . -619 Carcinoma of cervix ....... 620 Etiology and varieties ...... 620 Symptoms and progress . . . . . -621 Diagnosis and treatment ..... 623 Pregnancy in cases of cancer of cervix .... 625 Amputation of cervix uteri ....... 625 Amputation with bistoury or scissors ..... 626 Amputation writh ecraseur ....... 628 Amputation with galvano-cautery wire or knife .... 629 Amputation with thermo-cautery knife ..... 629 Vaginal extirpation of cancerous uterus ..... 630 Elytrorrhaphy or colporrhaphy ...... 630 Anterior colporrhaphy . . . . . . .631 Posterior colporrhaphy ....... 635 Median colporrhaphy ....... 636 Colpo-perineorrhaphy ....... 636 CONTENTS. XXV PAGE Episiorraphy . • . ... • • . . 637 Vaginismus 638 Coccygodynia ......... 641 Sterility ......... 642 Impotentia concipiendi - . . . , . 643 Impotentia gestandi ....... 644 Treatment . . . . . . . .645 Artificial fecundation ....... 647 Nymphomania ......... 647 THE CiESAREAN SECTION AND ITS SUBSTITUTES; LAPAROTOMY FOR RUPTURED UTERUS AND FOR EXTRA-UTERINE FCETATION. By ROBERT P. HARRIS, A.M. M.D., OF PHILADELPHIA. The Caesarean section ; gastro-hysterotomy or laparo-hysterotomy . . 649 History of Caesarean section ...... 649 Indications for operation . . . . . . .651 Risk in operating ........ 652 Causes of fatality ........ 653 Modes of operating ....... 653 Modern antiseptic operation ...... 654 Uterine sutures 655 New methods of performing gastro-hysterotomy . . . . 655 Cohnstein’s process ....... 655 Frank’s process > . . . . . .656 Kehrer’s process . . . . . . .657 Sanger’s process ....... 658 The Porro-Caesarean section; laparo-hystero-oophorectomy . . . 660 History of Porro operation . . . . . .660 Mode of operating . . . . . . .661 Muller’s modification ....... 662 Veit’s modification ....... 663 Other minor changes ....... 663 Effect of Porro mutilation upon subjects of malacosteon . . .664 Gastro-elytrotomy or laparo-elytrotomy . . . . 005 History . . . . • . • . . .665 Jorg’s, Ritgen’s, and Baudelocque’s methods .... 000 Physick’s, Bell’s, and Thomas’s methods .... 007 Method of operating ....... 007 Statistical record ........ 009 XXVI CONTENTS. PAGE Puerperal laparotomy or laparotomy after rupture of uterus . . .670 Laparo-hysterectomy . . . . . . .670 Operation . . . . . . . . .671 Puerperal laparo-eystotomy, laparo-cystectomy, and elytrotomy in ectopic preg- nancies ........ 672 Puerperal laparo-eystotomy . . . . . -672 Laparo-cystectomy ....... 675 Puerperal elytrotomy ....... 675 Secondary laparo-eystotomy . . . . . *676 OVARIAN AND UTERINE TUMORS. By CHARLES CARROLL LEE, M.D., SURGEON TO THE WOMAN’S HOSPITAL, CONSULTING SURGEON TO THE CHARITY HOSPITAL, NEW YORK. Ovarian tumors . . . . . . . .679 Ovarian cysts and cystomata . . . . . .679 Origin and causes . . . . . . .679 Morbid anatomy ....... 680 Course and natural history 682 Symptoms ........ 683 Diagnosis ........ 688 Prognosis ........ 693 Treatment ........ 694 Dermoid cysts of ovary ....... 694 Hydatids of ovary ....... 69.5 Solid tumors of ovary . . . . . . .695 Fibroma ........ 695 Sarcoma ...... . 696 Carcinoma ........ 696 Uterine tumors ........ 697 Uterine fibroids 697 Location and structure ...... 697 Degenerative changes ...... 698 Symptoms ........ 099 Diagnosis ........ 700 Prognosis . . * . . . • .701 Treatment . . . . . . . .702 Uterine fibro-cysts . . . . . . .704 Sarcomata of uterus ... . . . . .705 Pathology, etiology, and mode of occurrence .... 705 Symptoms, diagnosis, prognosis, and treatment . . . 706 Carcinomata of uterus . . . . . . .706 Pathology and mode of occurrence ..... 706 CONTENTS. PAGE Carcinomata of uterus— Symptoms ........ 707 Diagnosis ........ 708 Prognosis and treatment ...... 709 Affections likely to be mistaken for ovarian or uterine tumors . . .712 Cysts of the broad ligament . . . . . .712 Pelvic hasmatocele . . . . . . .713 Ilio-pelvic abscess . . . . . . .716 Operations for ovarian and uterine tumors ..... 718 Ovariotomy . . . . . . . .718 Vaginal ovariotomy . . . . . . .718 Abdominal ovariotomy . . . . . .718 Mode of performing operation ..... 720 After-treatment and complications . . . .724 Contra-indications ...... 724 Oophorectomy or Battey’s operation ...... 725 Vaginal method ........ 725 Abdominal section in laparotomy ...... 726 Extirpation of uterine appendages, or Tait’s operation .... 727 Hysterectomy . . . . . . . . .727 Vaginal hysterectomy ....... 727 Extirpation of uterus by abdominal section .... 728 Freund’s method ....... 728 Ordinary operation ....... 730 Hegar’s method . . . . . . .731 CONTENTS. APPENDIX. CONSTRUCTION AND ORGANIZATION OF HOSPITALS. By EDWARD COWLES, M.D., SUPERINTENDENT OF THE M°LEAN ASYLUM, SOMERVILLE, MASSACHUSETTS. PAGE History of hospitals . . . . . . . .733 Construction and organization of hospitals . . . . .735 General considerations as to hospitals . . . . .736 Location and site of hospitals . . . . . .739 Materials and foundations of hospitals ..... 739 Form and construction of hospital wards . . . . .740 Size of hospital and arrangement of wards and accessary buildings 749 Ventilating, warming, and lighting . . . . .754 Furnishing and fittings . . . . . . .760 Organization and management . . . . . .760 Nursing . . . . . . . . .761 Special hospitals . . . . . . . .762 Cottage and convalescent hospitals . . . . .763 PREPARATION OF MILITARY SURGEONS FOR FIELD DUTIES; APPARATUS REQUIRED; AMBULANCES; DUTIES IN THE FIELD. By BENNETT A. CLEMENTS, M.D., BREVET LIEUTENANT-COLONEL AND SURGEON, -U. S. ARMY. Introductory remarks ........ 764 Importance of discipline ....... 765 Examination of men for enlistment . . . . . .766 Medical equipment for a regiment . . . . . .767 Hygiene of camps and sanitary care of troops . . . . .769 Directions for cooking in camp ...... 771 Ambulance corps ........ 772 Field hospitals . . . . . . . . .774 Mode of supply of medicine and medical material . . . .776 Duties of medical officers in field . . . . . .778 CONTENTS. XXIX A HISTORY OF SURGERY. By GEORGE JACKSOY FISHER A.M., M.D., PAGE Surgery before the time of Hippocrates ..... 790 Surgery during the Hippocratic era . . . . . .792 Surgery during the Alexandrian era ...... 800 Surgery among the Romans . . ..... 800 Greek surgery from Galen to Paulus .ZEgineta ..... 809 Surgery during the Arabic period . . . . . .815 The School of Salernum ....... 821 Surgery among the Hindoos ....... 823 Surgery during the dark ages ....... 825 Early English surgery ........ 827 Surgery in the sixteenth century . . . . . . 829 Surgery in the seventeenth century ...... 840 Surgery in the eighteenth century ...... 842 Surgery in the nineteenth century ...... 844 GENERAL INDEX 847 OF SING SING, N. Y. LIST OF ILLUSTRATIONS. CHROMO-LITHOGRAPHS PLATE PAGE XXXIV. Tuberculosis of testis and elephantiasis of scrotum . . . 438 XXXV. Fibroma and carcinoma of testis; retained testis; epithelioma of scrotum; syphilitic testis ; diffuse orchitis ... 443 WOOD-CUTS. FIG. PAGE 1296. Fragments of bone lodged in oesophagus. (After Poulet.) . . 8 1297. Duplay’s resonator . . . . . . .11 1298. Perforation of oesophagus and aorta by a five-franc piece. (After Poulet, from Denonvilliers.) . . . . . . .13 1299. Perforation of inferior thyroid artery by bone. (After Poulet, from Pilate.) 13 1300. Pond’s forceps ........ 15 1301. Burge’s forceps ........ 15 1302. Cloquet’s toothed forceps ...... 15 1303. Cusco’s forceps ........ 15 1304. Mathieu’s jointed forceps . . . . . .16 1305. Grama’s forceps . . . . . . .16 1306. Petit’s hook . . . . . . . .16 1307. Graefe’s coin-catcher . . . . . . .16 1308. Bing coin-catcher . . . . . . .16 1309. Horse-hair parasol-snare ....... 17 1310. Traumatic stricture of oesophagus. (After Mackenzie.) . . 26 1311. General dilatation of oesophagus. (After Luschka.) . . .30 1312. Traction diverticulum. (After Zenker and Ziemssen.) . . .31 1313. Interior view of traction diverticulum. (After Zenker and Ziemssen.) . 31 1314. Exploration of diverticulum with sound. (After Zenker and Ziemssen.) 33 1315. Sectional outlines of Mackenzie’s bougie . . . .34 1316. CEsophageal dilators ....... 35 1317. Graduated oesophageal dilator of Trousseau . . . .35 1318. Mackenzie’s oesophagotome ...... 38 1219. Method of feeding through gastric fistula. (Whitehead’s patient.) . 42 1320. Instrument for drawing India-rubber through fistula from within outwards 105 LIST OF ILLUSTRATIONS. FIG. PAGE 1321. Spring-scissors with probe-point in grooved director . . .106 1322. Scissors for removing overlapping edges of skin in operation for fistula . 106 1323. Anal speculum . . . . . . . .111 1324. Four-bladed anal speculum . . . . . .111 1325. Rectal insufflator . . . . . . 0 .117 1326. Instrument for applying ointments to rectum . . . .117 1327. Instrument for detecting rectal stricture . ... . .119 1328. Rectal syringe . . . . . . . .119 1329. Clamp for hemorrhoids ....... 132 1330. Screw-crushing instrument for hemorrhoids .... 134 1331. Forceps for grasping hemorrhoids ...... 134 1332. Spring-scissors for hemorrhoids ...... 134 1333. Superficial dissection of inguinal and crural regions . . . 157 1334. Deep dissection of inguinal canal and abdominal wall . . . 158 1335. Internal abdominal ring ....... 159 1336. Diagram of congenital hernia . . . . . .162 1337. Diagram of infantile or encysted hernia . . . . .162 1338. Instruments required in operation for radical cure of inguinal hernia . 170 1339. The scrotal incision ....... 170 1340. Invagination of fascia by fore-finger . . . . .171 1341. Needle perforating the conjoined tendon ..... 171 1342. Introduction of the wire . . . . . . .171 1343. Needle penetrating Poupart’s ligament . . . . .172 1344. Needle crossing the sac . . . . . . .172 1345. Wire twisted and locked . . . . . . .172 1346. Modified operation for very large hernias ..... 173 1347. Compress in position ....... 173 1348. Diagram of cured inguinal hernia . . . . . .174 1349. Deep dissection of parts in crural rupture . .... 185 1350. The crural ring ........ 185 1351. Irregular arrangement of arteries in femoral hernia . . . 186 1352. Irregular course of obturator artery ..... 186 1353. Diagram of crural hernia ....... 187 1354. Subcutaneous-wire operation for crural hernia . . . .190 1355. Mode of securing the wire. ...... 191 1356. Umbilical hernia ........ 193 1357. Instruments used in operation for umbilical hernia . . . 199 1358. Introduction of first wire ....... 200 1359. Introduction of second wire ...... 200 1360. Ring closed by twisting wire ...... 200 1361. Diagram showing closure of ring . . . . . .200 1362. Pressure-gauge for ascertaining amount of hernial impulse and consequent strength required for truss-spring ..... 204 1363. Horseshoe-pad for inguinal hernia. . . . . .205 1364. Ring-pad for direct hernia. ...... 206 1365. Diagram of crural canal . ..... 207 1366. Truss-pad for crural hernia ...... 207 1367. Truss for umbilical hernia..... . 208 LIST OF ILLUSTRATIONS. FIG. PAGE 1368. Mercier’s instrument for removing elastic bougies from bladder . . 220 1369. Robert and Collin’s instrument for removing foreign bodies from bladder . 221 1370. Wood’s operation for extroversion of bladder. (After Aslihurst.) . 225 1371. Maury’s operation for extroversion of bladder .... 226 1372. Urinal for extroversion of bladder ..... 226 1373. Double-current catheter for washing out bladder .... 234 1374. Keyes’s apparatus for irrigation of bladder. .... 234 1375. Harrison’s catheter for introducing pessaries into bladder . . . 236 1376. Section of normal prostate ...... 266 1377. Enlargement of prostate towards rectum ..... 266 1378. Considerable enlargement of prostate towards rectum with straightening of prostatic urethra ....... 267 1379. 1380. Enlargement of third lobe of prostate .... 267 1381. Enlargement of third lobe of prostate . . . . .268 1382. Normal position of internal urinary meatus .... 268 1383. Internal meatus in ordinary form of enlargement of third lobe of prostate . 269 1384. Pedunculated hypertrophy of third lobe of prostate; urethra opening on either side ........ 269 1385. Bifid hypertrophy of third lobe of prostate. . . . .270 1386. Prostatic dilators ........ 271 1387. Mercier’s sonde coudee or elbowed catheter .... 272 1388. Poland’s case of prostatic calculus. ..... 281 1389. Gouley’s tunnelled catheter ...... 292 1390. Trocar and canula for puncture of bladder through perineum . . 303 1391. Tapping bladder from perineum through enlarged prostate . . 304 1392. Instruments for tapping bladder through rectum .... 306 1393. Exploratory bougie ....... 309 1394. Exploratory catheter . . . . . . .310 1395. Thompson’s catheter-sound . . . . . .310 1396. Exploratory sounding, first stage . . . . . .311 1397. Exploratory sounding, second stage . . . . .312 1398. Ordinary catheter . . . . . . .313 1399. Metallic catheter in sections ... . 313 1400. Gum catheters, straight and curved . . . . .314 1401. Elbowed catheters. . . . . . . .314 1402. Gum catheters, straight and curved, with conical and olive-shaped ends . 315 1403. Evacuatory catheterization, first stage . . . . .316 1404. Evacuatory catheterization, third stage . . . . .317 1405. Stylet ......... 317 1406. Calculus lodged in fossa navicularis. (After Voillemier.) . . . 332 1407. Urethral calculus composed of ten pieces. (After Voillemier.) . . 333 1408. Urethro-vesical calculus. (After Voillemier.) .... 333 1409. Urethral calculus of phosphate of lime, natural size . . . 335 1410. Jointed curette of Leroy ..... 336 1411. Hunter’s forceps ... .... . 336 1412. Nelaton’s urethral lithotrite ... . . 337 1413. Inflammatory stricture in lightest form ..... 342 1414. Inflammatory stricture in advanced stage ..... 342 XXXIV LIST OF ILLUSTRATIONS. FIG. PAGE 1415. Inflammatory stricture occupying almost whole length of urethra. (After Voillemier.) . . . . . . . . 344 1416. Cicatricial stricture. (After Voillemier.) .... 344 1417. Cicatricial stricture following chancroid ..... 345 1418. Traumatic stricture. (After Voillemier.) .... 343 1419. Otis’s urethrometer . .. . . . . . 349 1420. Elbowed and spirally twisted bougies ..... 355 1421. Rigaud’s dilator ........ 356 1422. Holt’s divulsor ........ 357 1423. Voillemier’s divulsor . . . . . . . 358 1424. Maisonneuve’s urethrotome ...... 359 1425. Congenital urinary pouch. (After Angers.) . . . 374 1426. 1427. Peno-scrotal hypospadia ...... 377 1428. Perineo-scrotal hypospadia ...... 378 1429,1430. Section of sub-penile band and straightening of penis . . 381 1431. Restoration of urinary meatus ...... 382 1432. Formation of new canal ....... 382 1433. Modified quill-suture ....... 383 1434. Section showing arangement of deep and superficial sutures . . 383 1435. Definitive result of operation for hypospadia .... 384 1436. Complete epispadia ....... 386 1437. Formation of new canal; shows raw surfaces and position of sutures . 388 1438. Modified quill-suture ....... 388 1439. Section showing sutures applied ...... 389 1440. Definitive result of operation for epispadia .... 389 1441. Urethrorraphy by Voillemier’s method ..... 404 1442. Nelaton’s method of urethro-plasty ..... 405 1443. Dislocation of penis. (From drawing in King’s College Museum.) . 418 1444. Dislocation of penis. (From patient of Sir W. Fergusson.) . . 418 1445. End of foreskin removed in phimosis, showing pin-hole-like orifice . 424 1446. Old case of amputation of penis ...... 434 1447. Pedunculated fibrous tumor of scrotum ..... 441 1448. Chimney-sweep’s cancer of scrotum ..... 442 1449. Epithelial cancer of scrotum, early stage .... 443 1450. Cleft scrotum ........ 445 1451. Relation of parts in vaginal hydrocele ..... 447 1452. Transverse section of vaginal hydrocele ..... 448 1453. Vaginal hydrocele with disease of testis ..... 449 1454. Encysted hydrocele of testicle, or spermatic hydrocele . . . 459 1455. Spontaneous hajmatocele from ruptured tunica vaginalis . . . 466 1456. Old haematocele ........ 467 1457. Dissection showing right spermatic valve. (After Brinton.) . . 470 1458. Instrument for treatment of varicocele . . . . .475 1459. Elastic ligature and leaden clamp for treatment of varicocele . .476 1460. Misplaced testicle ....... 484 1461. Benign fungus testis ....... 504 1462. Tubercular disease of testis . . . . . .511 1463. Cystic sarcoma of testis ....... 513 LIST OF ILLUSTRATIONS. XXXV FIG. PAGE 1464. Section of enchondromatous testicle ..... 517 1465. Spermatozoon of salamandra maculata ..... 527 1466. Human spermatozoa ....... 528 1467. Introduction of ligature to secure lips of cervix uteri by Jackson’s method 572 1468. Skene’s hawk-bill scissors . . . . . 572 1469. Tracheloplasty. (After Emmet.) . . . . . 573 1470. 1471, 1472. Tracheloplasty. (After Thorburn.) . . . 573 1473. Perineoplasty. (After Thomas.) ..... 579 1474. Perineoplasty; “ butterfly” denudation. (After Hildebrandt.) . . 579 1475. 1476. Perineoplasty, flap method ..... 580 1477. Perineoplasty, Hildebrandt’s method ..... 580 1478. Perineoplasty ; Hegar and Kaltenbach’s mode of fastening sutures . 581 1479. Perineoplasty; sutures fastened. (After Hegar and Kaltenbach.) . 581 1480. Perineoplasty ; denudation extending to vaginal cul-de-sac. (After Hegar and Kaltenbach.) . v . . . . . 532 1481. 1482. Perineoplasty ; Emmet’s method ..... 532 1483. Perineoplasty by continued catgut suture . . . . 533 1484. Deep sutures drawn tightly and superficial sutures introduced . . 533 1485. Completed operation, surfaces in apposition, and ends of sutures tied . 583 1486. Perineoplasty; catgut suture approximating walls of vagina . . 584 1487. Elephantiasis of vulva. (After Schroeder.) .... 596 1488. Operation for elephantiasis of vulva. (After Munde.) . . . 597 1489. Fibroid of labium majus. (After Storer.) .... 599 1490. Removal of vaginal cyst by Schroeder’s method . . . 603 1491. Diagram showing various forms of uro-genital fistula . . . 605 1492. Simon’s operation for vesico-vaginal fistula .... 609 1493. Vesico-vaginal fistula, freshening edges ..... 610 1494. 1495, 1496. Vesico-vaginal fistula, introduction of sutures . , 610 1497. Vesico-vaginal fistula; twisting the sutures .... 611 1498. Sigmoid catheter . . . . . 0 -612 1499. 1500. Amputation of cervix uteri by Sims’s method . . . 626 1501, 1502. Amputation of cervix uteri by Hegar’s method . . . 627 1503. Supra-vaginal amputation of cervix uteri by Schroeder’s method . 628 1504. Anterior colporraphy; Emmet’s method .... 631 1505. Anterior colporraphy; sutures adjusted ..... 632 1506. Anterior colporraphy; Hegar’s method ..... 632 1507. Anterior colporraphy; Schroeder’s method .... 633 1508. Posterior* colporraphy; Schroeder’s method .... 634 1509,1510. Posterior colporraphy; Emmet’s method . . „ 635 1511. Median colporraphy; LeFort’s method ..... 636 1512. Colpo-perineorraphy; Simon’s method ..... 636 1513. Colpo-perineorraphy; Hegar’s method ..... 637 1514. Restoration of perineum by Schroeder’s method .... 637 1515. Ward in Johns Hopkins Hospital ..... 742 1516. Pavilion of Johns Hopkins Hospital . . • • * 743 1517. The Toilet system ....... 744 1518. Square ward ........ 746 1519. Antwerp Hospital ....... 747 XXXVI LIST OF ILLUSTRATIONS. FIG. PAGE 1520. Isolating ward . . . . . „ . .748 1521. London Fever Hospital ....... 749 1522. Johns Hopkins Hospital ....... 751 1523. Boston City Hospital . . . . ... . 752 1524,1525. Stoves for hospitals ...... 756 1526, 1527. Barnes Hospital ....... 758 1528. Medicine-pannier . . . . . . .767 1529. Upper tray of medicine-pannier . . . . . .768 1530. Coolidge’s medicine-case or field-companion . . . .768 1531. Wheeling or Rosecrans ambulance-wagon . . . .773 1532. Rucker ambulance-wagon ...... 773 1533. New army ambulance-wagon ...... 774 1534. Halstead’s hand-litter . . . . . .774 1535. Regulation hospital-tent . . . . . . .774 1536. Autenreith medicine-wagon ... . 777 Note.—The thanks of the editor and publishers are due to the proprietors of “'The Sanitary Engineer” for their courteous permission to use several illustrations from “ Billings on Ventila- tion.” THE INTERNATIONAL ENCYCLOPAEDIA OF SURGERY. INJURIES AND DISEASES OF THE (ESOPHAGUS. BY J. SOLIS-COHEN, M IX, PROFESSOR OP DISEASES OF THE THROAT AND CHEST IN THE PHILADELPHIA POLYCLINIC, HONOBABY PEOFESSOE OP LARYNGOLOGY IN THE JEFFEESON MEDICAL COLLEGE, PHYSICIAN TO THE GERMAN HOSPITAL, ETC. Wounds and Ruptures of the (Esophagus. Wounds of the (Esophagus.—The whole of the oesophagus is so well pro- tected from ordinary injury that unintentional wounds of any portion of the healthy organ are quite rare. They occur in the usual varieties of contused, incised, punctured, lacerated, and gunshot wounds. They may be superficial or penetrating. They may interest the cervical or the thoracic portion of the oesophagus. Wounds in the thoracic portion are almost exclusively punctured or lacerated in character, the depth of that portion of the organ greatly protecting it from contused and incised wounds. The lesion may he produced by an injury from without or by an injury from within. Wounds from without occur most frequently as the result of military encounters, duels, attempts at assassination, or attempts at suicide. Wounds from within are produced most frequently by pointed, sharp, or jagged foreign bodies impacted in the tube. In several cases severe wounds have been received by jugglers in the feat of sword-swallowing. Wounds from without are most frequently associated with wounds of the air-passages, lungs, or great cervical bloodvessels. For anatomical reasons they are much more frequent in the cervical than in the thoracic portion of the oesophagus. Wounds from within are more frequently isolated than associated with wounds of other structures. Nevertheless, the peculiarity of circumstance may produce an unusual com- plication, as in the cases of three sword-swallowers. The one violently pushed the blunt end of his sword past an obstacle felt in his oesophagus, and it penetrated the anterior wall of the gullet and passed into the pericardium. A second pierced the pericardium in an attempt to swallow a 2 INJURIES AND DISEASES OF THE (ESOPHAGUS. long, blunt, juggler’s knife.1 In the third ease the weapon broke in the gullet, a portion remaining impacted. Attempts were made to push it into the stomach and to dislodge it by emetics, the result being to cause lacera- tion of the stomach by the point, and of the oesophagus by the jagged end of the fragment.2 Wounds or other injuries of the aorta or other great vessels, of the pleura, lungs, trachea, or bronchi, sometimes occur as sequelae of internal wounds of the oesophagus, originally isolated. Wounds from without.—Apart from the operative, incised wounds of oesopha- gotomy and oesophagostomy, incised wounds of the oesophagus—transverse, longitudinal, triangular, and irregular—have been produced by suicidal and murderous cuts, by cuts from weapons in the hands of antagonists and assailants, and by cuts from the surgical knife in awkward attempts at tracheotomy, whether in one stroke or by dissection. Punctured wounds have been due to the points of swords, bayonets, foils, and daggers, and to the horn of the ox.3 Lacerated and gunshot wounds have been chiefly due to injuries by missiles discharged from fire-arms large or small. As illus- trating the rarity of wounds of the oesophagus from external injury without involvement of the air-passages, a special investigation by Horteloup4 elicited but four recorded examples.5 Incised wounds of the oesophagus associated with wounds of the air-passages6 are more common, especially in cases of cut-throat; but many examples cited in that connection are in reality wounds of the pharynx, that cavity having been entered above the level of the anterior wall of the gullet. Incised wounds may be longitudinal, oblique, or transverse. Transverse or nearly transverse wounds sometimes implicate almost the entire circumference of the oesophagus, and occasionally sever the tube completely.7 Punctured, lacerated, and gunshot wounds pre- sent the physical features common to such injuries. Punctured wounds sometimes penetrate both walls of the oesophagus. Wounds of internal origin occur in the varieties of incised, punctured, and lacerated wounds. They may be intentional, as in the operations for internal cesophagotomy. They may be traumatic in origin, or the result of patho- logical processes, or they may be of combined origin. Accidental wounds are most frequently caused by sharp-pointed or irregular foreign bodies, such as nails, spicula of bone, dental plates, and the like ; but are sometimes the result of injury by weapons introduced accidentally or voluntarily. Punctured wounds may interest either the anterior or the posterior wall. The posterior wall has been penetrated by the point of a foil8 which entered the mouth and lacerated the soft palate. The patient recovered.9 The ante- rior wall has been penetrated by the point of the sword of a sword-swallower, the pericardium having been pierced as well.10 Lacerated wounds may be 1 Parkes, Trans. Path. Soc. Loud., 1848-9. A case of Dr. A. T. Thompson’s, cited by Walshe (Diseases of the Lungs, Heart, and Aorta, 2d ed., p. 201. London, 1854). 2 Gussenbauer, Wien. med. Blatter, 20 und 27 Dec. 1883 ; London Medical Record, April, 1884, p. 151. 3 Case cited by Knott (Pathology of (Esophagus, p. 151. Dublin, 1878); Dr. W. D. Hart- man, of West Chester, Pa., records a case of punctured wound of the oesophagus from the horn of a wild bullock. (Medical World, May, 1885, p. 171.) 4 Plaies du Larynx, de la Trachge, et de l’CEsophage. Paris, 1869. 5 Larrey, Clinique Chirurgicale, t. ii. p. 158. Paris, 1829 (in this instance the lung was wounded) ; Payen, case narrated by Boyer (Traite des Maladies Chirurgicales, t. vii. p. 279. Paris, 1831) ; Dupuytren, Blessures par Armes de Guerre, t. ii. p. 334. 6 Par6, (Euvres Completes (edition de Malgaigne), t. ii. p. 93. Paris, 1840. 7 Pare, op. cit. 8 Levillain, Journ. Univ. de Med., p. 238, 1820; cited by Mondiere (Arch. Gen. de'Med., 2e Serie, t. ii.), and by Mackenzie (Manual of Diseases of the Throat and Nose, vol. ii. p. 183. London, 1884). 9 A nearly similar case, recorded by Wilmer (Cases and Remarks on Surgery, p. 86) and cited by Knott (op. cit., p. 149, Dublin, 1778), terminated fatally. 10 Parkes, loc. cit. ; Walshe, op. cit. (Dr. A. T. Thompson’s case, already referred to.) WOUNDS AND RUPTURES OF THE (ESOPHAGUS. 3 produced by missiles from fire-arms, by jagged foreign bodies, by incautious use of instruments for exploration and for extraction, by articles inserted for juggling or for suicidal purposes, and by severe efforts at vomiting in sub- jects with diseases of the oesophagus, or with impacted foreign bodies.1 The pleural sac, the pericardium, and even denser tissues are sometimes lace- rated. Thus an instance of fracture of the fourth rib at the vertebral articu- lation is reported, in the case of an insane patient who introduced the handle of an explosive toy into the oesophagus.2 When the walls of the gullet are diseased, perforations or lacerated wounds are sometimes made with bougies and stomach tubes.3 Whether preceded or not by contused, punctured, or lacerated wounds, ulcerations of the walls of the oesophagus may result from inflammation set up by impacted or incarcerated foreign bodies. As a con- sequence, there may be penetration into the mediastinum, the trachea or bronchi, the pleura or lung, the aorta or other great bloodvessel, the peri- cardium, or even the heart.4 Indeed, a case has been recorded in which a fish bone had passed through the intervertebral substance of an infant, and had wounded the spinal cord ;5 and one in which caries of the cervical spine was produced by a nail which had penetrated the oesophagus.6 Symptoms of (Esophageal Wounds.—In penetrating wounds from without, the symptoms in their totality comprise pain in the region of the oesophagus or stomach, or in the direction of the wound through the neck and thorax, with nervousness, anxiety, dyspnoea, hiccough, thirst, and, if there be an opening at all large, external escape of air, mucus, blood, food, and drink. There may, however, be no characteristic symptoms whatever, and the nature of the lesion may remain unrevealed until examination after death.7 The special symptoms of contused wounds are said to be pain in swallowing, tumefaction of the overlying tissues, sometimes to such a degree as to impede deglutition and even respiration, with probably symptoms at a later period of suppurative inflammation and abscess. The symptoms of wounds from within comprise pain, cough, and dyspnoea, and the vomiting of mucus, blood, and food. Penetrating wounds produce additional symptoms. Thus, penetration into the mediastinum will occasion symptoms of collapse, and subsequently of suppurative inflammation of the connective tissue, and perhaps of pneu- monia ; penetration of the pleura will give rise to pleuritis with probable empyema, to pneumothorax, or to pneumonia; penetration of the peri- cardium, to pericarditis; of the bloodvessels, to hemorrhage; of the trachea or bronchi, to cough and expectoration of blood, mucus, saliva, and food. Diagnosis.—The history of the accident, the location and direction of the external wound, and the external escape of mucus, blood, saliva, food, or drink, will indicate the nature of the lesion in most instances of wound from without. It must be thoroughly ascertained, however, that such matters do not emerge from a wounded larynx or trachea. There may not be any escape of food passing along the oesophagus, and then the diagnosis cannot be made.8 It is believed that minute punctured wounds often elude detection in this way.9 Hsematemesis, however, following a penetrating wound of the neck or of the thorax, should be regarded as an indication of wound of the oesophagus. Superficial external wounds, giving rise to no characteristic symptoms, are difficult of diagnosis. Longitudinal penetrating wounds may 1 Gussenbauer, case cited by Carpenter (Medical News, July 7, 1883, p. 25). A broken blade in the oesophagus of a sword-swallower. 2 Guise, case cited by Horteloup (op. cit., p. 24). 3 Shaun, Brit. Med. Jour., Nov. 3, 1873. 4 Andrew, Lancet, 1860. 6 Mackenzie, op. cit., vol. ii. p. 192. 6 Steven, Brit. Med. Jour., Dec. 10, 1870. 7 Dupuytren, case cited by Horteloup (op. cit.). 8 Dupuytren’s case already cited. 8 Horteloup, op. cit., p. 19. 4 INJURIES AND DISEASES OF THE (ESOPHAGUS. elude detection when their edges remain in contact. Gaping transverse wounds speak for themselves. Violent thirst1 and continuous hiccough2 are said to be especially significant of wounds of the oesophagus. Contused wounds are difficult of diagnosis. Their existence is inferred from the evi- dence of serious injury of the overlying parts, coexisting with pain in the oesophagus, and with dysphagia and hiccough. In wounds from within, the diagnosis will depend on the history of a foreign body,; the presence of blood in matters vomited or regurgitated, dysphagia, thirst, and localized pain. Prognosis.—The natural history of operative wounds of the oesophagus, in both external and internal oesopliagotomy, indicates that but little danger is to be apprehended from a clean-cut longitudinal wound implicating no other important structure. Cicatrization may be expected in from five to eight days. Punctured wounds, and minute incised wounds, may be expected to unite in from three to four days. The arrangement of the muscular fibres of the oesophagus, in longitudinal and circular layers, favors muscular contraction in wounds of this character.3 Transverse wounds present a much graver prognosis on account of the greater liability that matters may escape from the oesophagus into the surrounding tissues, and thereby induce death by suffocation or by inflammatory processes. The edges of a transverse wound may be so widely separated *as to preclude the possibility of approximation,4 especially when the organ has been severed in its entire circumference. Even after recovery from such a complete severance, the edges of the result- ing fistula may remain so wide asunder as to necessitate permanent alimenta- tion by means of a tube passed through the opening.5 The same result follows lacerated bullet wounds,6 or other wounds which have destroyed integral portions of the oesophageal walls. The prospect is much the best in wounds from without, when the wound is slight, longitudinal in direction, situated high up, and unassociated with wounds of the air-tubes or of the great blood- vessels. Suicidal wounds implicating the bloodvessels are usually fatal by hemorrhage. When not immediately fatal, such wounds render the prognosis graver on account of the consequent debility produced by the hemorrhage. Wounds in the thoracic portion of the oesophagus are so inaccessible to sur- gical manipulation that the prognosis is rendered very grave indeed. In an undetailed mention by Mondiere of five personal observations7 of wounds in this region, recovery is reported in but one instance. Recovery from incised wounds of suicidal origin is not infrequent. Small punctured wounds are said to cicatrize spontaneously with great rapidity.8 Recovery has ensued from a severe bayonet wound9 in which the weapon had passed between the third and fourth ribs, wounding the lung, of course, in its transit. The prognosis does not seem to be particularly grave in gunshot wounds, even though the air-passage be implicated. In the tabular statement of a series of gunshot wounds of the neck occurring in the United States,10 it is to be noted that there were eight cases of wound injuring the oesophagus without injury to the air passages, with four recoveries; two cases of wound injuring the trachea and oesophagus, both fatal; one case of wound injuring the 1 Larrey, Clinique Chirurgicale, t. ii. p. 155. Paris, 1829. 2 Mondiere, loc. cit. 8 Larrey, op. cit., t. ii. p. 157. 4 Parg, op. cit. 5 Trion, case cited by Boulin (Sur les Plaies de l’(Esophage, p. 15. These de Paris, 1828), and by Knott (op. cit., p. 150) ; Henschen, Upsala Lakareforenings Forhandlingar, 1874, and London Med. Record, August 16, 1875. 6 Mondiere, op. cit. 7 Ibid. 8 Boulin, op. cit., p. 19. 8 Payen, case reported by Boyer (op. cit., t. vii. p. 279) ; cited by Boulin (op. cit., p. 15) ; by Nelaton (Elements de Pathologie Chirurgicale, t. iii. p. 477. Paris, 1854) ; by Horteloup (op. cit.) ; and by others. 10 Medical and Surgical History of the War of the Rebellion, Part III., Surgical Volume, p. 688. Washington, 1883. WOUNDS AND RUPTURES OF THE Q5S0PHAGUS. cricoid cartilage and oesophagus, with recovery ;* and one case of wound in- volving the pharynx and oesophagus, likewise with recovery. Internal hemor- rhage is given as the cause of death in one case of penetrating wound of the oesophagus. In the case of recovery after wound of the pharynx and oeso- phagus, loss of voice, difficulty of breathing, and constant cough, were noted as sequelae present seven years after receipt of the injury. A buckshot was still in the left side of the neck at the date of report. In the case of recovery after a penetrating wound of the cricoid cartilage, partial aphonia was noted as existing a few days before the patient was returned to duty. Cough, dyspnoea, and impairment of voice, therefore, are liable to be produced in injuries of this kind which may immediately or subsequently compromise the integrity of the fibres of the pneumogastric and inferior laryngeal nerves. Other recoveries have been noted in gunshot wounds, both in military2 and in civil practice.3 The difficulty of obtaining nourishment in a case of external wound of the oesophagus, may be so great as to exhaust the strength in a short time. Death has been recorded at thirty-six hours,4 but it is more frequent after the lapse of several days.5 A patient died suffocated and in convulsions on the seventh day, in a case which had been progressing favorably, the cause being the unauthorized deglutition of large morsels of bread and meat, and of a quantity of wine, which forced open a cicatrizing wound, so that large quantities of wine and water, and some of the solid food, escaped into the thoracic cavity.6 In wounds from within, the prognosis will depend upon the character of the lesion in the oesophagus, and upon that of any accompanying .lesions, primary or consecutive. Lacerated wounds are likely to be much more superficial than punctured or incised wounds, and thus offer a favorable prognosis upon withdrawal of the foreign body, provided that the wound has not been extensive. Punctured wounds are much less favorable. They are sometimes associated with punctured wounds of large bloodvessels, and are thus rendered especially serious. Death by hemorrhage may ensue from an internal wound by any sharp or pointed body, even a bone.7 Perforating wounds are not infrequently fatal, whether produced by stomach tube,8 bougie, or impacted foreign body—such as a dental plate9 or bone—even although there may not have been any evidence of its impaction.10 Penetration into the mediastinum, with the escape of fluids, is indicated by collapse, and is almost necessarily fatal. The same grave prognosis may be pronounced in cases of penetration into pericardium, pleura, lung, or air- passages, death being imminent from suffocation, or as the result of inflam- matory and eventually of suppurative processes set up in the invaded tissues. Treatment.—The treatment of wounds of the oesophagus must be con- ducted on the general principles of surgery, adapted to the requirements of the individual case. In wounds of external origin it is allowable, if not actually desirable, to unite the edges of the wound by suture, if the edges can be kept properly approximated. This is quite easy in accessible longitudinal wounds, in which, according to experiments on dogs11 and the results after oesophagotomy, union may be expected from the fifth to the eighth day. 1 Ibid., Part I., Surgical Volume, p. 408. Washington, 1870. 2 Baudens, case cited by Knott (op. cit., p. 152) ; Mondi6r,e, op. cit. ; Horteloup, op. cit., p. 24. 3 Charles, Brit. Med. Journ., March 31, 1883. 4 Etienne, Considerations G6n6rales sur les Causes qui gSnent ou empeclient la Deglutition, p. 8. These de Paris, 1806 ; cited by Mackenzie (op. cit., vol. ii. p. 183). 4 In Dupuytren’s case, due to a stab, death occurred on the seventh day. 6 Larrey, op. cit., t. ii. p. 162. 7 Annandale, Edinburgh Med. Journ., April, 1872. 8 Gaz. Hebd., 26 Sept. 1873 ; Phila. Med. Times, Oct. 25, 1873. 8 Smith, New York Med. Times, Sept. 1873. 10 Shaun, Brit. Med. Journ., Nov. 3, 1873. u Guattani, Mem. de l’Acad. de Chir., t. iii. p. 351; Jobert, case cited by Boulin (op. cit., p. 18). INJURIES AND DISEASES OF THE (ESOPHAGUS. Interrupted sutures should be used, and their ends should be cut close oft', so that the thread may find its way into the interior of the tube and be dis- charged with the contents of the bowel. In some cases, however, it may be requisite to avoid sutures, in order that the opening may be kept patulous for the introduction of a tube through which nourishment can be injected. In case of transverse wounds, whether sutured or not, the head should be bound down towards the chest.,1 to favor cicatrization. If the wound be closed by suture, attempts may be made at once to supply nourishment by the mouth. Should the wound be allowed to cica- trize without interference, it is deemed allowable to begin cautious adminis- tration of nourishment by the mouth as soon as cicatrization in its entire extent begins to be steadily progressive, say after the fifth or sixth day in longitudinal and in small transverse and punctured wounds. Under either condition, food should not be administered at first in larger quantities than a teaspoonful or so at a time. Should any food escape by the wound under either condition, resort must be had to rectal alimentation until such escape is no longer imminent. The use' of tubes passed through the mouth is generally considered injurious, whether employed shortly after the receipt of the injury, when cough and retching may enlarge the wound, or after cicatri- zation has begun, when the same effects may reopen it,2 Meanwhile, thirst is to be allayed, as well as may be, by injecting water into the rectum, by periodically sponging the surface of the body, and by moistening the lips, tongue, and gums at frequent intervals with cold water, simple or acidulated, with the juice of oranges or other fruits, with effervescing lozenges, or with pellets of ice. Cold, emollient baths, and continuous cataplasms over the stomach, have been highly recommended for the same purpose.3 Great care is necessary in returning to ordinary diet, lest the cicatrix suffer rupture, a condition under which food may escape into the thoracic cavity.4 It does not appear that stricture of the oesophagus is a likely sequel to a wound. [Fistulse, however, sometimes remain. They are said to heal promptly under pressure aided by mild stimulation of their edges with the actual cautery,5 solid silver nitrate, or cupric sulphate. Plastic operations are not deemed advisable. In the treatment of wounds from within, neither solid food nor liquid should be allowed by the mouth until several days have elapsed. Then fluids may be cautiously administered in gradually increasing quantities, the return to ordinary diet being quite gradual. Meanwhile, supplementary nourishment should be supplied by enemata. Thirst is to be allayed by enemata, by fragments of ice in the mouth, and by periodical sponging of the body ; and pain is to be subdued by the administration of anodynes, subcutaneously or by the rectum. The constitutional manifestations in all varieties of wounds are to be met on general therapeutic principles. Rupture of the (Esophagus.—Rupture of the oesophagus is an accident of rare occurrence. It takes place during violent retching and vomiting, usu- ally during a hearty meal or after it. Thirteen cases tabulated by Macken- zie,6 and one since reported by Purslow,7 probably comprise the entire record. The rupture is most apt to take place just above the diaphragm. It may take place as low down as the cardia, however, and may even extend into the stomach.8 The rent is usually longitudinal, only a single example of trans- 1 See Yol. Y. p. 238, supra. * Cooper, Lectures on Surgery, vol. ii. 3 Larrey : op. cit., p. 156. 4 Larrey, case cited. 6 Baudens’s case, already cited. 6 Op. cit., vol. ii. p. 178. 7 British Med. Journ., March 28, 1885, p. 658 (an infant aged eleven months). 8 Grammatzki, Ueber die Rupturen der Speiserohre. Konigsberg, 1867 ; cited by Mackenzie. FOREIGN BODIES IN THE (ESOPHAGUS. 7 verse rupture1 being on record. The length of the tear in recorded cases varied from half a centimetre to five centimetres. The mucous coat often suffers to a greater extent than the muscular and fibrous coats. The edges are usually clean cut. In six out of the fourteen cases alluded to, the left pleura was opened, and in one2 of these the diaphragm was ruptured in addi- tion. The contents of the oesophagus, food and blood, may be discharged into the pleura when that cavity is penetrated ; otherwise they are discharged into the mediastinum. The immediate cause of rupture is violent vomiting, when the stomach is well filled, whether the vomiting be spontaneous or produced by emetics. In two instances it has followed voluntary efforts to dislodge a foreign body. Al- though the healthy oesophagus has occasionally undergone rupture,3 the acci- dent usually occurs in the diseased organ,and especially in intemperate subjects.4 Symptoms.—The symptoms are sudden acute pain in the oesophageal region during vomiting, with the sense of something having given way inside, hsema- temesis, great distress and anxiety, emphysema of the neck, and rapid collapse from the shock. The emphysema may extend beyond the neck, over the trunk, and even over the greater portion of the body. Diagnosis.—This seems to be very obscure despite the characteristic features of the symptoms, the nature of the lesion having been but once recognized during life.5 Prognosis.—The prognosis is unfavorable. The patients die within a few hours from collapse, usually in from four to eighteen hours. One patient has been known to survive twenty-four hours, one fifty hours, and one seven days and a half.6 Treatment.—The fatal character of the accident shows that treatment is useless, except to relieve suffering. Rectal alimentation and stimulation seem indicated, with the hypodermic use of anodynes and diffusible stimu- lants, and the local use of ice to relieve thirst. The body and the injured organ should be kept as completely at rest as possible. Foreign Bodies in the (Esophagus. Foreign bodies often become temporarily lodged in the (esophagus, and frequently become impacted in the organ; usually singly, sometimes in numbers. Although in most instances the result of accident in deglutition, the lodgment may be intentional, whether the foreign body be introduced in jugglery; or swallowed in concealment of coins, jewels, or dispatches; or inserted or swallowed as a means of suicide. Matters which are vomited occasionally become lodged in the oesophagus, and, exceptionally, missiles from firearms. The objects most frequently lodged in the oesophagus are alimentary boluses, chiefly fragments of bone, of meat, or of vegetable, masticated or unmasticated, which have been swallowed inadvertently, and often matters swallowed in masses too large for descent by ordinary peristalsis. Extraneous bodies of the most varied character have become lodged in the oesophagus, such as coins, fish-hooks, pins, tacks, nails, blades, knives, forks, spoons, keys and key-rings, beads, sponges, dental plates with false teeth, palate-obturators, seat-worms, 1 Boerhaave’s case. 2 Williams, Trans. Path. Soc. London, vol. i. p. 151. 8 Boerhaave, Van Swieten’s Commentaries, vol. ii. p. 102. Edinburgh, 1786 ; Oppolzer, Vorlesungen iiber specielle Patliologie und Therapie, Bd. ii. Lief. 1, S. 151. Erlangen, 1872 ; Fitz, Am. Jour. Med. Sciences, Jan. 1877. 4 Charles, Dublin Jour. Med. Sci., p. 311, Nov. 1870. Cites in addition Dryden, Medical Commentaries, vol. ii. Decade 2, 1788, and gives several other references. 5 Meyer, Med. Vereinszeitung v. Preussen. Nos. 39, 40, und 41. 1858; cited by Mackenzie. 6 Fitz, case of Allen (Am. Jour. Med. Sci., Jan. 1,877, p. 17). 8 INJURIES AND DISEASES OF THE (ESOPHAGUS. tapeworms, round worms, leeches, living fish, detached carious bones,1 hydatid cysts, and what not. The subjoined table, from Poulet,2 with a few additions, shows the varieties of foreign body which have been encountered in the oesophagus:—■ Table of Foreign Bodies in the (Esophagus. Animate Leeches, fishes, salamanders, mice, eels, frogs, ascarides lumbricoides, tasnias, hydatids. Beef-bones, fish-bones, other food bones, nasal bones, vertebral sequestra, pieces of meat and vegetable, fruits and kernels, potato, pieces of wood and grain, lung, egg, hair, cork, comb, sponge, spindle, dominoes, violin-pegs, comfits, cake, flute-stopper, teeth, dental plates, masses of rags, feathers, tobacco. Organic. . Pins, needles, pens, coins, flat and round bodies (child’s saucer, medals), toys, dental plates, arti- ficial teeth (metallic), palate-obturator, knives, scissors, compass, razors, blades, sword-blades, forks, spoons, rings, buttons, buckles, keys, peb- bles, glass, vials, pieces of stone, brick, thermo- meters, bullets, bullets from projectiles, bars, pieces of pots, eyeglasses, butchers’ hone, iron file, brass chains, lead seals, tubes and pipes, diamonds, table-rollers, sucking bottle, beads, sounds, plaster, padlocks, fish-hooks, barbed wire, meat-skewers, tin tag from tobacco. Inanimate . Inorganic. . Irregular fragments of bone (Fig. 1296) may be regarded as the most likely substances to become impacted in the oesophagus. Theoretically, certain conditions predispose to the lodgment of foreign bodies in the gullet. Among these may be es- pecially enumerated loss of teeth; paralysis and spasm of the muscles of the face and lips, or of the tongue, palate, pharynx, and oeso- phagus ; inflammatory affections and neoplasms of the mouth, ton- sils, pharynx, oesophagus, epiglot- tis, larynx, and neck; enlarged cervical glands; goitre ; strictures and organic degenerations of the oesophagus. The accident is some- times due to imperfect cooking of food, or to failure to remove frag- ments of bone from soups, stews, and other dishes. False teeth some- times become detached in sleep, dislodged in eating, or dislodged while the individual is under the influence of an anaesthetic, and under all of these conditions have entered the oesophagus and become impacted there. Fig. 1296. Specimens of irregular fragments of bone lodged In the oesophagus. Natural size. Museum of Val-de-Grace. (After Poulet.) 1 Langenbeck, Memorabilien, Heft 1, 1877; New York Med. Journ., July, 1877, p. 99 k Op. cit., vol. i. p. 71. FOREIGN BODIES IN THE (ESOPHAGUS. 9 In patients with stricture of the oesophagus, want of care in swallowing only proper morsels of food, or carelessness in putting improper things into the mouth, will give rise to the accident. Impaction is the more serious by reason of the stricture.1 Points of Lodgment.—There being three anatomical regions at which the calibre of the oesophagus is normally smaller than elsewhere, there are that many points at which lodgment is the more likely to take place. These points are: (1) at the pharyngeal extremity of the tube: (2) at the point where the oesophagus is crossed by the left primitive bronchus; and (3) at the point where it passes through the opening in the diaphragm, just above the expan- sion into the cardiac extremity. Spiculated and irregularly shaped sub- stances are apt to become entangled or partially imbedded in the mucous membrane, and may become impacted at any portion of the oesophagus. • Effects, Immediate and Consecutive.—Sudden death by suffocation may ensue by compression of the trachea, by blocking the outlet of the air-passages when the foreign body is partly lodged in the pharynx, or by spasm of the glottis, due to irritation. Death occurring in this manner has sometimes been mis- taken for death by cerebral apoplexy. Laceration by jagged objects may produce hsematemesis. Prolonged detention of a foreign body may some- times result in dilatation of the oesophagus, annular or sacculated. Sometimes the foreign body becomes permanently lodged in the diverticulum.2 Foreign bodies sometimes remain for years in the oesophagus and cause comparatively little suffering. Sometimes, as with needles and pins, they work their way in safety through the different tissues to the surface of the body, even to the most unlikely regions.3 In some instances, when unheard of, they probably become encysted. In others they occasion abscesses at various portions of the surface, with the contents of which they are discharged, or through the openings of which they are extracted. They may escape through an abscess of the neck.4 Sometimes an oesophageal abscess, due to inflammation excited by a foreign body, communicates with the trachea, the bronchi, the pleura, the lung, the mediastinum, or the pericardium. Indigestible foreign bodies, propelled into the stomach, most frequently pass through the intestinal tract and are discharged by defecation. Some of them excite ulceration in the stomach, or in some portion of the intestine, and are discharged through an abscess bursting at the exterior of the body. They may thus escape at the epigastrium,5 at the extremity of the rectum, or elsewhere. In the valuable memoir of Ildvin,6 an instance is related in which three different substances, swallowed by the same individual, emerged through as many abscesses, at the right and left hypochondria, and at the lumbar region, respectively. Fish-bones are liable to produce serious multiple lesions. Thus, sudden death has been reported in a case of impaction in the oesophagus of a fish- bone which penetrated the stomach, the diaphragm, the pericardium, the posterior surface of the heart, the interventricular septum, and the left coro- nary vein;7 and of a fish-bone which penetrated the oesophagus, diaphragm, and pericardium, and wounded the surface of the left ventricle.8 Wound of 1 Menzel, Arch. f. klin. Chir., Bd. xiii. S. 678. 1872; Brit. Med. Journ., Aug. 31, 1872, p. 243. 2 Monti, Jahrb. fur Kinderlieilkunde, 20 Oct. 1875. 3 Cohen, Diseases of the Throat, etc., p. 319. New York, 1879. 4 Fortune, case cited by Poulet. 6 Cripps, Brit. Med. Journ., March 22, 1884, p. 561. 6 M6moire sur les corps etrangers de l’cesophage. Paris, 1743 ; de l’Academie Royale de Chirurgie, t. i. p. 561. Paris, 1761. 7 Andrews, Lancet, Aug. 25, 1860, p. 186. 8 Eve, Brit. Med. Journ., April 3, 1880, p. 517. 10 INJURIES AND DISEASES OF THE (ESOPHAGUS. the spinal cord1 has been discovered, after death, to have been due to penetra- tion by a fish-bone through the intervertebral substance. Symptoms.—The immediate symptoms, varying with the nature of the foreign substance, the position it occupies, and the condition of the oesopha- gus, are insignificant in some instances, and markedly characteristic in others. Sometimes large coins, bones, and other bodies remain impacted in such a position as to give no evidence of their presence, until sudden death by hemorrhage leads to a post-mortem examination, which reveals erosion into the aorta2 or some other important vessel.3 The immediate symptoms comprise in their totality: dyspnoea, sometimes suftbcative; dys- phagia or apliagia; dysphonia or aphonia; pain in the neck, thorax, or stomach; nervousness, dread of death from the accident; spasm of the oesophagus, of the air-passages, or even convulsive or tetanic spasm of the lower jaw and of the extremities; retching, vomiting, expectoration, and hemorrhage. The functional symptoms usually cease upon spontaneous ex- pulsion of the foreign body, or upon its passage into the stomach, or upon its impaction in some portion of the gullet. Subsequent to the sensory and spasmodic symptoms, others are developed, in cases of long or permanent retention, indicative of inflammation, suppuration, ulceration, and perforation of the oesophagus. Finally, there may be insomnia, innutrition, pyrexia, marasmus, hectic, and death by asthenia. Certain nervous symptoms some- times remain after expulsion of the foreign body, the result of its previous pressure, and torment the patient with fears that another foreign body is lodged in the oesophagus. A small, smooth substance may produce only a vague sense of discomfort, indicative of its detention in some defined or undefined portion of the oesopha- gus. The sensations of patients are not reliable guides to the locations of foreign bodies. A large body provokes retching, and is often ejected thereby, especially when of some regular form. Spiculated bodies become sometimes nailed, as it were, to the mucous membrane by the act of vomiting. A pin, tack, knife-blade, or the like, will he apt to give rise to sensations of pricking, and sometimes will occasion hemorrhage. Large bodies present a mechani- cal obstacle to the passage of solid food, and sharp ones produce pain in de- glutition. When respiration is mechanically impeded, the dyspnoea is usually greater in inspiration; when disturbed by nervous influence, the dyspnoea is usually equally manifested in expiration also. Diagnosis.—The first element in the diagnosis is the history preceding the immediate symptoms. This may be wanting in children, lunatics, and determined suicides. Inspection through the mouth is rarely of service, even though an cesophagoscope be employed. With the aid of oesophagoscopy, however, a small, flat piece of hone has been discovered two inches below the cricoid cartilage, on the anterior wall of the oesophagus.4 External palpation sometimes detects an impacted body high up. Large bodies sometimes cause suflicient projection in the left cervical region to attract attention by the deformity which they produce. Stability of position is almost invariable. In cases of fancied bodies in the oesophagus, the alleged position of the obstacle is usually varied from time to time. Digital exploration through the mouth, if the finger be long enough, is some- times suflicient to detect a foreign body lodged high up. Care must be taken not to mistake the tense edge of the pharyngo-epiglottic ligament for the edge of a fish-hone, needle, pin, or other substance. Palpation with a 1 Mackenzie, op. cit., vol. ii. p. 192. 2 B6gin, case cited by Poulet (op. cit., vol. i. p. 75). 8 Erichsen, Science and Art of Surgery, vol. i. p 189 4 Mackenzie, op. cit., vol. ii. p. 193. FOREIGN BODIES IN THE (ESOPHAGUS. 11 sound, catheter, or bougie is usually requisite to detect the position of the foreign body, and to determine its density, if unknown. This manipulation, however, is not always practicable. One of the best appliances for this pur- pose is the sound of Langenbeck: a flexible, whalebone rod, tipped with a smooth, polished, metallic knob. The knob as it strikes a hard foreign body produces a click. The sounds most in use have ivory knobs. Knobs of vary- ing sizes should be supplied with each rod, firmly attachable by a screw. A special resonator has been devised by Duplay, and perfected by Collin, pro- vided with a sounding-box and an ear-tube (Fig. 1297); but such an Fig. 1297. Duplay’s resonator. instrument of precision can rarely be required, although an instance has been recorded in which it permitted the recognition of a coin which could not be otherwise detected. Any instrument used in exploration should be marked in a graduated scale, so as to indicate the precise relations of a foreign body with the walls of the oesophagus. The sound, when possible, should be carried to the stomach. If no obstacle be encountered, it may be inferred, as a rule, that the foreign body has passed into the stomach, though the inference is not always reliable. The most careful sounding will some- times fail to detect the presence of a foreign body known to be in the oeso- phagus. Collections of mucus or of moist food around the foreign body, may cause the searcher to slip past it without detection. If the foreign body be of such a shape as to become closely applied to the wall of the oesophagus, the sound may slip by without encountering it.1 Fragments of bone may escape detection in this manner.2 In a case in which the fragment of a sword, broken off in the oesophagus, could not be detected in the gullet of a juggler, it was found, upon post- mortem examination after gastrotomy, that the fragment had become con- cealed behind a fold of injured membrane in which it had become caught, probably during vomiting in attempts at expulsion by emesis.3 Should ex- ploration of the oesophagus be impracticable without anaesthesia, the manipu- lations must be made with the patient recumbent. This is readily done by supporting the head a little below the level of the table or couch upon which the patient lies, thus bringing mouth, pharynx, and oesophagus into the same plane. Under other circumstances, the exploration is best made with the patient in the sitting posture, the head being well thrown back so as to 1 Case of English half-penny applied against anterior wall. Marston, Brit. Med. Journ., March 4, 1882, p. 305. (Welch’s case.) 2 Legouest, case cited by Michel (Diet. Encyclopedique des Sciences M4dicales, Art. (Esophage, p. 515). 3 Grussenbauer, Wien. med. Blatter, 20 und 27 Dec. 1883 ; London Med. Record, April, 1884, p. 151. 12 INJURIES AND DISEASES OF TI1E (ESOPHAGUS. bring the axis of the mouth and pharynx as nearly as practicable in a direct line with that of the oesophagus. The mistake is sometimes made of attribu- ting dyspnoea to the presence of a foreign body in the air-passage, under which circumstances a fruitless tracheotomy has been occasionally performed, when the foreign body has been detected in the oesophagus on examination after death.1 Careful exploration of the oesophagus during life should prevent such a mistake. It is possible, also, that late symptoms of suffocation may be attributed wholly to prolonged disease of the air-passages, when really due to compression by a foreign body in the gullet.2 Prognosis.—It is only exceptionally that death by suffocation from pres- sure upon the air-passages ensues before surgical help can be procured. Death by laryngeal spasm3 sometimes occurs. The prognosis is favorable in the majority of cases in which prompt measures are taken to withdraw or displace the impacted foreign body. Any injury already sustained by the oesophagus, or inflicted upon the organ in the surgeon’s manipulations, will serve to render the prognosis proportionately more serious. The patient, having safely passed over the immediate danger, is kept under observation for a few days, during which he is treated on the principles laid down for the management of oesophagitis and wounds of the oesophagus of internal origin, when, if no manifestations of severe injury remain, recovery may be confidently anticipated. The prognosis is grave in cases of foreign body retained in the oesophagus for more than a few days, although such bodies sometimes remain appa- rently or actually quiescent for periods varying from days to many months4 or years. Inflammation, abscess, ulceration, and perforation of the oesophagus and of adjacent structures, are the sequels© to be apprehended. Death by abscess6 occurs in some instances. In others, a foreign body makes its way to the exterior through an abscess, leaving a fistula of the oesophagus. More frequently, however, the abscess closes on removal of the foreign body, whether the removal has been spontaneous or operative. Should the abscess or ulcera- tion be located anteriorly, perforation may take place into the trachea, when the escape of the foreign body into the air-tube may-be followed by imme- diate death from suffocation, or by slow death from exhaustion due to the resulting inflammatory processes. Should, however, the foreign body still remain in the oesophagus, a tracheo-cesophageal or broncho-oesophageal fistula will be established, with all the dangers due to a wound of the oesophagus. Serious hemorrhage may take place when the foreign substance becomes dislodged by ulceration, though, as a rule, recovery is prompt after such dis- lodgment. Sometimes stricture is produced as a result of cicatrization. Death by hemorrhage may occur in consequence of erosions communicating with the aorta6 (Fig. 1298), or with other important vessels.7 Such perfora- tions are not uncommon.8 They have occurred as early as the third day.9 1 Cases cited by Desault ((Euvres, t. ii. p. 261) ; by Poulet; by Roberts (Bryant’s Manual for the Practice of Surgery, p. 451. Phila. 1882). 2 Caucbois, Bull, de la Soc. Anatomique, p. 44, 1872 ; cited by Poulet. 3 Bryant (op. cit., p. 451) records an instance in a two-year old child, with a piece of pudding impacted in the oesophagus. 4 A set of teeth has been ejected fifteen months after the accident (Hayem, case cited by Poulet). 5 Vanderwarker, New York Med. Jour., April, 1871, p. 453. 6 Begin, case cited by Poulet (op. cit., vol. i. p. 75) ; retention for fourteen days of a six-franc piece at the level of the bifurcation of the bronchi. 7 Erichsen, Science and Art of Surgery, vol. i. ; piece of gutta percha which had remained imbedded in the oesophagus unsuspected for six months. 8 Lavacherie, MSmoire sur les corps etrangers de l’oesophage (Mfitn. de l’Acad. Royale de M6d. de Belgique, 1848) ; Martin, Corps etrangers de l’oesopliage, Th&se de Paris, 1868 ; Poulet, op. cit., vol. i p. 91 ; and numbers of individual observations. 8 Spry, Trans. Path. Soc. Lond., vol. iv. 1853. FOREIGN BODIES IN THE CESOPHAGUS. 13 Iii a compilation of thirty-three instances of slow perforation of blood- vessels by ulceration,1 it was found that the aorta had been pierced in seven- teen, the left carotid in three, the vena cava in two, and the right carotid, the inferior thyroid (Fig. 1299), an abnormal right subclavian, the pulmonary and the oesophageal arteries each in one, undetermined arteries in four, and the right coronary and demi-azygos veins each in one instance. Primary perforation of the bloodvessels is rare;2 the only two cases collected by the author of the compilation alluded to involved the aorta, and were caused re- spectively by a pointed bone and a needle,3 and in both of them death by hemorrhage occurred shortly after the receipt of the injury Fig. 1298. Fig. 1299 Perforation of the oesophagus and aorta by a flve-franc piece. (After Poulet, from Denon- villiers.) Perforation of Inferior thyroid artery by'bone. (After Poulet, from Pilate.) Among other causes of death noted from retained foreign bodies in the oesophagus, may be mentioned eclampsia ;4 purulent oesophagitis,5 even from so simple an object as a bead ;6 caries of the vertebrae7 secondary to cesopha- 1 Poulet, op. cit. 2 Collins, Dublin Quart. Jour. Med. Sci., vol. xix. p. 325. 1855. 8 Lancet, vol. ii. p. 789. 1877. * Larrey, Clinique Chirurgicale, t. ii. p. 164. Paris, 1829; Mayer, Deutsch Arch, fur klin. Med., Bd. xvii. S. 121 (cited by Poulet). 6 Gussenbauer, Wien. med. Woch., S. 20. 1876 ; ten days after oesophagotomy and removal oi a large, bent table-knife. 6 Billroth, Clinical Surgery, p. 132. London, 1881. 7 A case in the Journal General de M6decine, etc., t. xiii. 1807 (cited by Poulet) ; Mondiere, Arcli. Gen. de Med., 1830; Galais, Gaz. des Hop. No. 20. 1864; Arch. f. klin. Chir., Bd. viii. S. 482; Steven, Brit. Med. Jour., Dec. 10, 1870, p. 529. 14 INJUR1ES AND DISEASES OF THE (ESOPHAGUS. gitis; disease of the cord consequent upon ulceration of the intervertebral substance,1 or wound of the cord from penetration through the same ;2 and ulceration of the pericardium with fatal pericarditis.3 Should it be impossi- ble to remove a foreign body, or should a foreign body remain undetected, death may take place by starvation, the patient perhaps dying in delirium.4 Substances sometimes remain impacted for considerable periods, the patients becoming very much reduced.5 In some of these instances, the presence of the foreign body is not suspected or has been forgotten, and the patients are treated for paralysis of the oesophagus, for phthisis, and for other disorders usually productive of the special symptoms manifested. Treatment—Should expulsion not take place spontaneously, or by the usual methods of relief employed by the sufferer or the bystanders, such as swallowing water or additional solid food, striking the patient on the back, or provoking emesis by titillating the uvula or the pharynx, the services of the surgeon become necessary to dislodge the foreign body or to withdraw it. Should suffocation be threatened, prophylactic tracheotomy would be indi- cated in advance of attempts at interference with the foreign body. The character of the body and its location, as determined by the fingers or sound, will indicate the special method to be employed. Emesis may be tried in suitable cases. Should swallowing be impracticable, the medicament may be injected through a catheter, if such an instrument can be passed beyond the obstruction ;6 otherwise a hypodermic injection of apomorpliine-hydro- chlorate, one-tenth of a grain for an adult, may be tried. Emesis is not advis- able in the case of sharp or irregular bodies, as it is likely to encourage further impaction, and to drive the points of the body into the mucous membrane or even through the walls of the cesophagus. If a coin or similar substance be lodged high up, it is recommended to lay the individual prone upon a table with the head supported over the edge by an attendant, and then to intro- duce the finger far enough to drag the base of the tongue forward, in hope that the retching induced will force the substance out of the mouth. Should instrumental aid be requisite, the choice of appliance—hook, forceps, swollen sponge, or snare—will depend on the resources of the surgeon and on the character of the foreign body. Before the instrument is introduced into the gullet, it is well to let the patient swallow a little oil, if he can, or to pour some oil into the oesophagus, as recommended by Langenbeck. The instru- ment must be warmed, to prevent spasm; and oiled, so as to glide easily. Substances not far from the orifice may be seized with slender curved forceps, several varieties of which are here figured. (Figs. 1300-1303.) These instru- ments, carefully introduced, are used first as searchers and then as extractors. Linked or jointed forceps (Fig. 1304) are said to be particularly service- able. The revolving forceps of Gama (Fig. 1305), and the modification by Bryant,7 present peculiar facilities for grasping irregular bodies. It is some- 1 Ogle, Trans. Path. Soc. Lond., 1853. 2 Mackenzie, op. cit., vol. ii. p. 192. 3 Buist, Charleston Med. Journal, 1858; Conant, Am. Med. Times, p. 209. 1864. 4 Toussaint Martin, Recueil de Mem. de M6d. de Chir. etde Phar. Militaires, 2e S6rie, t. xxxvii. p. 260. 5 Hayem, case cited by Poulet (a set of false teeth were ejected during a fit of coughing, fifteen months after the accident) ; Evans, Lancet, July 19, 1879, p. 75 (impaction of gold plate and false teeth for upwards of two years, patient having lived in a state of semi-starvation; ejected by emesis) ; Gastellier, Journ. G6n. de Med., t. xxiii. p. 147, cited by Poulet (a coin remained lodged for six months, the patient sinking into the last stages of marasmus, and then dropped into the stomach ; the patient discharged a large amount of pus ; the foreign body was not evacuated until thirty-five years afterwards) ; Gauthier, case cited by Poulet (a bone discharged by vomiting after fourteen years’ impaction in the oesophagus, patient recovering entirely from protracted emaciation and simulated phthisis within six weeks after expulsion). 6 Habel, Arch. f. klin. Chirurgie, 1862; cited by Poulet. 7 Op. cit., p. 450. FOREIGN BODIES IN THE (ESOPHAGUS. 15 times more feasible to pass a blunt hook or similar contrivance beyond the object, and then draw it back into the pharynx. Petit ingeniously bent a Fig. 1300. Fig. 1301. Fig. 1302. loop of strong silver wire into a blunt hook, and then rolled it for some distance into a spiral twist. (Fig. 1306) This, or some similar improvised Bond’s forceps. Barge’s forceps. Cloquet’s toothed forceps. Fig. 1303. appliance can be readily insinuated beneath favorably located bodies so as to draw them out. Coins may sometimes be readily removed with Graefe’s oscillating or swivel-basket coin-catcher (Fig. 1307), or with a rigid coin- catcher of similar construction (Fig. 1308). A number of similar instruments have been devised, but it would serve little purpose to enumerate them. They are pictured in the catalogues of the instrument-makers. A sponge probang, if it can be passed beyond the obstacle, may be left in situ for a while, Casco’s forceps. INJURIES AND DISEASES OF THE (ESOPHAGUS. Fig. 1304. Mathien’s jointed forceps. Gama’s forceps. until the sponge becomes swollen by imbibition of moisture, and on its with- drawal in that condition it often sweeps the foreign body before it. Pins Fig. 1306. Fig. 1307. Fig. 1308. Petit’s hook. small spicula of bone, and the like, are often readily removed by the horse-hair parasol-snare and pro- bang (Fig. 1309), which is intro- duced closed, beyond the foreign body, often quite into the stomach, Graefe’s coin-catcher. Ring coin-catcher. FOREIGN BODIES IN THE ESOPHAGUS. 17 and is then opened by pulling on the handle as it is withdrawn, so as to sweep the oesophagus and entangle any object which it encounters. Similar instru- ments with bags of silk and gauze, or with rubber obturators to be inflated with air or water, and the like, have sometimes been employed These instruments Fig. 1309. Horse-hair parasol-snare. should he used with due gentleness. Should the cricoid cartilage present any obstruction to their withdrawal, they should be pressed firmly against the pos- terior wall of the pharynx. Accidents sometimes follow the use of rigid hooks and coin-catchers. The latter are sometimes tightly caught,1 so that they become additional foreign bodies, requiring special devices for their removal, and occasionally oesophagotomy.2 Occasionally their use precipitates a fatal result.3 The mucous membrane is sometimes bruised in the bite of forceps. Erosions take place with the use of either the sponge or the horse-hair probang. Substances too large for safe withdrawal in bulk, can sometimes be fractured in the forceps so as to be withdrawn or ejected piecemeal, or be passed on into the stomach by peristalsis. It is possible that an operation like that of lithotrity might be practised to crush or drill through hard impacted bodies, especially when beyond the ordinary resources of surgical art, in the thoracic portion of the oesophagus. If at all practicable, all these manipulations should be performed without anaesthesia, as the voluntary co-operation of the patient is highly desirable, and sometimes all important. With children and nervous adults, anaesthesia is permissible when resistance is offered to the manipulations. Under all circumstances, and especially with children, it is a matter of useful precaution to bind the patient’s arms firmly to the trunk, so that he cannot use them to incommode or baffle the surgeon. When foreign bodies cannot be readily extracted, it is a common practice to attempt to force them into the stomach by mechanical means. This pro- cedure is perfectly legitimate with digestible substances, or those of a char- acter to favor their safe transit through the intestinal tract. While such irregular bodies as dental plates with teeth,4 keys, safety-pins,® and forks, etc.,6 have been safely voided through the rectum, a copper coin has been known to excite fatal enteritis.7 Some forethought is necessary before making this irrecoverable disposition of the foreign body. In an emergency, the stiff stem of some plant—that of the leek being especially adapted to the pur- pose—the handle of a whip, or some similar object, may be used to push the foreign body into the stomach. The sponge-probang securely attached to 1 Adelmann, cited by Langenbeck (Berlin klin. Woch. 17 und 24 Dec. 1876) ; London Med. Record, Feb. 15, 1878 ; Holmes, Med. Times and Gaz., Jan. 13, 1883. 2 Holmes, loc. cit. 8 Crequy, Gaz. Hebd., 1861 ; cited by Poulet (Demarquay’s case). 4 Several unpublished examples are known to me. 5 Packard, Philadelphia Medical Times, April 15, 1872, p. 26. 6 Adelmann (Congress of German Surgeons, Berlin, 1872), Medical Record, June 1, 1872. 7 Lee, St. George’s Hospital Reports, 1869, p. 219. 18 INJURIES AND DISEASES OF THE (ESOPHAGUS. a flexible rod of whalebone or of metal, is the special appliance most apt to be accessible, and is at the same time one of the best. Any instrument which is to be used, should be well oiled, introduced carefully, propelled without force, and passed on into the stomach, so as to afford as much evidence as possible that the foreign body has been pushed out of the oesophagus. It is not always possible to determine that the foreign body has reached the stomach. In case of doubt, the subsidence of characteristic symptoms and their non-recurrence may be regarded as indicating that such has been the case. Force should never be used, lest injury be done to the oesophagus. When resistance is encountered, it is far better to wait awhile, and then to try again. Soft substances undergo further softening during a few hours’ exposure to the secretions of the oesophagus, and then they yield more readily to pressure from above. Attempts should not be made to push irregular bodies, such as fragments of bone and dental plates, down into the stomach. It is only by accident that irreparable injury is not thus inflicted. I have elsewhere cited1 an instance of cesophago-traclieal fistula produced in this manner. In a more recent example of this silly and reprehensible prac- tice, it was possible subsequently to remove the foreign body with forceps ;2 but, as a rule, the offending substance is pushed beyond the reach of instru- ments, and the walls of the oesophagus are lacerated in addition. The pleura has been penetrated in this way, with fatal consequences.3 The aorta has been penetrated in forcibly propelling a plate with a probang, death ensuing speedily by hemorrhage.4 The fact that very irregular bodies, such as large plates for false teeth, sometimes pass safely through the alimentary tract, does not justify the practice of pushing such substances through the oesophagus into the stomach, unless they are wholly in the thoracic portion of the gullet; when in this situation, the procedure in question is the sole means of freeing the tube, the injury to which, by their retention, is more liable to be followed by fatal consequences than the injury done by forcing them onwards. It is the choice of the lesser of two great evils, and gives the patient the best chance of survival. Gastrotomy may become necessary in case the foreign body has reached the stomach.® In discussing this subject, Billroth6 calls attention to the fact that it may be necessary, as in a case nar- rated, to pass the hand directly backward through the abdominal wound in order to detect a foreign body in the posterior portion of the stomach, for the organ cannot be drawn completely out of the wound. The special character of the foreign body and its location sometimes spur the ingenuity of the surgeon into devising, for the occasion, special methods of treatment, both manual and instrumental. Thus, a large potato impacted in the cervical portion of the oesophagus has been broken up by external pressure with the fingers,7 so that its deglutition could be finished. Similar manipulations have sufficed to propel masses of meat downward in one instance, and within grasp of forceps in another ;8 and have partially suc- ceeded even at the hands of the patient.9 The extraction of fish-hooks has been accomplished by sliding a slit bullet10 along the line, to disengage the point of the hook by gravity, and then cover it with the slot; or with a reed attached, so as to protect the mucous membrane from laceration in its with- 1 Op. cit., p. 313. 2 Lyons, Med. Times and Gaz., March 5, 1881, p. 279. s Stromeyer, Handbuch der Chirurgie, S. 334. Freiburg, 1865 ; Green, Brit. Med. Jour., Dec. 17, 1870, p. 65. 4 Clark, Brit. Med. Jour., March 22, 1884. 5 See Vol. V., page 587, supra. 6 Medical Times and Gazette, April 18, 1885, p. 504. 7 Dupuytren, case cited by Luton (Diet, de Medecine, Art. (Esopliage), by Poulet, and by others. 8 Langenbeck. Berlin, klin. Woch., 17 und 24 Dec. 1876. 9 Atherton, Boston Med. and Surg. Journal, 1870; cited by Mackenzie. 10 Baud, Annales de la Soc. d’Anvers, and Rev. Med.-Chir. de Paris, t. iii. p. 44, 1848. MALFORMATIONS OF THE (ESOPHAGUS. 19 drawalf and the same object has been accomplished by passing a large catheter along the line2 to free the hook by pressure, and then drawing it within the instrument. An impacted bone, resisting dislodgment with for- ceps, has been removed in the following ingenious manner:3 A few lead pellets, firmly secured to suture-wires, were dropped down the oesophagus, the meshes of wire engaging the bone which was released from its position by pulling on the wires two or three at a time, and varying the tli reads at inter- vals. In case a foreign body is so firmly fixed in the cervical portion of the oesophagus that it cannot be dislodged by instruments passed through the mouth, the operation of external oesophagotomy is required. It is especially indicated in cases associated with stricture of the oesophagus. According to the expressed opinion of nearly all writers, it is of little avail, and often of none, in cases of foreign body in the thoracic' portion of the oesophagus. Yet it has been successful in apparently the only two cases4 of the kind in which it has been attempted, though it must be mentioned that the object was comparatively high up, in both instances. It is possible that the linked for- ceps (Fig. 1304) might be used after oesophagotomy with advantage, or that a specially constructed appliance for seizing a body and boring through it could be contrived, so as to render extraction or propulsion practicable, even for foreign bodies in the thoracic portion of the gullet. Oesophagotomy should be performed as soon as it is found that intra-oesophageal methods are fruitless. Delay merely compromises the success of a legitimate operation, and adds risk of serious sequelae, such as ulceration and septicaemia, in con- sequence. Oesophagotomy for foreign body is usually successful,5 even in the infant,6 if performed at an early date. After expulsion or extraction of the foreign body, the abnormal phenomena gradually subside, as a rule, the patient recovering within a few days, unless serious injury has been sustained by the oesophagus. Should grave injury have been sustained, the following sequelae may follow: oesophagitis, circum- scribed or diffuse, often proceeding to suppuration; or peri-oesophagitis, whether suppurative or not, terminating, perhaps, with perforation of the oesophagus into the mediastinum, the air-tube, the pleura, the aorta or other bloodvessel. These sequelae must be treated on general principles. Rest of body, and administration of nutriment by enemata, of tonics, and of anodynes by enema or by hypodermic injection, would constitute the general course of management, to be associated with the prompt evacuation of any abscess pointing externally, or otherwise accessible. The operative details of oesophagotomy will be considered hereafter. Malformations of the (Esophagus. Collations show that between sixty and seventy cases of oesophageal malfor- mation are now on record,7 four having been reported in the United States.8 1 Leroy, Medical Examiner; Rev. Mod.-Chir. de Paris, t. ii. p. 110, 1847 (cited by Luton). 2 Laurent, Lancet, vol. ii. p. 745. 1882. 3 Torrance, Brit. Med. Jour., June 19, 1875, p. 810. 4 B6gin, loc. cit., t. xxxiii. p. 244, 1832 (cited by Terrier) ; Arnold, II Morgagni, Anno IV., p. 352, 1864 (also cited by Terrier). 5 Ashhurst, Principles and Practice of Surgery, 4th ed. Phila. 1885 (fifty-two times out of sixty-five). 6 Billroth, Arch. f. klin. Chir., Bd. xv. S. 678 ; Id., Clinical Surgery, p. 131. London, 1881 (a child one year of age, with stricture). 7 Mondiere, Arch. Gen. de Med., t. ii. p. 505. 1833 ; Hirschsprung, Den Medfodte Tillukning af Spiseroret, cited by Mackenzie (op. cit., vol. ii., London, 1884) ; Michel, Dictionnaire Encyclo- pedique des Sciences Medicales, Art. CEsophage. Paris, 1880. 8 Catalogue of the Boston Society for Medical Improvement, p. 128 (two cases, specimens 456, 457) ; Catalogue of the U. S. Army Medical Museum. Washington, 1867 ; Lamb, Philadelphia Medical Times, 1873, p. 705. 20 INJURIES AND DISEASES OF THE (ESOPHAGUS. In addition, there are a few records of transposition of the oesophagus, and one or more of annular bifurcation with rejunction.1 The great majority of cases of malformation of the oesophagus occur in individuals *with malfor- mations elsewhere. Of 63 patients referred to by Mackenzie, concerning only three was it stated that there was no other deformity, while in 19 others the condition of other organs was not mentioned, or it was stated that they had not been examined. In fully two-thirds of these malformations, 43 out of 63, the deformity consisted of a central deficiency of the oesophagus, the two ex- tremities communicating with the air-passages—by far most frequently (40 instances out of the 43), with the trachea, aud in the remaining instances with the bronchi. This deformity approaches teratologically the annular bifurcation of the intact oesophagus, and seems to indicate that the gullet may be developed from centres at its extremities. In nine instances the oeso- phagus terminated in a blind pouch ; in five there was no oesophagus at all; in two there was inter-communication with the trachea, the oesophagus being otherwise normal; in one the diaphragm shut oft* the oesophagus ; in one there was a complete membranous partition in the cervical portion ; in one there was a permeable valvular membranous obstruction in the cervical portion ; in one there was a longitudinal division of the oesophagus; and in one there was a probably congenital pouch. Embryologists have not yet accounted satisfactorily for malformations of the gullet. Diagnosis.—The question of the existence of a malformation may be enter- tained when the infant rejects by mouth, or by mouth and nose, nearly all the milk taken, unaltered in appearance. Symptoms of suffocation often attend attempts to nurse, in instances where the oesophagus is in communication with the air-passage. Careful exploration with a sound, in such instances, ought to reveal either an obstruction at some point of the tube, or a com- munication with the air-passage. Prognosis.—Surgery as yet seems to afford no hope for relief in these cases. For cases of supposed simple imperforation, without communication with the air-passages, the suggestion has been made2 to cut down upon the point of a introduced into the pharynx, and then to attempt to trace the oblit- erated oesophagus down the front of the spine until its lower dilated portion should be found. Then a gum catheter could be passed through the lower portion. If the two portions were sufficiently near each other to be connected by silver sutures over the catheter, and if the latter could be retained until union had taken place, it is thought that permanent success might be obtained. I am unaware that these views have been adopted by other surgeons. It is possible that good results might follow attempts at relief by gastrostomy. In most of the cases alluded to, death has taken place at periods varying from two hours to twelve days—a matter of normal vigor, apparently indepen- dent of the nature of the malformation. In one exceptional case of tracheo- cesophageal fistula, with otherwise normal oesophagus, the subject lived seven weeks,3 owing to the favorable form of the fistula, which hindered to some extent the escape of matters into the air-passage. Morbid Growths of the (Esophagus. Benign Growths.—Benign morbid growths of the oesophagus are rare. As most of the recorded cases,4 some twenty-five in number, were not dis- 1 Blasius, Observationes medicae rariores. Lugd. Bat., 1674 ; cited by Mondiere (Arch. Gen. de Med., 2e serie, t. ii. p. 507, 1833) ; Sebastien and St. Hilaire, case cited by Michel (loc. cit.). 2 Holmes, Surgical Treatment of Children’s Diseases. 3 Lamb, loc. cit. 4 Collated by Voigtel, Handbuch der pathologisch. Anatomie, Bd. ii. S. 427. 1804 (cited by Zenker and Ziemssen) ; Mondiere, Arch. G6n. de M6d., Sept. 1833, pp. 53-57 ; Middeldorpf, De 21 MORBID GROWTHS OF THE (ESOPHAGUS. covered until after death, and some of them altogether independently of any oesophageal symptoms, it is not improbable that a number of cases of oeso- phageal tumor escape recognition altogether. In the cases recorded, males have been the subjects far oftener than females. These growths are much more frequently pedunculated than sessile, and hence the earlier cases have been chiehy mentioned as polypi. In about half the cases, attempts have been made at histological discrimination, in some instances with the aid of the microscope. Fibromata predominate. Then come myomata, of which there are records of four cases ;4 cystomata, three cases ;2 adenoma, one case ;3 inflammatory neoplasm4—probably a sub-epithelial granuloma—one case. Papillary excrescences, from the size of a pin’s head to that of a lentil, some- times single and sometimes multiple,5 are said to be quite frequent in elderly persons. Benign growths are almost always single, examples of multiple growth, other than the papilloma just alluded to, being quite rare.6 The size of cysts varies from that of a very minute pea to that of a hazel-nut, and exceptionally to that of an apple.7 Fibromas may reach the bulk of a sausage,8 but few of them are larger than hazel-nuts. They are usually smooth in contour, sometimes lobulated.9 Of a number of cases in which the location was determined, in seven the growths occupied the upper portion,10 in three11 the cardiac portion, in one a point just below the level of the bifurcation of the trachea,12 in one a point 6f inches below the glottis,13 in one the lower third,14 and in one the lower part of the middle third of the gullet.15 In two cases it is stated that the anterior wall was occupied, in two the posterior wall, in one the left side, and in one the right; so that there seems to be little special proclivity in regard to position. Some seem to have taken origin in the epithelium, some in the mucous follicles, and some in the muscular coat. Nothing positive is known of the etiology of these growths. Excessive use of snuff is mentioned as the cause in the title given to one of the earliest cases on record,16 and addiction to the pipe and the bottle in another.17 polypis oesophagi atque de tumore ejus generis primo extirpato. Bratislav., 1857 ; Zenker and Ziemssen, Cyclopaedia of the Practice of Medicine, vol. viii. pp. 167-170. New York, 1878; Mac- kenzie, op. cit., vol. ii. p. 99. 1 Eberth, Arch. f. path. Anat. u. s. w., Bd. xliii. S. 137. 1868 ; Coats, Glasgow Medical Journal, Feb. 1872; Fagge, Med. Times and Gaz., Nov. 28, 1874; Trans. Path. Soc. Lond., vol. xxxi. p. 94; Tonoli, Gazetta Medica Ital. Lombard., Serie viii., t. ii. No. 49, p. 439. 1880 (cited by Mackenzie). 2 Wyss, Arch. f. path. Anat. u. s. w., Bd. Ii. S. 144 (a vibratile cyst) ; Ziemssen, op. cit., vol. viii. p. 161 ; Sappey, Traite d’Anatomie Descriptive, 3rne ed., t. iv. p. 155. Paris, 1879 (cited by Mackenzie). s Weigert, Arch. f. path. Anatomie u. s. w., Bd. lxvii. S. 516. * Mackenzie, op. cit., vol. ii. p. 105. 5 Zenker and Ziemssen, op. cit., vol. viii. p. 168. 6 Schneider, Chirurgische Geschichte, Bd. x. Chemnitz, 1784; cited by Mondiere and others (three polypous excrescences, two pedunculated, one sessile) ; Bell, Surgical Observations, vol. i. p. 77. London 1816 ; Sappey, op. cit., t. iv. p. 155, cited by Mackenzie (about 20 small cysts). Wyss, loc. cit. 8 Monro, Edinburgh Physical and Literary Essays, vol. ii. p. 525, and vol. iii. p. 212; Monro, Jr., Morbid Anatomy of the Gullet, Stomach, and Intestines, p. 186. Edinburgh, 1811 (the tumor, a portion of which had been removed by ligature two years previously, was found, after death, to extend from a point of attachment on the anterior wall, three inches below the glottis, quite to the cardiac extremity of the stomach) ; Bell, op. cit. (a large irregular tumor) ; Rokitansky, Med. Jahrb. d. k. k. osterr. Staates, n. F., Bd. xxi. S. 225. 1840 (seven and a half inches in length, and two and a half inches broad at its broadest part. In Middeldorpf’s case, the part removed measured inches ; in Coats’s case, 4| x 2 x 1£ in. ; in Fagge’s 2 x 1£ x 1 in.). 9 Dallas’s case, reported by Monro and Bell. 10 Cases of Dallas, Bell, Dubois, Middeldorpf, Hofer, Arrowsmith, and Mackenzie (two). 11 Cases of Vater, Graef, Wyss. 12 Fagge’s case. i* Coats’s case. 14 Weigert’s case. 16 Tonoli’s case. 16 Schmieder, De polypo oesophagi vermiformi rarissimo a quotidiano pulveris sternutatorii Hispanise abusu progenito. Hake, 1717. 17 Graef, Diss. med. inaug. illustraus historiam de callosa, excrescentiS, oesophagum obstruente, mortis causa Altorfii, 1764. 22 INJURIES AND DISEASES OF THE (ESOPHAGUS. Some instances have been deemed congenital. It is probable that the excit- ing cause, as in many morbid growths elsewhere, is to he attributed to topi- cal inflammation, possibly the result of pressure. Symptoms.—Dysphagia, emesis, cough, dyspnoea, imperfect articulation, and pain in the throat, chest, or back, are the chief symptoms that have been manifested, not all of them, however, in any individual instance. Theoreti- cally, dysphagia would be deemed a prominent symptom; and in several in- stances progressive dysphagia has been experienced. \ et it has often been wanting, even when the tumors have been of the largest size.1 When pedunculated and situated high up, they are sometimes regurgitated into the pharynx,2 and, if at all large, may so threaten suffocation as to prompt the patient to his sole means of immediate relief—the swallowing of the tumor—so as to restore it to its safer position in the oesophagus. Dyspnoea, indistinct articulation, and great pain, have been experienced in individual cases. In several instances3 there have been no symptoms whatever to suggest the existence of a tumor. Diagnosis.-—In most of the cases on record the affection has been diag- nosticated after death.4 In a few cases it has been recognized during life,5 once by spontaneous ejection6 of the tumor, and in other instances by its re- gurgitation into the pharynx,7 or even into the mouth.8 Some growths have been detected by exploration with the sound ;9 sometimes the diagnosis has been made by finding the trachea free on catheterization for dyspnoea,10 and once by cesophagoscopy.11 Spontaneous exhibition and instrumental explora- tion, then, constitute the means of diagnosis. Auscultation of the oesophagus, too, might furnish additional indications of obstruction. Minute growths, even though they might give rise to dysphagia, would probably escape recognition. There are a few instances on record of tumors hanging into the oesophagus,12 their points of origin having been the epiglottis, the larynx, the pharynx, or the posterior nares. These are to be discriminated from essen- tial tumors of the oesophagus. Prognosis.—The prognosis is not unfavorable, provided that growths which give rise to dysphagia and to dyspnoea are amenable to surgical measures for relief. In the absence of such relief, the prognosis in such cases is unfavor- able. If dysphagia be progressive, and if the disease remain unrecognized or unrelieved, death ensues by inanition.13 Treatment.—Several instances have been alluded to in which the growth has been ligated. Operations of this kind are not easy of execution. In one case, the surgeon14 insured the appearance of the tumor by administering an emetic, and then, having seized it with Museux’s forceps, drew it to the left side to somewhat relieve the dyspnoea, and severed the polypus about three-fourths of an inch in front of the ligature, the entire procedure being performed in the midst of repeated vomitings and in the presence of great dyspnoea. The patient then swallowed the pedicle with the ligature, the ends of which were attached to the left ear for safety. The vomiting, the oppression, and the dyspnoea immediately ceased, not to return. The loop of the ligature appeared in the mouth on the eighteenth day. The patient was I Rokitansky’s case. 2 Cases of Dallas, Middeldorpf, Hofer, and Dubois. 3 Those reported by Sclimieder, Eberth, and Fagge. 4 Cases of Sclimieder, Schneider, Graef, Pringle, Baillie, Arrowsmith, Coats, and Fagge. 5 Those of Vater, Dallas, Hofer, Dubois, Tonoli, and Middeldorpf. 6 Vater. 7 Hofer, Dubois, and Middeldorpf. 8 Dallas. 8 Middeldorpf, Tonoli. 10 Richards, Proceedings of the American Laryngological Association, June 12, 1879. II Mackenzie, op. cit., vol. ii. p. 100. 12 Gibb, The Throat and the Windpipe, p. 361. London, 1861 ; Warren, Surgical Observa- tions, p. 116. Boston, 1866. 13 Cases of Schneider and Graef. 74 Middeldorpf. MORBID GROWTHS OF THE (ESOPHAGUS. doing well five years after the operation. In another case1 it was necessary to perform precautionary tracheotomy before ligating the tumor. In this instance the ligated portions of the tumor were passed by the rectum, but the patient died of inanition two years afterwards, from dysphagia caused by the portions left behind. The propriety of securing the ligature externally in order to control the tumor in case of accident, is exemplified by an instance in which a patient was found dead in bed some days after this operation, with the tumor in his pharynx completely occluding the larynx.2 Another success- ful case of ligature completes,3 it is believed, the records of this procedure. At the present day it is likely that the electric-cautery loop might be em- ployed instead of the ligature; but the fact that these tumors are sometimes very vascular, and that secondary hemorrhage might be serious, is not to be ignored in selecting the more rapid method of severance. That removal with the horse-hair parasol-probang can be accomplished in cases of growths with soft attachments, has been shown by two accidental instances in which that manipulation had been undertaken for supposed foreign bodies.4 One case of removal of a growth the size of a white currant, discovered cesophagoscbpically, is on record;5 but the nature of the operation is not indicated. (Esophagotomy has been suggested for access to tumors high up, and gastrotomy for those low down; but no records of these pro- cedures having been practised in cases of the kind now under consideration have come to my knowledge. Malign Growths.—(1) Sarcoma.—But two records of sarcoma of the cesophagus seem to be accessible. In one, digital exploration produced such dyspnoea that tracheotomy had to be performed immediately ; the tumor, a round-celled sarcoma, being subsequently removed by subhyoidean pharyn- gotomy from the right side of the oesophagus just below its pharyngeal orifice.6 The other, an alveolar sarcoma at the entrance of the oesophagus, occurred in a woman who died of inanition.7 Several tumors, partially con- nected, and varying in diameter from half an inch to two inches, occupied the lower part of the pharynx and the upper part of the cesophagus, almost occluding the latter. (2) Carcinoma.—Carcinoma of the oesophagus is far more frequent than the other varieties of morbid growth, if not more frequent than any other form of oesophageal disease. Judgiugfrom my own practice and that of my associates in Philadelphia, the belief is entertained that the published cases of carcinoma of the oesophagus represent but a small proportion of the cases actually observed. Still, it is far rarer than carcinoma of the stomach8 and of some other organs. Carcinoma of the oesophagus is most frequently of the squamous-celled vari- ety of epithelioma, fifty-four of the fifty-nine cases studied by Mr. Butlin9 having been of this histological character, as compared with three small spheroidal-celled (scirrhous), one large spheroidal-celled (medullary), and one 1 Dallas’s case, cited by Monro (London Medical Journal, 1771, and Edinburgh Physical and Literary Essays, vol. iii. p. 212) ; Monro, Jr., op. cit., p. 186. 2 Dubois, Propositions sur diverses parties de Part de guerir, p. 8. These No. 104, Paris, 1818 ; cited by Mondiere. 3 Hofer, Acta Helvetica, tom. i. ; cited by Mondiere. 4 Mackenzie, op. cit., vol. ii. p. 104. 5 Ibid. 6 Rosenbacli, Berliner klinische Wochenschrift, 20 und 27 Sept. 1875. i Chapman, Am. Journ. Med. Sci., Oct. 1877, p. 433. 6 Tanchon, in a total of 9118 cases of cancer, found 2303 of the stomach and but 13 of the oesophagus ; cited by Lebert (Traite Pratique des Maladies Cancereuses, Sect. III., p. 442. Paris, 1851). 8 Sarcoma and Carcinoma, p. 161. London, 1882. 24 INJURIES AND DISEASES OF THE (ESOPHAGUS. colloid carcinoma.1 There does not appear to be any marked proclivity in any special portion of the oesophagus to become affected. While some ob- servers note the disease as most frequent in the upper third,2 others note it most frequently in the lower third,3 and still others in the middle portion.4 The disease has been known to involve the entire length of the organ.8 What- ever portion be found involved after death, it is not always possible to de- termine whether the main tract of extension has been upward or downward. Carcinoma of the oesophagus is usually primary, and it does not always cause secondary infection. Secondary manifestations may occupy the lymph- atic bronchial glands, the liver—the left lobe most frequently—and the gas- tric glands. Secondary infection is much the least frequent in the small spheroidal-celled variety of carcinoma (scirrlius). The disease rarely remains limited to the organ. Infiltration of the stomach by contiguity is not uncommon when the cardiac extremity of the oesophagus is the seat of the disease. Infiltration takes place likewise into the cervical and mediastinal connective tissue; the trachea, bronchi, and lungs; the aorta and other blood- vessels. Ulceration ensuing, perforation may occur into the trachea, the bron- chi, the pleura, or the lung, the aorta, the pulmonary, subclavian, or carotid artery, or the internal jugular vein. Pressure on the recurrent laryngeal nerve gives rise to paralysis of the laryngeal muscles, necessitating trache- otomy when the dilating muscles are involved on both sides. Sometimes the disease is an extension from carcinoma of the tongue, epiglottis, larynx, pharynx, stomach, or mediastinum. The manner in which the disease begins and spreads is a matter chiefly of theoretical inference, literally beyond our ken. However this may be, it usually ultimately involves the organ in its entire circumference. Ulceration begins early in its pathological history, and very few specimens are observed without it.6 It usually involves the entire circumference in an irregular outline, isolated patches of ulceration being often found in addition. When the ulceration is not annular, it does not seem that the anterior wall is more apt to suffer than the posterior. The ulceration sometimes extends into the adjoining infiltrated tissues to which the oesophagus may have become agglutinated, and perforation thus takes place into the structures mentioned. As the disease progresses, it produces stricture, and then obliteration of the calibre of the oesophagus. After death, the diseased tissue appears in small, roundish, projecting masses covered by epithelium, or in the form of vege- tations or deeply ulcerating masses. The coats of the oesophagus in the vicinity are often thickened, especially the muscular coat; and then dilatation sometimes exists above the constriction. Etiology.—Sex, heredity, and age appear to be predisposing influences. Males are more liable than females. Thus Zenker reports 11 cases out of 15 in males, Mackenzie 71 out of 100, Butlin 47 out of 59, Lebert 8 out of 11, Petri 41 out of 44, and Ziemssen 17 out of 18. This preponderance may be due to the great tendency, in the other sex, for carcinoma to attack the mamma and the uterus.7 One observer8 found a family history of malignant disease in all the cases, ten, of carcinoma which he had met with; but this is an exceptional experience. Mackenzie9 found a similar history in but eleven cases out of sixty. Though carcinoma of the oesophagus is infrequent in the 1 Bristowe, Trans. Path. Soc. Lond., vol. xix. p. 228. 1868. 9 Hunter, Habershon, Mackenzie, Butlin. 3 Petri, Zenker, Ziemssen. 4 Klebs, Rindfleisch. 5 Zenker. 6 Five out of fifty-four in Butlin’s list. 7 Koenig, Pitba und Billroth’s Handbuch, Bd. iii. S. 32. 8 Richardson, Trans. Saint Andrew’s Med. Grad. Assoc., vol. vi. p. 184. 9 Op. cit., vol. ii. p. 73. MORBID GROWTHS OF THE (ESOPHAGUS. actual subjects of tuberculosis, it is met with sufficiently often in the children of tuberculous subjects to suggest the idea of some hereditary predisposition induced by that diathesis. From a comparison of several series of records, and of many individual reports, comprising a total of more than two hundred cases, it appears that the disease is rare before the thirteenth year of life. Few cases occur before the age of thirty-five, most of them between the ages of forty and seventy. Epithelioma, or squamous-eelled carcinoma, seems to be the only variety likely to appear before the forty-fifth year. The greatest pro- clivity seems to be manifested between the ages of fifty and sixty. The average age at which women are attacked is about ten years earlier than the average age in men, say forty-four and fifty-four respectively. It occurs in advanced old age, cases having occurred in subjects as old as eighty-four1 and eighty-six.2 It is frequently admitted that abuse of alcoholic beverages may predispose to the disease, but this point is a matter of uncertainty. Local inflammations, and injuries by pressure or by compression, are regarded as exciting causes. Symptoms.—These may be summed up as progressive dysphagia—first with solids and then with fluids likewise, sometimes becoming more and more painful and sometimes painless—regurgitation, vomiting, loss of appetite, dyspnoea, dysphonia, cough, pyrexia, and marasmus; and subsequently such symptoms as are produced by extension of the disease in adjacent organs and structures, and by perforation into them. Lancinating pains occur in some instances. After ulceration has taken place, enlarging somewhat the passage for food, the dysphagia undergoes proportionate temporary amelioration. Diagnosis.—The presence of several or all of the symptoms enumerated, their steady and rapid exacerbation, the age of the patient, and the recogni- tion of carcinomatous tissue in the purulent and sanguinolent matters vomited, furnish the chief grounds for diagnosis. The existence of obstruc- tion by tumor or by stricture, is determined in the usual manner by explora- tion with the sound, and by auscultation of the bolus. Characteristic shuttle- like pains are not common, and cachexia fails to be produced in many cases of rapid progress. Their absence therefore does not invalidate the diagnosis. In the earlier stages, carcinoma is liable to be mistaken for chronic oesopha- gitis, the presence of a cicatricial stricture or of a diverticulum, and involu- tion from compression on the exterior. Prognosis.—The prognosis is unfavorable, the disease being inevitably fatal at a period varying from three months to two years, or a little more. Death may even take place as early as seven or five weeks3 after the mani- festation of dysphagia.4 More than one-half the cases seem to terminate fatally within six months, and five-sixths within twelve months. Life is longest preserved in cases of small spheroidal-celled carcinoma (scirrhus), instances being on record of its preservation for more than two years, and exceptionally beyond three. While some cases are fatal by inanition, others terminate before this condition is reached, whether by pneumonia, gangrene, or other disease of the lung, or by suffocation, pericarditis, hemorrhage, or disease of the spinal cord, according to the direction and result of the con- secutive infiltration. The position of the disease and the liability to occlu- sion of the cesophagus and to the consecutive diseases and conditions just mentioned, influence the prognosis as to the probable length of life and the probable mode of its termination. Treatment.—This is palliative, and to be conducted on general principles. Arsenic may be employed medicinally with some hope of retarding the 1 Butlin’s list. 3 Mackenzie, op. cit., vol. ii. p. 92. 8 Behier’s list. Habershon. INJURIES AND DISEASES OF THE (ESOPHAGUS. progress of the disease in its earlier stages. Dilatation of the constricted canal is allowable only at the commencement. When alimentation becomes difficult, the stomach-tube may be cautiously used at first. At a later date a catheter may he retained in the oesophagus a few days at a time, for the purpose of injecting food into the stomach. Otherwise, rectal alimentation is indicated. This should not be delayed until it is absolutely necessary. Occa- sional rest to the part, afforded by resort to this mode of alimentation, some- times temporarily restores the ability to swallow. In the later stages, especially after ulceration has begun, there is great danger of penetrating the walls of the oesophagus with instruments, whether inserted for probing, for dilating, or for conveying nutriment. (Esophagostomy offers no hope of relief. Gastrostomy may permit the prolongation of life in cases favor- able for the operation. Resection of the oeso- phagus, partial oesophagectomy, seems in the light of present histological pathology to pre- sent considerable chance of benefit, if not of cure, provided that the whole of the diseased structure can be included in the excised por- tion of the oesophagus. The procedure is ap- plicable only to. disease of moderate extent, involving the upper portion of the gullet. At any stage of the disease, threatened suffo- cation, whether from compression of the air- tube or from paralysis of the laryngeal muscles, may demand tracheotomy. Fig. 1310. Stricture of the (Esophagus. Stricture of the oesophagus is occasionally congenital, and sometimes inflammatory; but it is much more frequently cicatricial, occurring usually as the result of injury to the part or of disease within the organ, in its walls, or directly outside. The intrinsic injuries are most fre- quently lacerative, and the diseases ulcera- tive. Cicatricial stricture is most frequent at the uppermost portion of the oesophagus, hut it also occurs lower down, even just above the cardiac orifice of the stomach.1 Traumatic stricture has been known to extend from within half an inch of the cricoid cartilage to within an inch of the cardia2 (Fig. 1310), but in most instances it does not extend over more than three inches. Usually there is but one stricture, but in some instances there are two, three, or as many as four.3 The occlusion of the canal is occasionally complete, and may vary between this extreme and very slight obstruction. Traumatic stricture of the cesophagus. (After Mackenzie.) 1 Maury, American Journ. Med. Sciences, April, 1870, p. 369 ; Rawdon, Liverpool Med. and Surg. Rep., vol. iii. p. 117 ; Reid, New York Medical Journal, Oct. 1877, p. 405. 2 Mackenzie, op. cit., vol. ii. p. 154. 3 Cohen, op. cit., p. 291. STRICTURE OF THE (ESOPHAGUS. Cicatricial strictures occur in the form of folds, bands, nodules, and aggluti- nations of opposing surfaces. Repeated detention of food sometimes dilates the oesophagus just above the stricture, hypertrophy occurring first, and fatty degeneration afterwards. Atrophy is not uncommon below tight stric- tures, and collapse of the tube usually follows. Etiology.—The causes of oesophageal stricture are obscure in some instances. They are most frequently traumatic, and due to scalds, to chemical disinte- gration following the deglutition of weak or strong acid or alkaline liquids, to laceration, or to destructive inflammation and cicatrization following me- chanical injury or the impaction of foreign bodies. Intrinsic strictures are also produced by carcinoma, syphilis, tuberculosis, neoplasms, varices, ab- scesses, connective-tissue or muscular hyperplasia, and even osseous infiltra- tion. Strictures by outside compression are produced by abscesses, morbid growths, enlarged thyroids, enlarged lymphatic glands, and aifeurisms of the aorta. Syynptoms.—The characteristic symptoms are persistent and often progres- sive dysphagia, and regurgitation. In addition, there may be pain, sense of oppression in the chest, and nervous disturbance. In organic stricture, impli- cating the course of the pneumogastric and inferior laryngeal nerves, there may be dyspnoea, dysphonia, and spasm. Diagnosis.—The history of the case, the existence of dysphagia and regurgitation, evidence on auscultation of impediment to the descent of the bolus, and obstruction detected in catheterization or exploration with the sound, are the pathognomonic guides to diagnosis. Dyspnoea and dysphonia will suggest stricture of organic origin, the latter more especially should a vocal band exhibit paralysis. Any morbid products or fragments of tissue, brought to light by regurgitation or by catheterization, will serve to indicate the nature of the lesion which produces the stricture. Prognosis.—The prognosis is unfavorable in incurable organic stricture. It is comparatively favorable in cicatricial stricture of moderate dimensions, especially when due to a curable disease, or when susceptible to dilatation, to division by oesophagotomy, or to circumvention by cesophagostomy or gastrostomy. Cicatricial stricture of traumatic origin may exist for many years before the patient succumbs to inanition. During the process of hyper- trophy above the stricture, muscular power forces nutriment through the stricture ; but when fatty degeneration begins, this power becomes lost and marasmus ensues. Meantime abscess may occur, and fatal pneumonia or pul- monary gangrene may end the struggle for life. Treatment.—The medicinal and hygienic treatment of patients with stric- ture varies with its character. The surgical treatment requires m the first place proper measures for the removal of any foreign body, morbid growth, collection of pus, or other pathological condition remediable by surgical means. For the cure or amelioration of the stricture itself, the treatment, according to the indications, will be by simple dilatation, forced dilatation, or dilatation after section of the stricture—whether by internal oesophagotomy, or by direct access through the wound of external oesophagotomy or that of gastrotomy. The value of persistent, progressive dilatation, especially in cases of traumatic stricture, is not sufficiently appreciated by all surgeons. That much of the difficulty in cases of supposed unyielding strictures is sometimes due to spasm from attendant irritation—as has been expressed by Michel, Annandale, and Campbell, in particular—seems demonstrated in the successful, accidental dilatation1 effected by the swelling of a piece of dried peach, incautiously swallowed in a case of supposed impassable stricture. 1 Smith, Med. and Surg. Reporter, Dec. 6, 1884, p. 641. 28 INJURIES AND DISEASES OF THE (ESOPHAGUS. This hint might be utilized in suitable cases by allowing the patient to swallow some easily distensible substance (sponge, leather, or other suitable material) secured to a string, so that it might be promptly and safely with- drawn. Proper care would be required to avoid risk of rupturing the oesophageal wall in thus doing. If the stricture be impassable by bougie or inaccessible to cesophagotomy, gastrostomy may be practised. Internal cesophagotomy and digital divulsion are sometimes practised through the wound of gastrotomy. Cauterization and electrolysis are claimed as legiti- mate procedures, but both are risky—the former as likely to increase the stricture, and the latter as liable to excite fatal syncope by irritating the pneumogastric nerve. Coarctation-Stricture. {Extraneous Stenosis.)—This form of stricture is due to compression outside the oesophagus, forcing one wall close to the other, or into actual contact. It may be due to abscess, enlarged bronchial glands, enlarged thyroid, morbid growth, aneurism, or pericardial effusion. It is to be carefully discriminated from intrinsic stricture. The diagnosis is made by exclusion, and by the recognition of cervical or thoracic disease outside of the gullet. The characteristic symptoms are dysphagia and pain. The prognosis, dependent upon the curability of the primary disease, is on the whole unfavorable. The treatment consists in management on general principles, and in careful attempts at dilatation and catheterization for the better supply of nourishment. Cure, or even amelioration of the causal affection, will relieve the constriction. In all cases, however treated or of whatever origin, the importance of keeping up nutrition by rectal alimentation even before this procedure is imperatively necessitated, cannot be too strongly insisted upon. Spasm and Paralysis of the (Esophagus. Spasm of the (Esophagus, or (Esophagismus.—This is a neurosis which may exist alone or in association with pharyngismus. It may affect any portion of the tube. The inability to swallow, or rather to complete the process of deglutition, may be transient, or persistent during consecutive series of hours. It is usually manifested irregularly, often suddenly, but may be definitely intermittent, or may even precede every effort at deglutition. In some sub- jects it occurs only on attempts to swallow certain sorts of food, hot or cold, soft or hard. It is often associated with regurgitation of air or of flatus, and with the globus hystericus. It may be painless or painful. When severe, there may be spasm of the glottis, cardiac disturbance, and syncope. Etiology.—(Esophagismus occurs in diseases of the oesophagus, but it is usually a reflex neurosis excited by disease of the viscera, genital organs, or nerve-centres, as in hydrophobia. It occurs at all ages, and principally in females, especially hysterical and nervous ones. Symptoms.—The symptoms are sudden dysphagia, giving way as suddenly as it begins, either at once, or after a prolonged interval which may comprise several hours; and regurgitation, immediate or nearly so when the spasm is located high up, delayed for hours or even for days when the spasm is low down. Diagnosis.—The suddenness and intermittence of the paroxysms will suggest the diagnosis, and successful catheterization of the oesophagus will confirm it. The tube or bougie is usually arrested at the seat of spasm, but after a few moments’ or a minute’s rest will glide readily onward on the occurrence of relaxation. The differentiation of nervous spasm from spasm of organic origin, rests in the main on the conservation of good nutrition. dilatation and sacculation of the oesophagus. Prognosis.—This is usually favorable, unless there be some serious disease of the nerve-centres, or of some other important organ. Treatment.—The first passage of the bougie often permanently cures the spasm. Should the relief he but temporary, the procedure can be repeated from time to time. Relaxants, anodynes, and antispasmodics are indicated as medicinal remedies. The periodic warm bath is an excellent measure for children. Painting the pharynx with a weak solution of iodine or of silver- nitrate, every few days; deglutition of these substances in glycerine or in ointment; or their passage along the oesophagus on the probang, cures many obstinate cases. Electrization, sometimes successfully employed, is objec- tionable for the reasons indicated in speaking of oesophageal stricture. Paralysis of the (Esophagus.—This may be partial or complete. It may be, and often is, associated with paralysis of the pharynx, palate, tongue, or larynx, with so-called bulbar paralysis, and with general paralysis. Etiology.—It may be due to disease of the oesophagus; to mechanical restraint by external adhesions ; to disease or injury of the fibres of the pneumogastric nerve ; to external pressure; to neurasthenia from hemor- rhage or from protracted disease ; to septic poisoning in syphilis, diphtheria, or plumbism. It may occur suddenly, from shock by fright, or from reaction by chilling the overheated body. Symptoms.—Partial paralysis may afford no symptoms at all. Dysphagia, deglutition easiest in the erect position, escape of saliva, and, towards the end, escape of fluids and food into the air-passages, constitute the charac- teristic symptoms. Diagnosis.—The differential diagnosis rests on the absence of pain and regurgitation, symptoms present in dysphagia from mechanical occlusion of the oesophagus. Auscultation of the bolus may indicate the position and extent of the paralysis. Prognosis.—This is favorable in idiopathic cases, and in those due to cura- ble diseases or injuries, especially when the paralysis is confined to the oesophagus; but recovery is rarely rapid. The prognosis is unfavorable under almost all other conditions. Treatment.—Surgical treatment is restricted to the passage of the stomach- tube, when required to insure due supplies of nourishment. Preparations of strychnine are indicated for internal administration. Electric treatment is almost as likely to increase the paralysis as to diminish it, and internal electrization is liable to induce fatal syncope. Dilatation and Sacculation of the (Esophagus. Dilatation of the oesophagus, or oesophagocele, may be general or partial. General dilatation involves the whole of the oesophagus from pharynx to stomach, the organ often being stretched as well as dilated (complete general dilatation). Partial dilatation presents itself in three forms. (1) It may in- volve the greater portion of the oesophagus from the cardiac orifice to the cervical portion ; a form pathologically allied to general dilatation (incom- plete general dilatation). (2) It may be circumscribed—a limited, circum- ferential dilatation, forming an ampulla (annular dilatation). (3) It may in- volve but a portion of the periphery in a diverticulum or pouch (, oesophagus ; 2?,stomach. (After Luschka.) * Rokitansky, Manual of Pathological Anatomy, vol. ii. p. 8. London, 1849. 2 Luschka, Arch. f. Anat., Marz, 1868, S. 473. 3 Gradenwitz, Schmidt’s Jahrb., Bd. ci., S. 298. 1859 (cited by Mackenzie) ; Davy, Dublin Hospital Gazette, May 1, 1875 (cited by Knott). 4 Cases of Raymond (Gaz. Med. de Paris, No. 7, 1869), and of Hanney (Edin. Med. and Surg. Jour., July, 1833). 6 Hanney, loc. cit. 6 Nicoladini, Wien. med. Woch. 1877, No. 25 ; cited by Zenker and Ziemssen. DILATATION AND SACCULATION OF THE (ESOPHAGUS. 31 seat of the dilatation is where the oesophagus is crossed by the left bronchus ;* hut when not due to stricture its seat is usually just above the diaphragm. The pouch-like dilatation, diverticulum, or sacculation, is most frequently a pharyn- geal diverticulum reaching down behind the oesophagus {pressure diverticulum, Zenker and Ziemssen). These cases cannot be very rare, although some forty only appear to be on record,2 for several have been seen in my own practice. The formations appear to be single only, as a rule.3 They are usually located posteriorly, sometimes in the median line, sometimes on one side of it. They are attributed to pressure from above, due to retention of food which Fig. 1312. Fig 1313. Traction diverticulum. Apex held fast by contracted glands to the bifurcation of the trachea. (After Zen- ker and Ziemssen.) Interior view of a traction diverticulum, to exhibit the orifice. (After Zenker and Ziemssen.) gradually distends and elongates them. They vary in size from the dimen- sions of a pea to that of a duck’s egg. True oesophageal diverticula {trac- tion diverticula, Zenker and Ziemssen) are attributed chiefly to traction on 1 Laborde, Compte Rendu de la Soc. de Biologie, p. 43, 1853 ; cited by Michel. * Most of these are cited by Zenker and Ziemssen (op. cit., vol. viii. p. 52). 3 Littre observed four cylindrical sacs in one instance. Collection AoadSmique, t. iv. p. 371 ; cited by Mondiere (Arch. G6n de Med., Sept. 1833, p. 52). 32 INJURIES AND DISEASES OF THE (ESOPHAGUS. the anterior walls, after inflammatory adhesion to outside tissues, caused usually by the subsidence of tumefied lymphatic glands, which in shrinking draw the side of the tube into a funnel-shaped sac, constricted at its margin by recession of the muscular coat.1 A case in which the apex of the sac was thus agglutinated to the trachea at its bifurcation, is illustrated hy Zenker and Ziemssen.2 (Fig. 1312.) Such diverticula are most frequent at this point, and are rarely found at any considerable distance therefrom. They are rarely deeper than from 9 to 12 millimetres, and are usually less than 8. The orifice is round or elliptic, and variable in size. (Fig. 1313.) Other diverticula have been attributed to hernia-like protrusions of the mucous membrane through ruptures of the muscular coat, sus- tained by falls or blows, or by violent efforts of deglutition. They have likewise been attributed to strictures of carcinomatous,3 and perhaps of other origin. When low down, such a diverticulum may overlap the orifice of the stomach in such a way as to prevent the entrance of food.4 Etiology.—General dilatation may be congenital.® A number of reported cases are apparently congenital, there having been no stricture below them to favor mechanical distention.6 Other instances are apparently due to mechanical distention the result of constriction at the cardia.7 The lesion has been attributed by observers to blows on the chest,8 to lifting heavy weights,9 to detention of a hot solid bolus,10 to gastric fever,11 to distention by large quantities of water,12 to oesophagitis,18 and to fatty degeneration.14 It is not unlikely that inflammation following injury may be the starting point of the process in cases of pathological origin. It is occasionally due to stricture at the cardia in connection with stricture at the pylorus,15 and exceptionally to stricture at the pylorus alone, with limited distensive power in the stomach.16 Paralysis, softening, and ulceration favor dilatation from distention. Annular dilatation is almost always due to mechanical distention above a stricture, whether congenital, cicatricial, or due to morbid growth or foreign body. Instances are on record of annular dilatation from all these sources. Carcinoma is less frequently a cause than has long been generally supposed, probably because it undergoes degeneration so soon, and thus presents less resistance to pressure. Pharyngeal diverticula are sometimes due to congeni- tal defect, and sometimes to pressure, perhaps to both causes in most instances. This defect, according to Bardeleben and to Billroth,17 is attributable to par- tial external closure of one of the branchial fissures, the internal opening remaining patent. True oesophageal diverticula are attributable to defect or rupture of the muscular coat, permitting hernia of the mucous and interme- diate coats; or to external traction, the result of agglutination with swollen and inflamed tissues. Symptoms.—The symptoms of general dilatation are impediment to the passage of food into the stomach, hyper-salivation, and regurgitation—some- times of unaltered and sometimes of fermented food—ultimately culminating in dysphagia and aphagia. The impediment to swallowing sometimes exists I Rokitansky, op. cit. 2 Op. cit. * Grisolle, Bull, de la Soc. Anat. 1832, p. 113 ; cited by Michel (a posterior pouch at middle portion of oesophagus). 4 De Guise, Dissertation sur l’Anevrysme, suivie de Propositions Medicates. Paris, An. xii.; cited hy Mondiere (Arch. Gen. de Med., Sept. 1833, p. 34). 5 Zenker, Ziemssen’s Cyclopaedia of Pract. Med., vol. viii. p. 51 (autopsy of a seven-months child, seven days old). 6 Cases of Hanney, Chiaje, Luschka. 7 Cases of Lindau, Rokitansky, Wilks. 8 Hanney, Purton. 9 Davy. 10 Spengler. II Chiaje. 12 Oppolzer. 13 Stern. 74 Klebs. 16 Lindau, Casper’s Woch., 1840, S. 356 ; cited by Zenker and Ziemssen. 16 Klebs, ibid. 17 Clinical Surgery, p. 130. London, 1881. DILATATION AND SACCULATION OF THE OESOPHAGUS. 33 from infancy to advanced maturity, or even from birth to advanced old age.1 Hiccough occurs in some instances. Complete dilatation is believed to give rise to habits of rumination, not at all unpleasant. Annular dilatation pre- sents the usual symptoms of stricture, to which are added regurgitation at unusually long periods after deglutition, and almost continuous escape of the fetid gases of decomposition. An oesophageal diverticulum will not produce dysphagia, unless it be so situated as to compress the main channel or overlie the stomach, under which circumstances it will give rise to symptoms like those of intrinsic stricture, or of compressing stricture from tumor outside. As long as sufficient aliment reaches the stomach, nutrition remains well preserved ; but when the passage of food becomes impracticable, progressive emaciation ensues, with its usual manifestations. A pharyngeal diverticulum, while filled, may so compress the oesophagus as to render deglutition impracticable, when exter- nal compression will empty part of its contents into the mouth. Diagnosis.—Apart from the symptoms mentioned, the diagnosis will depend upon the results of ausculta- tion of the bolus and exploration with the sound. In general dilatation, auscul- tation indicates too rapid a descent of the mouthful of water and in a larger stream than usual. A diverticulum, it is claimed, can be detected by the deviation of the sound from the usual line. Palpa- tion with the bougie, in general dilatation, reveals a large sac in which the end of the instrument is freely movable. In exploring for pharyngeal sacculation, the sound may slip by the entrance of a diverticulum, especially when the latter is empty (Fig. 1314, B)\ consequently the unhindered passage of the instrument into the stomach is not positive evidence that sacculation is not present. Tem- porary external swelling by filling of the the sac, and its partial discharge by external upward compression, will indi- cate the existence of a pharyngeal diverticulum. Prognosis.—The prognosis is unfavorable as to remedying the lesion. Neither medicine nor surgery is of much avail. The prognosis as to life is not unfavorable under ordinary conditions. Many years may elapse before the fatal termination takes place, whether by accidents of perforation and ulceration, or by inanition. Extreme old age has been reached by subjects who presented evidence of the lesion from infancy. When inter-current disease or consecutive lesion does not terminate life, death eventually ensues by starvation. Treatment.—Surgery offers little in the way of remedy. Chronic oeso- phagitis, stricture, foreign body, or whatever may be the apparent cause, requires appropriate treatment. Feeding through a stomach-tube, well in- troduced, would prevent detention of food in a sac or diverticulum. Paraly- sis would indicate the medicinal use of phosphorus and of strychnine. The use of the stomach-tube for feeding, and of electrization for attempted cure, has been suggested for general dilatation, but the prospects of good results Fig. 1314. A, direction of sound when the diverticulum is full. B, when it is empty. (After Zenker and Ziemssen.) 1 Cassan, Arch. Gen. de Med., 2e serie, t. ii. p. 79. 1836 ; citfed by Michel (pharyngocele in a male patient, who died at 77). 34 INJURIES AND DISEASES OF THE (ESOPHAGUS. from electricity are hardly sufficient to justify the risk of injury by undue excitation of the pneumogastric nerve. Exsection of a pharyngeal diverticu- lum, through the external wound of pharyngotomy or oesophagotomy, has been suggested as a feasible operation, but I am unaware of any instance in which this operation has been attempted. (Esophageal Instruments. Introduction of the Stomach-Tube.—The patient should be in the sitting position, with the head bent back and supported upon the breast of the sur- geon, or of an assistant, in such a direction as to bring the mouth and pharynx as much as possible in line with the oesophagus; or the recumbent position may be adopted, with the head hanging down beyond the edge of the couch or table, and supported in the hands of an assistant. The tube, previously warmed by friction or by hot water, and then lubricated with vaseline, gly- cerine, ointment, or oil, is next taken in one hand, while with the index or middle huger of the other, the surgeon directs the instrument beyond the epi- glottis, or into one of the sinuses between the larynx and pharynx, and then gently presses it down into the oesophagus, the patient, if conscious, making voluntary efforts to swallow its extremity. Should resistance from spasmodic contraction be felt, the tube should be held in position for a few moments, and should be pushed onward at the first sign of relaxation of the spasm. The tube should then be passed down until its extremity has entered the stomach, the average distance of which from the teeth is about twelve inches in the full-grown adult. In the presence of actual or threatened softening or ulceration, the possibility of perforation or rupture from frequent introduction of the tube is to be appre- hended. Under these conditions it is preferable to keep the instrument con- tinuously in position, for which purpose a soft-rubber or other flexible tube is used, of no greater calibre than can be passed through the nose. When the end of the tube reaches the pharynx, it is directed into the (Esophagus by the fingers of the surgeon’s unengaged hand. The free extremity is secured by threads and adhesive strips, or bandages, to the ear or top of the head,and is kept occluded by cork or string when not in immediate use. Krishaber has reported four cases1 in which a soft-rubber tube, passed through the naris, was safely retained in position for periods varying from forty-six to three hundred and five days, for the latter period in a case of carcinoma. Bougies and Dilators.'—Various forms of bougie are used for the purpose of detecting and dilating strictures. They are introduced in the same manner Fig. 1315 Sectional outlines of Mackenzie’s bougie. as the stomach-tube. Bougies similar to those used in dilating urethral stric- tures, but of larger size, are much employed, some of equal calibre throughout, 1 Trans. Int. Med. Congress, vol. ii. p. 392. London, 1881. OPERATIONS ON THE (ESOPHAGUS. 35 some with attenuated or rat-tail extremities. These are usually cylindrical. As remarked by Mackenzie, however, inasmuch as the transverse diameter of the oesophagus ex- ceeds its antero-posterior diameter, bougies constructed upon that model (Fig. 1315) ought to be better theoretic- ally ; and Mackenzie has found his views confirmed by experience. Whalebone stems with ivory knobs (Fig. 1316) are also much used. The knobs should be much more tapering at the top than those usually made, so as to present less difficulty in disengaging them from beneath a stricture. The knobs should be securely fastened, and the fastening should be thoroughly tested each time that they are used, lest they should be accidentally detached in with- drawal. Ivory and metallic knobs are sometimes so ar- ranged as to be screwed at will upon the guiding rod, a method of fastening much more secure than glueing or riveting. The safest instrument by far is the graduated oesophageal dilator of Trousseau (Fig. 1317), made of ca- theter material or of whalebone. It permits testing the capacity of the stricture, and systematic dilatation, without change of instrument. Dilating machines, constructed of split metallic sounds, the sides of which can be separated mechanically by the action of a screw at the free extremity, have been employed by some surgeons. It is questionable whether they are safe instruments. Another mode of dila- tation which may be mentioned, consists in using a thin rubber tube which is passed through the stricture by the aid of a rigid conductor, on the withdrawal of which the tube is to be distended with compressed air, with water, or with mercury. Fig. 1316. (Esophageal dilators. Fig. 1317. Graduated oesophageal dilator of Trousseau. Operations on the (Esophagus. (Esophagotomy and (Esophagostomy.—Three operations are included under this head : (1) An incision from the exterior through the entire parietes of the oesophagus, for the purpose of reaching its interior to remove a foreign body, etc. (external cesophagotomy), or to establish a fistula (oesophagostomy); (2) a nick or an incision through cicatricial or diseased tissue, or through the mucous membrane and as little deeper tissue as possible, by means of an instrument passed through the mouth, for the purpose of permanently enlarg- ing the constricted calibre of the gullet, or for facilitating subsequent dila- tation (internal oesophcigotomy); and (3) a procedure in which the external wound is utilized to afford access to a cutting instrument within the oesopha- gus (l. cviii. 65 Solly, it it Lancet, vol. i., 1856. 66 Id. a It Ibid., 1857. 67 Teale, a Died. Med.-Chir. Trans., vol. xxxv. 68 Thompson, Not stated. it Lancet, vol. i., 1859. 69 Id. Amussat. it Med. Times and Gazette, vol. i., 1877. 70 Trevor, 41 it Lancet, vol. ii., 1867. 71 Verneuil, Littre. it Med. Times and Gazette, 1869. 72 Weir, Amussat. it New York Med. Journal, vol. xxi. Table XVI.—Showing the Results of 9 Cases of Colotomy for Various Lesions. (Condensed, from Dr. W. R. Batt’s Table.') No. Operator or Reporter. Nature of case. Form of operation. Result. Reference. 1 Amussat, Iliac phlegmon. Amussat. Recovered. Gazette des Hopitaux, 1842. 2 Druitt, Obliteration of bowel. << Died. Lancet, vol. i., 1860. 3 Hulke, Contraction of bowel after dys- entery. 44 << Med. Times and Gazette, vol. i., 1879. 4 Kundsen, Hernia and gangrene. Not stated. Recovered. Van Erckelens, loc. cit. 5 Maisonneuve, Hernia and gangrene. << << Archives Gen. de Medecine, 4e S., t. vi. 6 Nicaise, Intestinal cicatrix. Littre. Died. Gazette Med. de Paris, 1875. 7 Tliaden, Intussuscep- tion. U << Archiv f. klin. Chirurgie, 1862. 8 Tiingel, Volvulus. U Recovered. Ibid., 1861. 9 Weber, Hemorrhoids. Amussat. << Personal communication. An analysis of these tables shows that of the whole 351 cases, 133 ended fatally, a mortality in determined cases of 37.9 per cent. The most favorable cases are those of intestinal fistula, of which only 10 per cent, end in death, and the least favorable those of imperforate rectum, of which more than half (52.9 per cent.) prove fatal. As regards the form of operation, it may be said, in general terms, that more than one-third die after colotomy by Amussat’s or Callisen’s method,1 and more than one-half when Littre’s plan is adopted. These points may he conveniently seen in the annexed summaries:— 1 Callisen’s differs from Amussat’s operation merely in the fact that the external incision is longitudinal instead of transverse. operative treatment of intestinal obstruction, 87 Analysis of 351 Cases of Colotomy embraced in Tables X.—XVI Nature of affection. Cases. Result not ascertained. Recovered. Died. Mortality per cent, of terminated cases. Cancer of bowel 154 1 104 49 32.0 Intestinal fistula 20 18 2 10.0 Imperforate rectum . 52 1 24 27 52.9 “ Obstruction of the bowel” 40 2 19 19 50.0 Ulceration of the bowel . 4 3 1 25.0 Stricture of the bowel 72 41 31 43.1 Various lesions 9 ... 5 4 44.4 Aggregates 351 4 214 133 37.9 Mortality Form of operation. Cases. Result not Recovered. Died. per cent, of ascertained. terminated cases. Amussat 244 2 164 78 32.2 Littre .... 82 1 38 43 53.1 Callisen .... 10 1 2 7 77.7 Fine .... 4 4 ... 0.0 Not stated . . 11 6 5 45.4 Aggregates . 351 4 214 133 37.9 Enterectomy, or resection of a segment of the small intestine, has usually been performed in cases of gangrene of the bowel following strangulated hernia, or in those of fecal fistula; but it may also be properly performed, subsequent to laparotomy (when it is called lajxiro-enterectomy), in cases of gangrene, certain cases of intestinal stricture and tumor, occlusion of the bowel by inseparable adhesions, volvulus, and irreducible, chronic intussus- ception. It is, of course, a more dangerous operation than laparo-enterotomy; but, on the other hand, offers, as that does not, a prospect of perfect and permanent cure. The operations of enterectomy and laparo-enterectomy may each be done in two ways: (1) the diseased portion of bowel may be simply cut away, and the ends attached to the external wound so as to form an arti- ficial anus ; (2) after resecting the diseased segment, the ends may be approx- imated with sutures and the gut returned into the abdominal cavity. The latter plan is the proper one in cases of fecal fistula, and in some cases of obstruction very high up in the small intestine, as in the duodenum, where the establishment of an artificial anus would very much interfere with the patient’s nutrition; but in all ordinary cases of intestinal obstruction, as in gangrene after strangulated hernia, it is safest at first to make an artificial anus, and on a subsequent occasion, if necessary, to attempt to restore the continuity of the intestine. In cases of hernia and fecal fistula, the operation is performed at the seat of disease; in other cases it is better, as a rule, to make the incision in the course of the linea alba, and endeavor to bring the affected bowel to the median line, where, after resection, its ends can be most conveniently fastened; but if this cannot be done, a second incision must be made directly over the obstructed part. It is often of the greatest importance, in this operation, to prevent the extravasation of blood and fecal matter into the abdomen ; hence, as soon as the diseased portion of bowel is exposed, it should be well drawn out, and the external wound either closed as far as possible, or filled with soft sponges so as to cut off' all communication with the parts within. Several surgeons, 88 INTESTINAL OBSTRUCTION. including M. Rydygier, Mr. Treves, and Mr. Gibson, of Manchester, have devised ingenious clamps for temporarily compressing the gut, and thus pre- venting the escape of its contents. The section of the bowel is best made with scissors, a portion of healthy bowel being left between the cut and the clamp, so as to allow space for the adjustment of the sutures. A triangular piece of the mesentery should also be excised, the base of the triangle cor- responding to the extent of the resected intestine, and the wound being closed with fine sutures. The clamps are then cautiously removed, first from the lower and afterwards from the upper end, and the parts are attached to the external wound by numerous stitches. When an attempt is made to restore the continuity of the gut, either as a primary or secondary procedure, the clamps, carefully adjusted, are fastened together so as to approximate the cut ends of bowel, and these, having been freshened, if necessary, are then secured to each other by two rows of sutures, one bringing together the edges of mucous membrane, and buried in the tissues of the gut, and the other applied through the serous and muscular coats, as in Lembert’s method.1 Mr. Treves justly condemns Gussenbauer’s suture as needlessly complicated. In order to facilitate the introduction of the stitches, cylinders of dough, decalcified bone, etc., have been introduced into the bowel, but are objectionable as exposing to the risk of at least tem- porary obstruction; if any guide is needed, a bag of thin India-rubber may be used, as suggested by Treves, being inflated after its introduction, and being allowed to collapse again, and withdrawn, before adjusting the last suture. The operation is completed by returning the sewed-up bowel into the abdomen, and closing the external wound. Colectomy, a resection of a portion of the large intestine, is less often practised than enterectomy, and indeed can seldom be recommended except in certain cases of malignant stricture of the colon, or of fecal fistula, or what Mr. Morris calls “ false anus,” of this part.2 In cases of this kind the place of incision is, of course, determined by that of the fistula, but under other circumstances colectomy is, as a rule, best effected through an incision in the lumbar region, as in lumbar coiotomy, the bowel being drawn out and dealt with in the manner, and with the precautions, described in speaking of enterectomy. Nicolaysen has reported a successful case of colectomy per- formed through the rectum. The statistics of these operations, enterectomy and colectomy, have been made a subject of special study by Madelung,3 Rydygier,4 Reichel,5 and Makins.6 To the histories tabulated by these writers I have been able to add a num- ber of others, and the following table contains references to 186 cases, a larger series than has yet been collected:— 1 See Fig. 1211, Vol. V. p. 587, supra. 2 See Vol. V. page 583, supra. 3 Archiv f. klin. Chirurgie, Bd. xxvii. S. 277. 4 Berliner klin. Wochenschrift, 18 Jahrgang, Nos. 41-43. 5 Deutsche Zeitschrift f. Chirurgie, Bd. xix. S. 230. 6 St. Thomas’s Hosp. Reports, N. S., vol. xiii. p 181. OPERATIVE TREATMENT OF INTESTINAL OBSTRUCTION. Table XVII.—Cases of Resection with or without Suture of the Intestine. (Enterectomy and Colectomy.) No. Operator. Result. Reference. 1 Albert, Recovered. Wien. med. Presse, 1881. 2 Aman, Died. Hygeia, Bd. xliii. 3 Ambrosi, 4 4 Indipendente, tomo xxxiii. 4 Amitesarove, Recovered. Union Med., t. i. Caracas, 1881. 5 Banks, 4 4 Clinical Notes on Two Years’ Surgical Work, etc.,p. 96. (3 Bardeleben, ied. Deutsch. med. Wochensclirift, 1883. 7 Id. 44 Ibid. 8 Id. 44 Ibid. 9 Bardenheuer, Recovered. Die Drainirung der Peritoneal-hohle, 1881. 10 Id. Died. Ibid. 11 Barton, 44 British Med. Journal, Jan. 31, 1885. 12 Baudens, 44 Clinique des Plaies d’Armes A Feu, 1836. 13 Baum, ti Centralblatt f. Chirurgie, 1879. 14 Id. Recovered. Berlin, klin. Wochenschrift, 1881. 15 Id. Died. Fortschr. d. Med., 1884. 16 Beebe, Recovered. Ill, Medical Record, Sept. 22, 1883. 17 Berger, Died. Bull, et M6m. de la SociSte de Chirurgie, 1880. 18 Bergmann, Recovered. Deutsch. med. Wochenschrift, 1883. 19 Billroth, 44 Wien. med. Wochenschrift, 1879. 20 Id. 44 Ibid. 21 Id. u Ibid., 1881. 22 Id. u Archiv f. klin. Chirurgie, Bd. xxiv. 23 Id. 4t Ibid., Bd. xxvii. 24 Id. Died. Wien. med. Wochenschrift, 1881. 25 Id. , 44 Ibid. 26 Id. ; Recovered. Am. Journ. Med. Sciences, April, 1883. 27 Bouilly, Died. Bull, de la Society de Chirurgie, t. ix., 1883. 28 Boyer, 44 Traite de Chirurgie. 29 Bryant, Recovered. Lancet, May 13, 1882. 30 Bryk, Died. Przeglad Lekarski, 1881. 31 Id. 44 Ibid. 32 Byrd, Recovered. Medical Record, Aug. 5, 1882. 33 Id. 44 Ibid. 34 Cal ton, 44 Edinb. Med. and Surg. Journal, vol. xii. 35 Cherni, Undeterm’d. Index Medicus, Jan. 1881. 36 Cooper, Died. Anat. and Surg. Treatment of Hernia. 37 Id. (4 Ibid. 38 CredS, Recovered. Archiv f. klin. Chirurgie, Bd. xxvii. 39 Id. 44 Ibid. 40 Czerny, 44 rl. klin. Wochenschrift, 1880. 41 Id. Died. Ibid. 42 Id. Recovered. Ibid. 43 DiefFenbach, 44 Caspar’s Wochenschrift, 1836. 44 Dittel, 44 Wiener med. Wochenschrift, 1878. 45 Duverger, 44 Mem. de l’Acad. Royale de Chirurgie, t. iii. 46 Esmarch. Died. Verhandl. d. Deutsch. Gesellsch. f. Chir., Bd. viii. 47 Feld, Recovered. Archiv f. klin. Chirurgie, Bd. xxx. 48 Fischer, Died. Deutsche Zeitschrift f. Chirurgie, Bd. xix. 49 Id. Recovered. Ibid. 50 Id. Died. Ibid. 51 Id. Recovered. Ibid. 52 Id. Died. Ibid. 53 Id. Recovered. Ibid. 54 Id. 44 Ibid. 55 Id. 44 Ibid. 56 Id. Died. Ibid. 57 Id. 44 Ibid. 58 Id. 44 Ibid. 59 Id. Recovered. Ibid. 60 Id. 44 Ibid. 61 Id. 44 Ibid. 62 Id. Died. Ibid. 63 Id. 4 4 Ibid. 64 Folker, Recovered. 1 British Med. Journal, Feb. 7 and Aug. 15, 1885. 90 INTESTINAL OBSTRUCTION. Table XVII. ’.—Continued. No. Operator. Result. Reference. 65 Forbes, Died. Episcopal Hospital Records, 1885. 66 Fuller, Recovered. Medical Record, vol. xxii. 67 Id. cc Ibid. 68 Gaston, cc Med. and Surg. Hist. War of Rebellion, Second Surgi- cal Volume. 69 Gentilliomme, Undeterm’d. Index Medicus, April, 1883. 70 Grindon, Recovered. St. Louis Courier of Medicine, 1884. 71 Gussenbauer, CC Archiv f. klin. Chirurgie, Bd. xxvii. 72 Id. CC Ibid. 73 Id. Died. Ibid. 74 Guyon, it Peyrot, De PIntervention Chirurgicale dans PObstruc- tion Intestinale, p. 84. 75 Hagedorn, Recovered. Verhandl. d. Deutsch. Gesellsclt. f. Chirurgie, 1880. 76 Id. (( Ibid. 77 Hardie, cc Medical Chronicle, January, 1885. 78 Heusner, Died. Deutsch. med. Wochenschrift, 1880. 79 Hofmoker, CC Wiener med. Presse. 80 Howse, CC Med.-Chir. Trans., vol. lix. 81 Hueter, cc Deutsch. Zeitschr. f. Chirurgie, Bd. ix. 82 111, Recovered. Medical Record, Sept. 22, 1883. 83 Id. Died. Ibid. 84 Jaffe, Jessop, Recovered. Sammlung klinische Vortrage, No. 201. 85 cc Brit. Med. Journal, May 2, 1885. 86 Id. cc Ibid. 87 Jobert, Died. Archives Gen. de M6decine, 1824. 88 Id. CC Mem. de l’Acad. Royale de Med., t. xii. 89 Jones, CC British Med. Journal, Feb. 7, 1885. 90 J ulliard, Recovered. Revue Med. de la Suisse Rom., 1881. 91 Id. Cl Centralbl. f. Chirurgie, 1882. 92 Id. CC Ibid. 93 Kinloch, CC Am. Journ. Med. Sciences, vol. liv. 94 Kooher, CC Bull, de la Soc. Med. de la Suisse Rom., 1880. 95 Id. Died. Centralbl. f. Chirurgie, 1880. 96 Id. Recovered. Correspondenzbl. f. Schweizer Aerzte, 1878. 97 Koeberle, CC Gazette Hebdomadaire de M6d., 1881. 98 Korzenowski, Died. Berliner klin. Wochenschrift, 1881. 99 Kosinski, cc Ibid. 100 Kraussold, Recovered. Sammlung klinische Vortrage, No. 91. 101 Id. Died. Ibid. 102 Kues ter, CC Verhandl. d. Deutsch. Gesellsch. f. Chirurgie, 1879. 103 Id. CC Ibid. 104 Id. cc Ibid. 105 Id. CC Archiv f. klin. Chirurgie, Bd. xxvii. 106 Lammiman, Cl Lancet, Aug. 4, 1883. 107 Langenbeck, Cl Archiv f. klin. Chirurgie, Bd. xix. 108 Lavielle, Recovered. Journ. Gen. de Med., de Chir. et de Pliar., t. xliii. 109 Leisrink, Died. Archiv f. klin. Chirurgie, Bd. xxviii. 110 Lucke, ( C Deutsch. Zeitschr. f. Chirurgie, Bd. xii. 111 Ludvik, Recovered. Wiener med. Presse, 1880. 112 Luzenberg, CC Gross, Medical News, May 3, 1884. 113 MacDonald, Cl Lancet, Feb. 9, 1884. Archiv f. klin. Chirurgie, Bd. xxvii. 114 Madelung, Cl 115 Id. cc Berliner klin. Wochenschrift, 1881. 116 Maisonneuve, Died. Gazette des Hopitaux, 1854. 117 Id. ( t Ibid. 118 Makins, Recovered. St. Thomas’s Hosp. Reports, N. S., vol. xiii. Ill, Medical Record, Sept. 22, 1883. 119 Marcy, Died. 120 Marshall, Cl Lancet, May 6, 1882. 121 Martini, Recovered. Zeitschrift i'. Heilkunde, 1880. 122 Maydl, CC Wien. med. Presse, 1883. 123 Mensel, CC Deutsch. med. Wochenschrift, 1883. 124 Id. cc Ibid. 125 Moldenkow und Minin, cc Centralbl. f. Chirurgie, 1881. 126 Morisani, Died. Rivista Internaz. di Med. et Cliir., tomo i. pag. 146, 127 Nayler, Recovered. Cooper, op. cit. OPERATIVE TREATMENT OF INTESTINAL OBSTRUCTION. 91 Table XVII.—Concluded. No. Operator. Result. Reference. 128 Neuhauss, Recovered. Bull, et Mem. de la Soc. de Chirurgie, 1880. 129 Nicoladoni, 44 Wiener med. Blatter, 1879. 130 Nicolaysen, 4 4 Nord. med. Arkiv, Bd. xiv. 131 Novaro, Died. Centralbl. f. Chirurgie, 1882. 132 Obalinski, 44 Berliner klin. Wochenschrift, 1881. 133 Id. 44 Ibid. 134 Id. 44 Ibid. 135 Id. 44 Ibid. 136 Perier, 44 Gazette Medicale, 12 Fev. 1881. 137 Pirogoff, Recovered. Grundziige der allgem. Kriegschirurgie, S. 578, 1864. 138 Pitcher, 44 Med. and Surg. Hist. War of Rebellion, Second Surg. Vol. 139 Pollard, Died. Lancet, March 17, 1883. 140 Porter, Recovered. Boston Med. and Surg. Journal, May 15, 1884. 141 Id. 44 Homans, ibid., July 30, 1885. 142 Prati, Died. Amer. Practitioner, Nov. 1883. 143 Ramdohr, Recovered. Hallerus, Disputat. Anatom., tom. vi. 144 Rehn, 44 Med. News, March 14, 1885. 145 Reybard, 44 Memoire sur une Tumeur Cancereuse, etc. 146 Richter, 44 Medical News, Sept. 30, 1882. 147 Robson, Died. Medical Record, August 8 and 22, 1885. 148 Rochelt, 44 Wiener med. Presse, Bd. xxiii. 149 Roggenbau, Recovered. Berliner klin. Wochenschr., 1881. 150 Roser, Died. Centralbl. f. Chirurgie, 1881. 151 Rydygier, Recovered. Deutschr. Zeitschr. f. Chirurgie, Bd. xv. 152 Id. Died. Berliner klin. Wochenschrift, 1881. 153 Salen, Undeterm’d. Index Medicus, March, 1883. 154 Schede, Recovered. Verhandl. d. Deutsch. Gesellsch. f. Cliir., 1879. 155 Id. Died. Ibid. 156 Id. Recovered. Ibid. 157 Id. Died. Ibid., 1878. 158 Schinzinger, 44 Wiener med. Wochenschr., 1881. 159 Id. Recovered. Ibid. 160 Schmid, 44 Hallerus, Bibliotheca Cliirurgica, tom. ii. 161 Schonborn, Died. Deutsch. Zeitschrift f. Chirurgie, Bd. viii. 162 Socin, 4 4 Centralbl. f. Chirurgie, 1881. 163 Sutton, Recovered. Med. News, June 16, 1883. 164 Tandler, Died. Archiv f. klin. Chirurgie, Bd. xxvii. 165 Tauber, 4 4 Verhandl. d. Deutsch. Gesellsch. f. Chirurgie, Bd. ix. 166 Thiersch, Recovered. Berliner klin. Wochenschrift, 1881. 167 Id. Died. Verhandl. d. Deutsch. Gesellsch. f. Chirurgie, 1878. 168 Id. 4 4 Beger, Berlin, klin. Wochenschr., 1882. 169 Trelat, “ Peyrot, op. cit. 170 Id. Undeterm’d. Gazette Medicale, 12 Fev. 1881. 171 Id. (4 Ibid. 172 Treves, Died. Lancet, Dec. 16, 1882. 173 True, Recovered. Lyon Medicale,. 1882. 174 Vermale, 44 Obs. et Remarques de Chirurgie Pratique, 1767. 175 Yiertel, 44 Deutsch. med. Wochenschrift, 1877. 176 Volkmann, 44 Kompe, Aertzliches Intelligenzblatt, 1883. 177 Wahl, Died. St. Petersb. med. Wochenschrift, 1879. 178 Id. 44 British Med. Journal, May 26, 1883. 179 Weinlechner, Recovered. Wiener med. Wochenschrift, 1881. 180 Id. Undeterm’d. Aertzl. Ber. der k.-k. allg. Krankenh. zu WTien., 1883. 181 Weiss, Died. Berliner klin. Wochenschrift, 1881. 182 Id. 44 Ibid. 183 Wells, Undeterm’d. British Medical Journal, Nov. 15, 1884. 184 Whitehead, Died. Ibid., Jan. 24, 1885. 185 Wolfler, 44 Wiener med. Wochenschrift, 1881. 186 Id. Recovered; Medical Record, May 19, 1883. Of the 186 eases embraced in the preceding table, 98 are reported as re- coveries and 86 as deaths, the result in 7 not having been ascertained; the mortality of determined cases is therefore, according to these figures, 48 per cent. This corresponds very closely with the percentages given by Makins 92 INTESTINAL OBSTRUCTION. and Reichel, the former writer tabulating 94 cases with 44 deaths, or 46.8 per cent., and the latter 121 cases with 58 deaths, or 47.9 per cent. The mortality is least in cases of false anus (37.8 per cent., Reichel; 38.4 per cent., Makins), and increases progressively to 40 per cent, in cases of injury to the bowel, 50 per cent, in cases of intestinal cancer, 52 per cent. (51.8 per cent., Reichel; 52.7 per cent., Makins) in cases of gangrene following hernia, and 75 per cent, in cases of intestinal occlusion. Even, however, in the most favorable cases—those of false anus—the operation is a much graver one than that of Dupuytren1 (use of the enterotome), 83 examples of which, collected by Ileimann, gave 50 complete and 26 partial successes, and only 7 deaths (8.4 per cent.). * See Vol. V., page 581, supra. INJURIES AND DISEASES OF THE RECTUM BY WILLIAM ALLINGHAM, E.R.C.S., SURGEON TO ST. MARK’S HOSPITAL, LONDON. Anatomy and Physiology of the Rectum. The last portion of the intestinal canal, the rectum, measures from its commencement at the left sacro-iliac synchondrosis to its termination at the anus, from six to eight inches in the adult. The name rectum has but partial justification, and that only in comparison with the great bulk of the intes- tinal tract; for this tube is anything but straight, having antero-posteriorly two well-marked curves, an upper, which follows precisely the curve of the sacrum and coccyx, and a lower, which commences at the tip of the coccyx, with its convexity forwards, and terminates about an inch from it at the small orifice known as the anus. Besides these antero-posterior curves, a lateral one, from left to right, is usually described, beginning at the left sacro-iliac synchondrosis, and termin- ating at the third sacral vertebra. But from observations in the post-mortem room I am inclined to think that no hard and fast line can be drawn about this lateral curve. The meso-rectum gives the first part of the rectum great play, and as often as not, on opening a body, what corresponds to the com- mencement of the rectum is found close to the right instead of the left synchondrosis. About an inch and a half from the orifice of the anus, which distance is occupied by the internal sphincter, a dilatation occurs in the lumen of the gut, and in those suffering from chronic constipation this may assume enormous dimensions. I have myself found an impaction of feces lodged in this part, the size of a foetal head. The structure of the rectum differs in some respects from that of the large intestine generally. Muscular Coat.—This is much thicker than in other parts of the bowel, for in defecation the expulsion of feces is greatly dependent on its action. As throughout the remainder of the intestinal tract, it consists of two layers— an external longitudinal, and an internal circular. The former of these, how- ever, is pretty evenly distributed around the gut, and is not collected into three bundles, as in the colon. On the anterior surface of the bowel the fibres are found lying thicker and closer than elsewhere. The termination of these lon- gitudinal fibres is interesting. Some of them, according to Dr. Garson, pass from the rectum to the bladder, immediately beneath the peritoneum. The remainder are continued to the lower margin of the internal sphincter, where some, according to Dr. Horner, who wrote in 1826, turn under this margin, between it and the external sphincter, and then extend upwards for an inch or two in. contact with the mucous membrane, into which they are finally inserted. I must confess that I have not succeeded in proving to my own 94 INJURIES AND DISEASES OF THE RECTUM. satisfaction this terminal arrangement of fibres, although I have examined many rectums for that purpose. Other fibres are said to pass between the bundles of the external sphincter, and to be inserted into the subcutaneous connective tissue around the anus; while still a third set pass backwards towards the coccyx, into the anterior surface of which they are inserted by means of a very thin tendon. We now come to the circular fibres. Of these there is little to be said, except that, like the longitudinal, they are far better represented in the rectum than elsewhere throughout the intestinal tract. At the terminal inch and a half of the bowel they are collected in great numerical force, and constitute the internal sphincter. I have often observed how this muscle varies in different individuals, both in extent and power, while dilating it previous to operating on internal hemorrhoids. In some it readily yields after a moment’s effort, while in others I have to use my whole strength for a considerable time. The explanation probably is, that, in the latter cases, the muscle has been subjected to frequent contractions in consequence of the pre- sence of a fissure or an ulcer of the anus, which has produced an increase in its strength, and possibly in its bulk. A third sphincter has been described by O’Beirne, as situated high up, near the sigmoid flexure. Nelaton, too, has described a partial sphincter two and a half inches from the anal orifice. I must say that I myself do not believe in the existence of either the one or the other of these additional sphincters, except as an occasional, and, in my expe- rience, an exceedingly rare, anatomical curiosity. The submucous connective tissue of the rectum is abundant, especially at its lower part, where it forms the nidus in which the rectal vessels ramify after having made their way through the muscular coat, as will be described hereafter. Strong septa pass between the bundles of muscular fibres, which form a kind of framework for them, to the fibrous stroma of the fat surround- ing the rectum. The mucous membrane lining the rectum does not materially differ, as far as I am aware, from that found in the remainder of the large intestine; like that it consists of closely packed Lieberkiihn’s follicles, with here and there a solitary gland which is only a circumscribed nodule of lymphoid tissue. Immediately over the solitary glands, Lieberkiihn’s follicles are absent. The muscularis mucosa—or unstriped muscular layer of the mucous membrane proper—is said to be well developed around the anus, and to counteract any tendency, should such exist, to prolapsus. Certain marks and folds of the mucous membrane are interesting, and will now be examined. First, there is the white line around the anus which marks the junction of mucous mem- brane and skin, as also the linear interval between the internal and external sphincters. Hext, the columnae of the rectum, or the pillars of Glisson or of Morgagni. These, from six to eight in number, commence at the point of union of skin and mucous membrane, and extend about three-quarters of an inch or more up the bowel. They are permanent—that is, they are present even when the anus and lower part of the rectum are distended—and in each is found one of the parallel rectal arteries, branches of the superior hemor- rhoidal, described by Quain. Little arches of mucous membrane, with their concavities upwards, unite the anal extremities of these pillars, and have been called “ anal valves.” They are often so indistinct as not to be recog- nizable. Lastly, I must just mention the so-called valves of mucous mem- brane described by Houston, in the year 1830, although I may at once say that I do not believe in their existence. He enumerates four, arranged in a spiral manner, the second, which is the largest, being on the anterior wall opposite the base of the bladder, and he ascribes to them the function of sus- ANATOMY AND PHYSIOLOGY OF THE RECTUM. 95 tabling the fecal mass to avoid pressure on the sphincter, until the rectum is fully distended. Having already stated my disbelief in their very existence, I need not space in refuting the physiological functions ascribed to them, but will pass at once to the consideration of the muscles of the rectum and anus. Muscles of the Rectum and Anus.—The external sphincter consists of voluntary fibres, which arise by a tendon from the tip of the coccyx, and are inserted into the central tendon of the perineum. It is elliptical in shape, and about half an inch in breadth. Its function is to close the anus under the influence of the will. Mr. Hilton, in his Lectures on Rest and Pain, has so admirably described what we occasionally owe this indomitable little sphincter, that I cannot refrain from quoting him:— The strength and endurance of the anal sphincters are well exemplified by their suc- cessful antagonism to the peristaltic action of the colon and rectum upon large quanti- ties of fluid or solid feculent matter, constantly gravitating towards the anal aperture, guarded by the watchful sphincters. Who is there that has not felt this kind of com- petitive struggle, this intestinal warfare going on within himself, fearing the issue, and has not been thankful for the result, and full of gratitude for the enduring strength of the little indomitable sphincter, which has averted a possible catastrophe. The nerve-supply of the external sphincter is derived from the hemor- rhoidal branch of the internal pudic nerve, and from the fourth sacral. The internal sphincter has already been described, in connection with the circular fibres of the rectum of which it is only an accentuation. Its nerve- supply is derived from Auerbach’s plexus, and also from the hemorrhoidal branch of the internal pudic. The levator ani is an irregularly quadrilateral muscle, which, with its fellow of the opposite side, forms a kind of inverted cone with two openings in- teriorly for the transmission of the rectum and the urethra, in the male, the vagina of course in the female also passing through it. It arises from the posterior surface of the descending ramus of the pubis, sometimes from the articular cartilage, from the white line which marks the division of pelvic into obturator and recto-vesical fascia, from the internal surface of the spine of the ischium, and from the lesser sacro-ischiatic ligament. From this ex- tensive origin most of the fibres pass down towards the median line, and are inserted as follows : The anterior fibres course down along the side of the prostate, beneath which they meet their fellows at the central tendon of the perineum ; the middle fibres are inserted into the side of the rectum; and the remaining fibres pass between the rectum and coccyx into a median raphe, the posterior of these being inserted into the sides of the coccyx. It should be mentioned that a set of fibres belonging to the levator ani have been described as almost horizontal in direction, arising from the pubis and being inserted into the coccyx. The action of the levator ani is likely enough to become a subject of dispute, as recently a new theory has been started, namely, that this muscle assists defecation by compressing the rectum at a point about two and a half inches from the anus—the point, in fact, at which the horizontal fibres are said to cross the rectum. I myself am not yet a convert to this novel view, and prefer to regard the levator ani, first, as an antagonist of the dia- phragm and abdominal muscles when compressing the abdominal contents ; secondly, as an antagonist of the sphincters in defecation by opening the anus. As this muscle when in action exerts pressure on the neck of the bladder through the fibres passing to the central tendon, thus preventing urine from entering the urethra, micturition and defecation cannot well occur 96 INJURIES AND DISEASES OF THE RECTUM. simultaneously. After an operation for internal hemorrhoids, it is usually necessary to pass a catheter the first night, in order to empty the bladder. I am not quite clear in my own mind how far the levator ani is directly re- sponsible for this, or whether the retention is due to nervous influences. The nerve supply of the levator ani is from the fourth sacral and from the internal pudic. The transversus perinei arises from the inner surface of the descending ramus of the pubis, close to the ischial tuberosity, and is inserted into the central tendon of the perineum. Its action has been described by Cruveilhier as assisting that of the external sphincter in compressing the anus. It has, however, always appeared to me to be mainly concerned in steadying the central tendon while the other muscles inserted into it are in action. Its nerve comes from the internal pudic through the perineal nerve. Vessels of the Rectum and Anus.—The blood supply of the rectum is derived from two sources, the inferior mesenteric and the internal iliac artery. The first terminates in the superior hemorrhoidal artery, which passes down behind the rectum between the two layers of meso-rectum, and soon divides into two branches, which in their turn break up into seven or eight—the parallel rectal arteries which are found in the pillars of Glisson already referred to. The internal iliac usually gives off' the middle hemor- rohidal, through the inferior vesical, and the inferior hemorrhoidal through the internal pudic artery. Both these arteries are small, and are distributed to the lower part of the rectum and anus only. The veins correspond to the arteries, that is to say, there are three sets—superior, middle, and inferior— which, according to my observation, communicate freely in a plexus around the lower part of the bowel, the hemorrhoidal plexus. The superior hemor- rhoidal vein is, like the artery, single. It is the commencement of the inferior mesenteric, and so joins the portal system ; like the other veins of this system, it is devoid of valves. Verneuil, who has devoted a great deal of time and labor to the elucidation of the anatomy of these veins,says that they commence at the upper border of the internal sphincter, and lie under the mucous membrane of the rectum. At a definite height of about four inches, they perforate abruptly the muscular coats of the bowel through “ veritables boutonnieres musculaires,” and unite to form five or six large veins found in the meso- rectum ; these then join the inferior mesenteric vein, as already explained. Verneuil is also of opinion that little or no anastomosis takes place between the superior and the other hemorrhoidal veins, and that, at least as far as this region is concerned, the portal and general systems are practically dis- tinct. I have already said that I by no means participate in this view. The yniddle hemorrhoidal veins, one on either side, join the internal iliac veins; they arise from the hemorrhoidal plexus, and, according to Buret, are formed by two venous trunks, one in front of and the other behind the rectum. The inferior or external hemorrhoidal veins are also connected with the above- mentioned plexus, and empty themselves into the internal pudic veins. Nerves.—The sensory nerves which supply the skin around the anus are the inferior hemorrhoidal and the posterior superficial perineal—branches of the internal pudic—and the posterior branches of the lower sacral nerves. The nerve supply of the muscles has already been referred to in the descrip- tion of these. The mesenteric and hypogastric plexuses supply many branches to the rectum, the muscular coat of which is provided with Auerbach's plexus, an offshoot of that first mentioned. The external sphincter is maintained in a state of tonic contraction by a centre in the lumbar portion of the MALFORMATIONS OF THE RECTUM AND ANUS. 97 spinal cord. During defecation this centre is inhibited by the action of the will, by emotions, or by other nervous events (Foster.) Lymphatics.—Those from the skin around the anus pass to the glands of the groin ; those from the rectum proper communicate with the glands in the hollow of the sacrum and the lumbar glands. So that in fissure or ulcer of the anus, the inguinal glands, and in cancer the pelvic and lumbar glands, will be affected. Relations of Rectum.—The relation of the peritoneum to the rectum is by far the most important, and I will therefore begin with its consideration. The question is, how far down the rectum does the peritoneum extend ? how much of the rectum can be excised without running the risk of laying open the peritoneal cavity ? I have myself removed five inches of bowel from a male, without even seeing the peritoneum. In a female patient on whom I ope- rated, Douglas’s pouch was only two inches from the anus. In another case, that of a male, three and a half inches of rectum were cut off, the peritoneal cavity was thereby opened, and a coil of intestine protruded. From these examples it will be seen that no hard and fast line can be drawn as to the distance down the rectum which the peritoneum extends. Still, bearing in mind the variations which have occurred in the practice of a single individ- ual, three inches may be taken as a fair average when the bladder is fairly distended with urine; a little less if it be empty, a little more if it be fully distended. The upper portion of the rectum, which terminates at the third vertebra of the sacrum, is surrounded by peritoneum; it has, in fact, a meso- rectum, which allows it considerable play. Thus Mr. Davy, by means of his lever in the rectum, easily compresses the right common iliac artery. The other parts in relation with the rectum are, behind, the pyriformis muscle, sacral plexus of nerves, and branches of the internal iliac artery, and in front, in the male, the bladder and coils of small intestine; in the female, the uterus takes the place of the bladder. The middle portion of the rectum begins at the third vertebra of the sacrum, and ends at the tip of the coccyx. It has behind it the sacrum and coccyx, and in front, at its upper limit, the peritoneal fold of Douglas, and then the base of the bladder, vesiculse seminales, and prostate gland. The lower .portion has in front of it the membranous part of the urethra, separated by the triangular ligament on either side of the levator ani, and it is surrounded at its termination by the external sphincters. Malformations of the Rectum and Anus. As my personal experience of these errors in development has not been greater than that of any hospital surgeon not especially devoting himself to rectal surgery, I intend to treat this subject briefly, referring those among my readers who desire further information to Dr. Wm. Bodenhamer’s ex- haustive treatise on the “ Etiology, Pathology, and Treatment of the Con- genital Malformations of the Rectum and Anus.” The classification which I propose to adopt has, if no other merit, that ot simplicity. I shall divide all these cases into four divisions, as follows:— I. Those in which the anus is closed, the rectum being either partially or wholly deficient. II. Those in which the anus exists in its normal condition, but opens into a cul-de-sac, the rectum being partially or wholly deficient. III. Those in which a membranous septum, like a hymen, or a hand of 98 INJURIES AND DISEASES OF TI1E RECTUM. skin derived from the scrotum and fixed to the coccyx, stretches across the orifice—in the first case preventing, and in the second obstructing the outflow of meconium. IV. Those in which the anus is absent, and in which the rectum opens into the bladder, urethra, or vagina, or in some other abnormal position. In regard to the treatment to be adopted in cases of the first three divisions, there can be room for no two opinions: an outlet must be effected ; obviously through the anus, if possible, but if not, through the sigmoid flexure in the left groin. In those cases in which a membranous septum, or a band of skin, stretches across the orifice, the treatment is easy and successful. A crucial incision through the first obstruction, the removal of the second by means of a snip at either extremity, is all that is required. Not so, however, in the class of cases in which the rectum itself is more or less deficient. Here the surgical procedure is difficult, and, as a rule, not very successful. In the new-born infant, the pelvic measurements are naturally very small: the antero-posterior, from the tip of the coccyx to the symphysis pubis, and the lateral, from one tuber ischii to the other, are each but little over an inch. When therefore it is considered that a dissection of an inch and a half or more, up the pelvis, may have to be undertaken before the blind extremity of the rectum is found, the advantages of adopting M. Verneuil’s mode of procedure, namely, excising the coccyx, appear very great. Some surgeons recommend this step after a diligent search for the gut has been already made, but I am certain that this is a mistake. I think that in a case of this kind, in which life and death are in the scales, it is the operator’s duty to give himself every chance from the beginning; and, always, of course, ex- cepting those cases in which a bulging shows that the rectum is low down, removing the coccyx, although it be a mere nodule, increases the space in which to work in the right direction, that is, posteriorly. If the surgeon has succeeded in finding the rectum, should he bring it down and attach it by sutures to or as near to the skin as possible ? I am inclined to answer this question in the negative. If traction has to be put on the intestine to lower it, it is quite sure that the sutures will only tear or ulcerate through the wall of the gut, which will then certainly recede and fix itself at some higher point; -whereas, if the intestine comes down readily without traction, I do not know that much is gained by putting in sutures, though something may be lost by preventing matter from being evacuated from between the sides of the intestine and the wound. The great tendency to contraction which exists in these cases must be overcome by most diligent dilatation, at first with the little finger, and afterwards with the forefinger, three times a day ; after some months it may be sufficient to pass the fingei only once a day, and perhaps, when a year has passed, once a week may suffice Still, the most rigid watch must be kept, and at the slightest sign of contrac tion the times of dilatation must be redoubled. Supposing that, after a most careful and prolonged search for the rectum, the surgeon fails to find it, what should be his next step ? Some writers recommend waiting half a day, in the hope that the bowel may come down during straining, but I am of opinion that this chance is exceedingly small, and that the delay will considerably lessen the probability of success attend- ing an operation in the groin. The incision should be parallel with Poupart’s ligament, and should begin outside of its centre. It should be not less than an inch and a half in length, and about a third or half an inch from the ligament. After dividing the skin and muscles, the fascia transversalis is reached, with the peritoneum beneath it. I doubt if it would be possible to insure dividing them sepa- INJURIES OF THE RECTUM. 99 rately ; at any rate, nothing would be gained by the attempt, so that they may be simply cut through together cleanly on a director. The large intestine can be recognized by the absence, or at all events shortness, of mesentery, which conveys a feeling of fixity to the hand, and by the mesen- tery being attached to the left side of the intestine, as well as by the saccu- lated appearance of the latter. The other distinctive signs of the large intestine—its longitudinal bands and appendices epiploicse—are generally too ill marked in the new-born child to be of diagnostic use. When the intestine has been found, it must be closely attached to the edges of the wound, peri- toneal surface to peritoneal surface, with fine sutures, and then a very small opening made into it. Nelaton recommended an opening of less than a third of an inclr. When this operation of emergency has been successfully performed, should an attempt be made to establish a normal outlet by passing down a bougie through the wound in the intestine into the blind rectum, and directing it towards the perineal wound ? I think not, for the following reason : A very thorough search has already been made from below, which has proved fruit- less. Therefore there is strong reason to assume that the rectum terminates within the peritoneal cavity, and that its cul-de-sac is covered by peritoneum. At least so it has proved in several cases in which this procedure has been attempted, but has resulted in acute peritonitis and death. In those cases, in the female, in which the rectum communicates with the vagina, and has no other outlet, the treatment indicated is as follows : If the bowels can be properly relieved through the opening, the surgeon may wait until the child is six months old, when it will be better able to bear the ope- ration, which will also be rendered easier on account of the parts being larger. If, however, it is a question of urgency, through the opening being too small for the passage of meconium, a bent probe should be passed through the fistula and directed towards the perineum, and then cut down upon. The prognosis in these cases is favorable. [If the rectum, in the male, open into the bladder or urethra, the best that can be done is to introduce a grooved director or small staff, and cut down upon this as in the operation of perineal section, thus forming a common cloaca for the escape of both fecal matter and urine. The opening must be kept patulous by subsequent dilatation. If the gut open on the surface of the body, at a distance from the normal position of the anus, it will usually be proper to decline an operation, and merely dilate the opening so as to prevent fecal accumulation.] In conclusion, it must be mentioned that, although one would naturally suppose a speedy death to be the inevitable consequence of a rectum with no outlet, unrelieved by surgery, yet several cases are recorded in which periodic fecal vomiting has prevented such an issue. [Injuries of the Rectum. Wounds of the Rectum.—Incised, lacerated, contused, punctured, and gunshot wounds are all met with in the rectum, but, provided that they are uncomplicated, usually heal without difficulty, and present no points calling for special notice. If the lesion involve the vagina or bladder, recto-vaginal or recto-vesical fistula may follow, and a plastic operation may ultimately be required. If the peritoneum be opened, in a deep rectal wound, peritonitis is, of course, apt to ensue, though not inevitable, and death may result under these circumstances. Hemorrhage from a rectal wound should be controlled by the application of ligatures, if the bleeding points can be seen, but if not, 100 injuries and diseases of the rectum. by pressure, which may be applied by means of Bushe’s apparatus, an instru- ment resembling the colpeurynter—an India-rubber bag which can be intro- duced in a flaccid state, and afterwards distended with air or iced water—or, perhaps even more securely, by packing the gut around a tube or English catheter provided with an apron, as is done with the perineal wound after the operation of lithotomy. A remarkable case is recorded by Dr. Otis,1 in which a distinguished officer, conducting a retreat under a heavy fire from the enemy, was killed by a ball entering his anus as he leaned forward over his horse’s neck; no external wound was perceptible, and the nature of the lesion was not recognized until, when the body was embalmed, the ball was found lodged in the patient’s lung. Foreign Bodies in the Rectum.—These may have been directly introduced into the rectum through the anus, or through a wound, or may have de- scended from a higher point, having been swallowed, or, as in the case of gall-stones, having originated in another part of the patient’s body. The variety of substances which have been found in patients’ rectums, having been introduced either by themselves or by others, is very great,2 embracing such diverse substances as pebbles, slate-pencils, diamonds, bottles, beer-glasses, forks, files, snails, and a pig’s tail.3 The symptoms caused by foreign bodies in the rectum are those of local irritation, often attended by great pain, with con- stipation, sometimes ending in complete obstruction. Peritonitis may ensue. The treatment consists in extraction, by such means as may be suggested by the requirements of the particular case and the inventive faculty of the surgeon. Anaesthesia is usually required, and advantage may be derived from thorough dilatation of the sphincter. If necessary, Yerneuil’s operation of linear rec- totomy may be performed, as in cases recorded by Raffy and Turgis. Ano- dynes should be given afterwards in the form of suppository. Prompt treat- ment is essential in these cases, as the foreign body, if allowed to remain, may perforate the rectum, causing fistula; may ulcerate its way into the bladder, vagina, or peritoneum ; or may slip up into the sigmoid flexure or descending colon, from which it could only be removed by a more dangerous operation.] Fistula in Ano. Fistula is the most common rectal disease affecting the adult, certainly in hospital practice, and probably in private practice too. Men are more sub- ject to it than women. This disease is most frequently met with during middle age, but it is by no means restricted to that period of life. I have often operated upon infants in arms, and upon men from seventy to eighty years of age. Causes of Fistula in Ano,—The causes of fistula, or of abscess ending in fistula, are : Injuries to the anus; injury to the mucous membrane of the bowel by very costive motions, by straining at stool, or by foreign bodies swallowed (fishbones and the bones of rabbits are occasionally found in rectal abscesses) ; exposure to wet and cold, and particularly sitting upon damp seats after exercise, when the parts are hot and perspiring. I have traced many cases of rectal abscess to sitting on the outside of an omnibus, shortly after active 1 Medical and Surgical History, etc., Second Surgical Volume, p. 319. 2 See Poulet’s curious Treatise on Foreign Bodies in Surgical Practice, vol. i. pp. 217 et seq. New York. 1880. 3 See Marchettis’s case, Vol. V., page 592, supra. FISTULA IN ANO. 101 exertion. Predisposing causes are the scrofulous diathesis and certain de- praved conditions of the blood, such as frequently give rise to boils or carbuncles. Here I would observe that sudden and deep-seated suppuration is often found to occur after severe itching in the part, with only slight ery- thematous redness on the surface. Fistula in children almost always results from the presence of worms, or from injury to the anal region. Course op Fistula in Ano.—Fistula, in the majority of cases, commences by the formation of an abscess immediately beneath the skin, just outside of the anus ; it is generally said to commence in the ischio-rectal fossa, but I am certain that this is the rarer situation. It may also begin by ulceration of the mucous membrane of the rectum, as is seen in phthisical patients ; when it arises in this manner fecal matter collects in the connective tissue, and thus an abscess forms and opens on the outside. Lastly, an abscess may form in the submucous connective tissue of the rectum, and then burst into the bowel. This is its ordinary termination, but it may insidiously undermine the rectum in any direction, and I am convinced that the more serious forms of tistula not uncommonly originate in this manner. Rectal abscess may arise rapidly, when there will be redness, tenderness, and often very acute pain, with constitutional disturbance; or it may he months in formation, and be perfectly painless even on manipulation, the only evidence of the abscess being a flat, boggy, crepitating enlargement which can be felt at the side of the anus. This form of abscess is the most danger- ous, as it is apt to be neglected ; it has little tendency to open spontaneously, and it results in a burrowing up by the side of the rectum to some distance, as well as under the skin towards the perineum, or buttock, or both. I think, on the whole, by far the most usual course is for the abscess to form rapidly, with great pain, and if not interfered with to burst externally; the patient then becomes suddenly easy, and fancies that his trouble is over. The cavity of the abscess seldom entirely closes, but sooner or later it contracts, leaving a weeping sinus with a pouting, papillary aperture, which may be situated near or far from the anus. It is not often that one sees a rectal abscess very early; either the patient is not aware of the importance of attending to the early symptoms, or he temporizes, using fomentations or poultices; or even when seen by the surgeon, the proper treatment is not always promptly adopted. I have seen large abscesses painted with iodine, in the hope of obtaining absorption. It is well to remember that, as soon as pus is formed, there is only one method of treatment to be tor a moment considered, and that is incision. It is certainly less damaging to cut into an inflamed swelling near the anus without finding pus, than to let a day pass over after suppuration has com- menced ; the longer the abscess is left unopened, the greater is the danger of the formation of lateral sinuses. Before any pus exists, rest, warm fomenta- tions, and leeches may cut short the attack, but such a result is very rare. Very small abscesses can be well and easily opened in the following way: The patient being placed on the side in which the swelling exists, the surgeon passes the forefinger of the left hand, well anointed, into the bowel, and then places the thumb of the same hand below the swelling, on the skin. ISTow making outward pressure with the finger in the bowel, and thus rendering the swelling quite tense arid defined, it being in fact taken between the finger and thumb, a curved bistoury is to be thrust well into the abscess, in a direction parallel to the long axis of the bowel, and made to cut its way out towards the anus; it is well to make a thoroughly free incision, corn- 102 INJURIES AND DISEASES OF THE RECTUM. mencing at the outermost part of the swelling. If the part be thoroughly frozen by the ether-spray, this operation is rendered painless. The method of operating above described is, however, by no means suitable to a severe or deep-seated abscess; but I can safely say that, if a patient suffering from this latter form will allow the surgeon to act in the proper way, it will be almost certain that no fistula will result. The following is the method which I adopt. The patient must take an anaesthetic, as the operation is very painful. I first lay open the abscess outside of the anus, from end to end, and from behind forwards, that is, in the direction from the coccyx to the perineum. I then introduce my forefinger into the abscess and break down any secondary cavities or loculi, carrying my finger up the side of the rectum as far as the abscess goes, probably under the sphincter muscles, so that only one large sac remains; should there be burrowing outwards, I make an incision deeply into the buttock, at right angles to the first. I then syringe out the cavity, and carefully fill it with wool soaked in carholized oil, one part to twenty ; this I leave in for a day or two, then take it out and examine the cavity, and dress the part again in the same manner, but in addition I now use, if I think it necessary, one or more drain- age-tubes. In a remarkably short time these patients recover; the sphincters have not been divided, and the patient therefore escapes the risk of incon- tinence of feces or flatus, which sometimes occurs when both the sphincters are deeply incised. I could cite numbers of cases of very unfavorable aspect, and in old persons, that have done quite well, when treated as I have de- scribed. To give the patient the best possible chance of recovery, he should be kept on the sofa, if not in bed. I always think it advisable to clear out the bowels once, and then to confine them by an astringent dose of opium for three days; entire rest is thus secured to the parts, and every opportunity is given for the cavity of the abscess to fill up. After a time the carholized oil should he discarded, and lotions used containing sulphate of zinc or copper, or friar’s balsam, which last does great good. The surgeon should never stuff' an abscess, but put wool in very lightly, and use drainage tubes, of which those of India-rubber are the best. The questions naturally arise, why do these abscesses usually fail to close up? Why do they form sinuses? There are doubtless several reasons, but the following may be sufficient: The constant motion of the parts, caused by action of the bowels and by movement of the sphincters, almost at every breath, and the presence of much loose areolar tissue and fat. The vessels also, near the rectum, are not well supported, and the veins have no valves ; there is therefore a tendency to stasis, and this is inimical to rapid granulation. We know that abscesses are always apt to degenerate into sinuses when situated in any lax areolar tissue, as in the axilla, neck, or groin. After an abscess has long existed, the discharge loses its purulent charac- ter and becomes watery ; the cavity gradually contracts, and at last only a sinus, very often formed of dense tissue, remains. If now a probe be passed very tenderly into this sinus, allowing it to follow its own course, and after this is done, the finger be placed in the rectum, it will probably be found that the probe has traversed the sinus and passed through an internal opening, and that it can be felt in the bowel. In this case there would be a typical, simple, complete fistula ; and this is by far the most common variety, very few fistulie that have existed for more than three months being without an internal opening. Besides this common form there are two other descriptions of fistula, viz., the blind external fistula and the blind internal fistula. In the blind externalfis- tula there is an external opening, and it is therefore called an external fistula, but no internal opening, and hence a blind external fistula. In the other FISTULA IN ANO. 103 variety there is an internal opening, and consequently it is an internal fistula, but there is no external opening, wherefore it must be called a blind internal fistula. The blind internal form of fistula results usually from some injury to, or ulceration of, the lining membrane of the rectum, or abscess in the con- nective tissue beneath the mucous membrane, and it is most commonly found in consumptive patients.. Now, these terms “ complete,” “ blind external,” and “ blind internal” are useful, but surgically they are of little moment; there is, however, an impor- tant division of fistulse as regards both patient and surgeon, and that is into anal fistulse and 'pelvic or rectal fistulee. An anal fistula is one which commences in the skin a few lines from the margin of the anus, opens just inside the orifice, passe's at most under a few fibres of the external sphincter, and is trivial and can be rapidly and safely cured. By pelvic or rectal fistula I mean a fistula which, commencing pro- bably by an abscess in the isehio-rectal fossa, passes underneath both sphincter muscles, and opens possibly high up in the bowel, indeed in the pelvis. This is the fistula which is dangerous to the patient, and it will call forth all the knowledge and experience of the surgeon to bring it to a successful issue. A patient with fistula should be examined in the following manner: He should be placed upon a hard couch, on the side upon which the disease is supposed to be situated, the buttocks being brought close to the edge of the couch, and the knees drawn up. The anus and surrounding parts should be carefully inspected to detect any visible malady. The orifice of a sinus may be seen, or some discoloration of the skin may show the site of the disease; then, feeling gently all around the anus with the forefinger, the surgeon will often, by the induration, detect the course and position of the sinus, which feels like a pipe or piece of wire beneath the skin. Having satisfied himself in these respects, he passes the probe into the external aperture, holding it with a very light hand, and letting it almost find its own way. In many cases, as I have before said, it will pass right into the bowel; when the probe has been passed as far as it will go without using any force, the surgeon in- troduces the forefinger of the left or right hand into the rectum, and feels for the internal opening of the fistula, if the probe has not passed through it; having found it, he can with the other hand guide the probe towards it. The internal opening is usually situated just within the anus, in the depres- sion which exists between the external and internal sphincters. I think that the reason that the internal opening is situated so often in this position, is because when the abscess forms, as in most cases it does, just outside of the anus, it does not burrow deeply, but passes close under the external sphincter ; it thus is prevented from ascending higher up the bowel by the thick band of the internal sphincter, and consequently is turned inwards, and makes its way through the lax areolar tissue, in the space between the two muscles. When the abscess really commences in the ischio-rectal fossa, it burrows deeply, and then most usually passes beneath the internal sphincter, and opens, if at all, high up in the rectum. Occasionally more than one internal opening exists, and I have many times seen what the late Mr. Syme declared could not occur—viz., two internal openings in the same patient at the same time. It is all-important that this internal aperture be felt with the finger (so that in operating it may be included in the incision), for not infrequently, from the tortuous nature of the fistula, the probe cannot readily be got through it. This is markedly the case in the horse-shoe form of fistula, which is not uncommon. The sinus here runs around, generally from one side of the anus to the other, so that the external and internal openings are placed on opposite sides of the bowel. This variety, if not properly diagnosed, is rarely cured by one 104 INJURIES AND DISEASES OF THE RECTUM. operation, the sinus being laid open on one side of the bowel, and left un- touched on the other. This mistake may generally be avoided by careful examination with the linger externally, as a hardness can be felt on both sides of the anus ; the patient will also sometimes give assistance by saying that he has felt something like a “piece of wire” on both sides of the boweh When the surgeon passes his linger into the bowel to search for the internal opening, he should never forget to carry it higher up, to see if the rectum be otherwise healthy ; he may find stricture, ulceration, or malignant disease coexistent. Without this precaution these conditions may be overlooked. Fistula may exist for years without causing much pain or inconvenience to the patient. I have met with many persons who had had rectal sinuses for ten years and upwards, and had never had anything done beyond the occasional passing of a probe when the external aperture had got blocked up, and when pain had been caused by the formation and retention of matter. When the tissues around the sinus become very dense, there may be for a long period an arrest of burrowing, but an attack of inflammation set up at any time will cause a fresh abscess. I am often anxiously asked by sufferers if a fistula can be cured without an operation. To this I reply, that I have seen fistulse of all kinds get well without treatment, but that these occurrences are quite excep- tions to the rule, and should not be depended upon ; still, if the fistula be sim- ple, and the patient be unwilling to submit to any operation, certain methods may fairly be tried. For the last few years I have been successful on many occasions in curing blind external, and even complete, fistulae, by means of carbolic acid and drainage-tubes. This mode of treatment offers, in my opinion, the best chance for the patient. I first dilate the outer opening of the fistula for a few days with a small portion of sea-tangle or sponge-tent. When the opening is large enough, I clean out the sinus Avell, and then rapidly run down to the end of it a small piece of wool saturated in strong carbolic acid, with ten per cent, of water. I mount this wool upon a stiff* piece of wire set in a handle, and just roughened at the free end ; I then withdraw the wire and put in a drainage-tube, just large enough to fill the sinus, and keep it in; the interior of the sinus is, by the acid, induced to granulate, and, if successful, it will be found, almost day by day, that a shorter drainage- tube will be required until the whole sinus is filled up. It may be neces- sary to apply the acid more than once, and to use other stimulants, such as friar’s balsam, solutions of sulphate of copper or nitrate of silver, etc. I have succeeded usually in some bad cases by scraping the walls of the sinus with a small curette of steel. I do not advise injecting the sinus; wool on a probe is a much better mode of medicating. Care should always be taken to keep the external opening well dilated. A perforated ivory collar-stud answers admirably in effecting this, the small hole allowing pus to dribble through. One practical point I would mention. Tjie further the external opening is from the sphincter, the more likelihood is there that a sinus may heal. It is very important in these cases not to do any harm. The surgeon should always enjoin rest after a strong application, and watch that not too much inflammation be set up. It must be remembered that most of the so-called spontaneous cures are illusory, and that the disease returns in time, and the same may be said even of those in which treatment, short of division, has seemed effectual. In my opinion there is nothing equal to the division of the fistula, and getting it to fill up soundly from the bottom. Whilst describing the treatment of fistula without cutting, I must refer to the use of the elastic ligature, so valuable in cases in which the knife is contra-indicated. The advantages of the ligature are the following: There is little or no pain, during or after its use, and there is no bleeding—a manifest advantage in dealing with patients whose tissues bleed copiously on incision. FISTULA IN ANO. 105 In phthisical patients it is, in my opinion, the best means of dividing a sinus. In very deep, bad fistulse, the elastic ligature is most valuable as an auxiliary to the knife. In sinuses running high up the bowel, where large vessels are inevitably met with, I use the ligature in preference to the knife, as I by this means often avoid dangerous hemorrhage. The objection to the general use of the ligature is that it is impossible, in many instances, to be absolutely sure that only one sinus exists. If there are lateral sinuses, or a sinus burrowing beneath or higher up the rectum than the main trunk through which the ligature is passed, the patient will not get well with one operation. In these complicated cases, the knife alone, or conjoined with the ligature, is the trustworthy remedy. I have for a long time now used only solid India-rubber, so strong that I cannot break it; and I put it on as tightly as I can, and fasten it by means of a small pewter clip pressed together by strong forceps. The ligature cuts through in about six days. I have devised an instrument (Fig. 1320) for passing the India-rubber through a fistula, which renders this generally tedious process easy and expeditious. Fig. 1320. Instrument for drawing India-rubber through fistula from within outwards. And now we come to the consideration of cutting operations for fistula. First of all, the patient’s bowels must have been well cleared out; a purge three days before the operation, and again the night before, and an injection in the morning, will effect this. The patient should be placed on a hard mattress, on the side in which the fistula exists, the buttocks being brought quite to the edge, and the knees well drawn up to the abdomen. The surgeon now takes a Brodie’s probe- director made of steel, with a small probe-point; oils it and passes it into the external opening, through the sinus and the internal opening, if possible; then inserts his finger into the rectum, and on feeling the point of the director in the bowel, if the patient be not anesthetized, tells him to strain down ; he will thus be able, without difficulty, to turn the point of the instrument out of the anus. This done, the tissues forming a bridge over the director are to be divided with a curved bistoury. If the fistula be deep, running beneath the sphincters, it will not be possible to get the point of the probe out at the anus, even if the patient be anaesthetized ; in such a case the surgeon must pass the director well through the sinus, then insert his left forefinger into the rectum, steady the director, and run a straight knife along the groove, cutting carefully towards the bowel until the parts are severed. To inex- pert surgeons I recommend my deeply-grooved director and scissors (Fig. 1821); I may add that gentle dilatation of the sphincters under these diffi- culties gives the surgeon an immense advantage of which I now constantly avail myself. If there be no internal opening, there will almost always be found some part where only mucous membrane intervenes between the point of the probe and the finger. At this spot, the director should be worked through, and the point brought down as before. When the fistula has been divided from the external to the internal opening, search is made higher with the probe 106 INJURIES AND DISEASES OF THE RECTUM. for any sinus running up beyond the internal opening; if such exists, it must be laid open. Search is next made for lateral sinuses extending from the outer opening; also for any burrowing outwards beyond the same point. A fistulous orifice is often not at either end of the sinus, but somewhere in its Fig. 1321 Spring-scissors with probe-point in grooved director. course. The part should be carefully examined to see if there is a secondary sinus running from and beneath the main track. Frequently, in fact nearly always, in old-standing cases, the deeper sinus does exist, and unless it be incised with the rest, the patient will not get well. When all the sinuses are slit up, the surgeon with a pair of scissors (Fig. 1322) takes off a portion of the overlapping edges of skin; they are often thin Fig. 1322. Scissors for removing overlapping edges of skin in operation for fistula. and livid, having very little vitality. If not removed, they will fall down into the wound and materially retard the healing process I have frequently in- duced healing in a fistulous track which had been only laid open, by paring off the edges of the skin which were undermined. In old-standing cases, where there is much induration, it is very good practice to draw a straight knife through the dense track of the fistula, and outwards beyond the external open- ing; it is wonderful how rapidly quite cartilaginous hardness passes away after this has been done. This incision was practised by the late Air. Salmon, and is called his “back cut.” Having completed the operation, the surgeon takes some absorbent cotton-wool, and with a probe packs it well into the bottom of the wound, packing it into every part, and being the more particular about this if the incisions have been extensive, or pass high up the bowel, or if the parts are very dense and gristly, and especially in cases operated on for the second time. Of course, if a large vessel is seen spirting, it is secured either by a ligature or by torsion before packing. The last step is to place a good firm pad between the buttocks, over the wounds, and a T bandage to exert pressure on it. The most painful form of fistula, but at the same time fortunately the most uncommon, is the blind internal fistula. I have seen man}7 cases where the aperture was one third of an inch in diameter. The feces, when liquid, pass into the sinus and create great suffering, a burning pain often lasting all day after the bowels have acted. In operating upon a blind internal fistula, if the surgeon can feel by the FISTULA IN ANO. 107 hardness externally the site of the abscess, he may plunge his knife into it, and thus make a complete fistula through which of course he passes his direc- tor. If he cannot feel any hardness or see any discoloration to guide him to the situation of the sac of the abscess, the best way of proceeding is to bend a silver probe-director into the form of a hook, and then hook tliis into the internal aperture, and bring the point down close under the skin ; he then cuts upon it, thrusts it through, and completes the operation. In operating upon women suffering from fistula (especially when the sinus is near the perineum), I cut as little as possible, for anything like too free incisions are apt to end in incontinence of feces, or, at all events, in such par- tial loss of power in the sphincter as to prevent the patient retaining flatus, a result which I need scarcely say is a most disagreeable one. Even in males, incontinence of wind and liquid feces almost always results from cutting the muscles, and principally the internal sphincter, in more than one place. It should be made a rule to divide the sphincters at right angles to the direc- tion of their fibres. If the muscles are divided at all obliquely, good union is never obtained, and even in comparatively slight cases incontinence may follow. The method which I have adopted in cases of incontinence of flatus and liquid feces, is the use of Paquelin’s thermo-cautery. Its judicious employ- ment will stimulate the muscular fibres and cause them to contract, and by diminishing the circumference of the anus induce action of the fibres which are left. After an operation for fistula, the bowels should be confined for three days; a mild purge must then be administered, and full diet allowed. The wool usually comes out when the bowels act; if not, I gently remove it. As a matter of fact I generally remove a portion of the wool the day after the operation, leaving only some at the bottom of the wound. If the whole plug is left in, the patient will probably be very uncomfortable, as he cannot easily get rid of wind, and the danger of primary hemorrhage being over in twenty-four hours, there is nothing gained by retaining a mass of wool in the bowel. Very little dressing is required in the after-treatment of fistula; in fact, it is better to do too little than too much. The wound should be gently cleansed every day by allowing some weak Condy’s solution or carbolic lotion (1 in 60) to flow over it, then tenderly dried with cotton-wool, and lastly a little wool soaked in olive oil should very gently belaid in the wound. Only when the wound is sluggish do I prescribe lotions; then, according to circumstances, blackwash, carbolic acid, sulphate of zinc or copper, tartrate of iron, or friar’s balsam, may be advantageous. Iodoform, finely powdered or in ointment, I have found to be an excellent application. Although the surgeon should not interfere with nature’s work, he must be always on the watch during the healing process for any burrowing or formation of fresh sinuses. Whenever the discharge from a wound is more than its extent of surface seems to warrant, the surgeon may be sure that burrowing has commenced, and should search diligently for the sinus at once, for the longer it is left the larger and deeper it will get. Sometimes it is under the edges of the wound that it commences; at other times, at the end of the wound internally or externally; and occasionally it seems to dive down from the base of the main fistula. Such a sinus should be laid open at once. The patient, too, should always be encouraged to report immediately any pain in or near the healing fistula; often he will be the first to discover, by the existence of some unpleasant sensation, the commencement of a small abscess or sinus, and will be able also to indicate its situation. It is important that the recumbent position should be kept for some time, but not necessarily in bed. After the first week or ten days subsequent to the 108 INJURIES AND DISEASES OF THE RECTUM. operation I usually allow my patients to recline upon tlie sofa for the greater part of the day. Never, if it can be avoided, should a fistula be operated upon that is from any cause acutely inflamed. While inflammation is going on, fresh sinuses are likely to form, the areolar tissue breaking down very readily ; if an ope- ration is performed under these conditions, failure is almost certain to ensue. All that should be done is to make a free dependent opening, and wait till the sac of the abscess contracts before laying open the resulting fistula with its offshoots. The subject of fistula in conjunction with phthisis, which I have treated of very fully in my book on Diseases of the Rectum, I can only just advert to here, on account of want of space. From my cases I find that 16 per cent, of patients with anal fistulre have had well-marked phthisis either active or latent. Fistulse in persons of a phthisical tendency have the following pecu- liarities : They have a disposition to undermine the skin and mucous mem- brane with remarkable rapidity, but not to burrow deeply. The internal aperture is almost always large and open ; on passing the finger into the bowel the opening can be felt most distinctly, often a third of an inch in diameter. The external opening is also frequently large and ragged, not round ; it is irregular in form, and surrounded by livid flaps of skin ; when the probe is passed into this aperture, it can be swept around over an area of more than an inch, and not infrequently the skin is so thin that the probe can be seen beneath. The discharge is thin, watery, and curdy, very rarely really purulent. The sphincter muscles are almost always very weak. When the surgeon introduces his finger into the bowel, he is hardly sensible of any resistance being offered. It is common to observe in these patients much longish, soft, silky-looking hair around the anus. When a case of this kind comes to me, I am never in a hurry to operate. I like to watch the patient for a little while, and observe whether the lung mischief is advancing, and also find out if the cough is constant. I wait, if I can, for genial weather when the patient need not be confined to a close room. As for the operation, it must be thorough, but as little interference as possible with the sphincter muscles, especially the internal, should be made. After the operation the patient should not be confined to bed, but should be allowed to lie for hours on a mattress in a bedroom facing south or west, well covered up on a couch, by the open window. He should not be purged after the operation, but his bowels should be opened by diet and mild laxatives. If his bowels act once in three days, it is usually quite sufficient. For my own part, I do not think that there are any clinical facts tending to show that the operation for fistula in phthisical patients renders the lung affection worse, or makes it more rapidly progressive. Except in the case of rapidly advancing phthisis, if the operation be performed discreetly, at the right time of year, and with favorable surroundings, the patient does well, and will be benefited, not damaged, by the cure of his rectal malady. Fissure and Painful Irritable Ulcer of the Rectum. These are found more frequently in women than in men, although not rare in the latter. I have seen fissure in a baby in arms, and in an old woman of eighty, who was also suffering from impaction of feces. By far the most usual seat of fissure is dorsal or nearly dorsal. It may be brought about by an injury or tearing of the delicate mucous membrane at the verge of the anus, such as may be caused by straining, or by tlie passage of very dry, hard motions; sometimes it follows severe diarrhoea; it is frequently FISSURE AND PAINFUL IRRITABLE ULCER OF THE RECTUM. 109 the sequel of a confinement, or the accompaniment, and occasional result, of polypus. Syphilis is the origin of many fissures. In fissure the pain during action of the bowels is more or less acute; some describe it as like tearing open a wound, and doubtless it is of a very excruciat- ing character. I have known patients who for hours could not bear to stir from one position, the least movement causing an exacerbation of the pain. This agony induces the sufferer to postpone relieving the bowels as long as possible, the result being that the motion becomes desiccated and hardened, and inflicts more grievous pain when at last it has to be discharged. After an action of the bowels, the pain may in a short time entirely cease, and not return at all until another evacuation takes place ; but often it continues very severe, and of a burning character, or it is of a dull heavy kind and accom- panied by throbbing, lasting for hours, sometimes even all day, so that the patient is obliged to lie down, and is utterly incapable of attending to any business. In some instances the pain does not set in until a quarter or half an hour after the bowels have acted. In children and young persons, unless a polypus complicates the fissure, I think it is almost always curable without operation. In children suffering from hereditary syphilis, numerous small cracks around the anus are common, and they cause much pain. Mercurial applications and extreme cleanliness soon cure them, but they will return from time to time unless antisyphilitic medicines be taken for a lengthened period. Fissure, although really so simple a matter, and its cure generally so easy, wears out the patient’s health and strength in a remarkable manner, the constant pain and irritation to the nervous system being more than most per- sons can bear. What under these circumstances is very extraordinary, is the length of time that people go on enduring the malady without having any- thing done for it. It is common for fissures to heal for a time, and then break out again, so that patients are apt to think that a perfect cure will presently result, and therefore defer proper treatment. The usual position on the right side is the best for making an examina- tion. The patient raises the upper buttock with the hand, and the surgeon then with forefinger and thumb gently opens the anus, telling the patient to strain dowm; at the same moment he will thus be able to see just within the orifice an elongated ulcer, shaped like a split grain of barley; its floor may be very red and inflamed, or, if the ulcer be of long standing, of a grayish color, with edges well defined and hard. Frequently the site of the fissure is marked externally by a small clavate papilla, or minute muco-cutaneous poly- poid growth; this must not be confounded with ordinary polypus, and is not the cause of the fissure, but the result of the local irritation and inflam- mation which have been going on. Sometimes the situation of the fissure is indicated by an inflamed and swollen piece of skin, and in this case ulcera- tion through this portion of integument not infrequently occurs, and a small but extremely painful fistula results. When operating for the fissure this club-shaped papilla ought to be snipped off, or the case may not do well, as it falls down into the wound and retards or quite prevents healing. Of course, too, if a fistula exists, it also must be laid open throughout its whole length, as otherwise no recovery will ensue. Fissure is very commonly associated with uterine displacement. The suc- cessful treatment of this may be sufficient to cure the fissure (if no polypus exists), or at all events the ulcer will afterwards yield to local applications and general treatment. Even if the fissure be benefited by operation, as long as the uterine malady exists, there will be constant danger of a relapse taking place. If in combination with uterine displacement chronic cystitis and spasmodic pains in micturition are present, the surgeon may depend upon 110 INJURIES AND DISEASES OF THE RECTUM. it that the case will call for all his skill and patience to bring it to a success- ful issue. Gelatinous and fibrous polypi are not uncommon complications of fissure, and are generally situated at its upper or internal end. If the polypus is not removed at the time that the ulcer is divided, failure is certain to result. If the fissure is of recent origin, it may often be cured without operation, especially if it is situated anteriorly. In women this can almost certainly be accomplished. The syphilitic fissure is the most amenable to general treatment, and syphilitic fissures are often multiple. If an operation be re- quired for multiple fissures, one incision through the sphincters will be suffi- cient. In all cases of fissure, rest in the recumbent position should, as much as possible, be adopted. Mild laxatives should usually be given to keep the bowels open once daily, but diet will sometimes effect this. The domestic remedy of figs soaked in oil, or onions and milk, at bedtime, may be sufficient, I often order a combination in equal parts of confection of sulphur and con- fection of senna; small doses of sulphate of magnesium or of sulphate of potassium, half a tumbler of Pullna or Hunyadi-Janos water taken in the morning fasting, the compound liquorice powder of the German Pharmaco- poeia, and the liquid extract of cascara sagrada, are great favorites of mine. It is necessary to alternate the medicines, as one or other seems to lose its effect. All drastic purges should be avoided, but I do not object to small doses of the aqueous extract of aloes combined with nux vomica and iron. The patient should manage to get the bowels to act the last thing at night, instead of in the morning, as the pain does not continue as long when lying down, and this habit may be brought about by a nightly injection of half a pint of cold water. After the action, xx to f 5ss of liq. opii sed. should be injected with f 3ij of cold starch. As an application, I know of nothing better than the following ointment : Hydrarg. subchloridi, gr. iv; Morphiae sulphatis, gr. j; Ext. belladonnse, gr. ij; tTng. sambuci, 3j, to be frequently applied. I have effected many cures with this ointment alone. A very light touch with the nitrate of silver, not to cauterize, but to sheathe the part with an albumi- nate of silver, is occasionally advisable. Should one little spot in the ulcer be particularly painful, it is probably due to the exposure of a nerve filament, which may be destroyed by the application of the acid nitrate of mercury. If there be severe spasm of the sphincter, extract of belladonna should be thickly smeared around the anus over the muscle. If ointments disagree with the sore, finely powdered iodoform may be tried, mixed with white vase- line, or lead-water in combination with opium. Painting over the part with liq. plumbi subacetatis is a most successful remedy. But it must be acknowl- edged that the most carefully devised and carried out general treatment frequently fails. If the base of the ulcer be gray and hard, and if on passing the finger into the bowel, the sphincter is found hypertrophic and spasmodically contracted, feeling as it often does like a strong India-rubber band with its upper edge sharply and hardly defined, nothing but the adoption of operative measures to prevent all action of the muscle, for a greater or less length of time, is likely to effect a cure of the fissure. The operation may be aided by intro- ducing a speculum; this enables the surgeon to see exactly where his knife should go, and the parts are also rendered tense, so that their division is facilitated ; the incision should commence a little above the upper end of the fissure, and should terminate a little beyond its outer end, so that the whole sore may be cut through. As a general rule, the depth of incision should not be less than a quarter of an inch. If the outer end of the fissure be marked by a swollen and inflamed piece of Fissure and painful irritable ulcer of the rectum. 111 skin, it is better to remove that with a pair of scissors, for by so doing the healing process is greatly expedited ; the small polypoid growth also, so often found in fissure, must be at the same time snipped off, and a fistula, if such exist, laid open. If the fissure is quite dorsal, the fibres of the muscle should Fig. 1323. Fig. 1824. Anal speculum. Four-bladed anal speculum. be divided somewhat laterally. A small piece of cotton-wool should be placed in the wound, and allowed to remain for from twenty-four to forty- eight hours. The bowels must be kept confined for two or three days after the operation. Usually there is no occasion to keep the patient in bed; a few days’ rest on the sofa suffices. If, however, there be any uterine complication, the patient must be kept entirely at rest and lying down until the wound has soundly healed, as otherwise the wound will not close, or, what is worse, unhealthy ulceration will supervene. I come now to the consideration of the small circular ulcer usually situated higher up in the bowel than fissures are, and differing from them somewhat in symptoms, but not in treatment. The common situation of the small circu- lar ulcer is above, or about the lower edge of, the internal sphincter. There is less severe pain at the moment of defecation, but it comes on from five minutes to a quarter or half an hour after that act, and then is quite as in- tolerable as that resulting from fissure. These minute ulcers are more diffi- cult to find than fissures, as they often cannot be seen without using a speculum, or getting the patients to strain violently, which they will not do for fear of exciting pain. An educated finger detects these ulcers directly ; they feel much like the internal aperture of a fistula, but their edges are harder, and therefore more defined, and there is no elevation above the surface of the surrounding mucous membrane, as is frequently the case in fistula when a pouting opening exists. These ulcers often burrow, and then they become the internal openings of blind internal fistulse. A great many apparently anomalous symptoms are produced by small painful ulcers of the rectum: retention of urine, pain in the back, and pain and numbness down the back of the legs, leading to unfounded fears of paralysis, may be mentioned as not uncommon. I cannot conclude my remarks on fissure and painful ulcer of the rectum without adverting to a mode of treatment which I have practised with success, especially in cases in which a cutting operation has been contra-indicated. I refer to dilatation. Originated by Recamier and much practised by Dolbeau, this manoeuvre, when properly carried out, cures fissures and ulcers on the same principle as dividing the sphincter with the knife, by paralyzing it until the ulcer has healed. 112 INJURIES AND DISEASES OF THE RECTUM. The patient should be thoroughly anaesthetized, and then the two thumbs should be introduced, one after the other, taking care to press the ball of one thumb over the fissure and the other directly opposite to it; this prevents the fissure from being torn through,and the mucous membrane from being stripped off. The thumbs are gradually separated, and the stretching is then repeated in the opposite direction, that is, at right angles, and then in other directions until every part of the anus has been dilated. Considerable pressure should then be applied to the sphincter muscles all around, pulling apart the anus with four fingers, two on each side, and kneading the muscles thoroughly ; by thus gently pressing and pulling, the sphincters completely give way, and the muscle, previously hard, feels like putty. This will occupy at least five or six minutes to do thoroughly; there is scarcely more than a drop or two of blood seen, but for a few days extravasation is noticed about the anus. This operation appears, as far as I know, to be quite safe, and very little pain follows, much less indeed than one would expect. Many years ago I was in the habit of subcutaneously dividing the sphincters in cases of fis- sure, and just recently Mr. Pick, of St. George’s Hospital, has spoken favor- ably of the method; for my own part I gave it up, because there is great difficulty in knowing whether enough of the sphincter muscles has been divided; also, when the patient is under ether, the muscle has no tension, and it is really impossible to cut with precision. I also found much pain after the operation, and very uncertain results. Abscess occurred in more than one instance. If the surgeon wants to avoid cutting, dilatation is on the whole very satisfactory, and I have very rarely failed to cure a simple fissure in this way. It is well to put half a grain of morphia into the rec- tum, and to apply cold water very freely, which soon does away with suffer- ing. It happens sometimes that the patient derives more relief from hot water than from cold. After the stretching, the bruising looks really alarm- ing, but it soon passes away, and I have only rarely seen an abscess follow. Proctitis. Inflammation of the rectum may occur in both a chronic and an acute form. The symptoms are a sensation of heat and fulness in the rectum, frequent desire to go to stool, and great tenesmus; there may be a discharge of blood and mucus. With these symptoms impaction may be suspected, but a digital examination will settle that point. The acute form of the disease is very rare in this country, and is generally produced by some mechanical cause, such as the introduction of a foreign body. I call to mind a case of acute proctitis which resulted as a conse- quence of an unnatural offence committed by a husband on his wife. Here there was no doubt of the rectum being acutely inflamed, as there was a well-marked blush around the anus and over the buttocks, as well as severe pain and tenderness in the rectum. But I saw no discharge. The most obstinate constipation was present, but was overcome by the use of O’Beirne’s long tube as soon as it could be passed. Idiopathic acute inflammation of the rectum resembles dysentery in its symptoms, but is distinguished from it by the absence of abdominal pain or tenderness and of severe constitutional disturbance ; the pain is generally confined to the sacrum and perineum; the bladder is often sympathetically affected, and there is not infrequently difficulty in passing water. The most effective treatment for this condition would be the use of leeches around the anus, hot baths, injections of water in small quantities as hot as could be borne, to which might be added a drachm of Battley’s sedative. A ULCERATION AND STRICTURE OF THE RECTUM. 113 hot bath, followed by a hypodermic injection of morphia, is likely to be of benefit. The patient should keep the recumbent position, and take very light, unstimulating nourishment; no irritating purges should be given. If it be necessary to relieve the bowels of their contents, a flask of warm olive oil as an enema is the best that can be employed. I have seen very few such cases in this country, but they are not very uncommon in hot climates. The chronic of proctitis occurs in old people, and is best treated by injections of starch and opium, and by the internal use of such medicines as turpentine, aloes, confection of black pepper, and copaiba. I usually order frequent and small doses of Barbadoes aloes; these act as a stimulant to the rectum, and induce healthy action, and very soon the disorder subsides. Hamamelis is another useful remedy; it is in fact rapidly curative in some cases. It may be used as an injection, and may also be administered by the mouth. Ulceration and Stricture of the Rectum. Ulceration extending above tlie internal sphincter, and frequently situated entirely above that muscle, is not a very uncommon disease ; it inflicts great misery upon the patient, and, if neglected, leads to conditions quite incurable, and the patient dies of exhaustion unless extraordinary means are resorted to. In the earlier stages of the malady, careful, rational, and prolonged treatment is often successful, and the patient is restored to health ; but not so in severe and long-standing cases. Ulceration of the rectum can only be mistaken for malignant disease ; but with care and a well-educated finger an error in diagnosis should be a great rarity, though I must confess that I have made the mistake myself. As the earlier manifestations are fairly amenable to treatment, it is of the utmost importance that the disease should be recognized early. In the majority of these cases, the earliest symptom is morning diarrhoea, and that of a peculiar character; the patient will tell you that the instant he gets out of bed he feels a most urgent desire to go to stool; he does so, but the result is not satisfactory. What he passes is generally wind, a little loose fecal matter, and some discharge resembling coffee grounds both in color and consistency ; occasionally the discharge is like the “ white of an unboiled egg,” or a “jelly fish more rarely there is matter. The patient in all proba- bility has tenesmus, and does not feel relieved ; there is a somewhat burning and uncomfortable sensation, but not actual pain ; before he is dressed, he very likely has again to seek the closet; this time he passes more feces, often lumpy, and occasionally smeared with blood. It may also happen that after breakfast, hot tea or coffee having been taken, the bowels will again act; after this he feels all right, and goes about his busiuess for the rest of the day, only, perhaps, being occasionally reminded by a disagreeable sensation that he has something wrong with his bowel. Hot by any means always, but at times, the morning diarrhoea is attended with griping pain across the lower part of the abdomen, and great flatulent distension. All these symptoms are also met with in cases of malignant disease. When a medical man is consulted, the case is, in all probability and quite excusably, considered one of diarrhoea of a dysenteric character, and is treated with some stomachic and opiate mixture, which affords temporary relief. After this condition has lasted for some months, the length of this period of comparative quiescence being influenced by the seat of the ulceration and the rapidity of its exten- sion, the patient begins to have more burning pain after an evacuation ; there is also greater straining, and an increase in the quantity of discharge from 114 INJURIES AND DISEASES OF THE RECTUM. the bowel; there is now not so much jelly-like matter, but more pus, more of the coffee-ground discharge, and more blood. The pain suffered is not very acute, but very wearying; it is described as like a dull toothache, and is induced now by much standing about or walking. At this stage of the complaint the diarrhoea comes on in the evening as well as in the morning, and the patient’s health begins to give way—only triflingly so perhaps, but he is dyspeptic, loses his appetite, and has pain in the rectum during the night, which disturbs his rest; he also has wandering and apparently anomalous pains in the back, hips, down the leg, and sometimes in the penis. There is yet another symptom present in the later stages, marking the existence of some slight contraction of the bowel—alternating attacks of diarrhoea and constipation ; and during the diarrhoea the patient passes a very large quantity of feces. These seizures are attended with severe colicky pains in the abdomen, faintness, and not unfrequently sickness. As the ulceration extends, attempts at healing take place; these result in infiltration and thickening of the mucous and submucous tissues, and conse- quent diminution of the calibre of the bowel, so that real stricture of various forms supervenes. Coincident with all this there results a gradual loss of the contractile power of the rectum, and almost complete immobility, so that the lower part of the gut is converted into a passive tube through which the feces, if fluid, trickle; but, if solid, stick fast until pushed through by fresh formations above them. Invariably also there is loss of power in the sphinc- ters. When diarrhoea is present, the patient has little or no control over his motions. Usually by this time abscesses have formed, or are in process of for- mation, and these breaking soon become fistulse. I have seen persons with eight external orifices, some situated three inches or more from the anus. On examining these cases of ulceration of the rectum, the surgeon may often feel, in the earlier stages, an ulcer situated dorsally about one and a half inches from the anus, oval in form, perhaps an inch long by half an inch wide, surrounded by a raised and sometimes hard edge; there is acute pain caused on touching it, and it may be readily made to bleed. With a speculum he can distinctly see the ulcer, the edges well marked, the base grayish or very red and inflamed-looking, the surrounding mucous membrane being proba- bly healthy ; in the neighborhood of the ulcer may often be felt some lumps, which are either gummata or enlarged rectal glands. This is the stage in which the disease is often curable. At a later period of the malady, he will observe deep ulcers with great thickening of the mucous membrane, often also roughening to a considerable extent, as though the mucous mem- brane had been stripped off. At this stage there are generally, outside of the anus, swollen and tender flaps of skin, shiny, and covered with an ichorous discharge ; these flaps are commonly club-shaped, and are met with also in malignant disease ; but during the early development of the disease no ulcera tion is found near the anus, nor at the aperture. I must positively repeat that the large majority of these cases do not commence by any manifestation at the anus, such as growths or sores ; occasionally a fissure may be the first lesion, and the ulceration may extend from the wound made in attempting to cure it; this is, however, the exception to the rule. So definite is this external appearance in long-standing disease, that one glance is sufficient to enable an expert to predicate the existence of either cancer or severe ulceration ; these external enlargements are the result of the ulceration going on in the bowel, and the irritation caused by almost constant discharge. The ulceration may be confined to a part of the circumference of the bowel, or it may extend all around, and for some distance, but not usually more than four inches, up the rectum. ULCERATION AND STRICTURE OF THE RECTUM. 115 It also probably will have travelled downwards close to the anus, and there the pain is sure to be very severe, because the part is more sensitive and more exposed to external influences and accidents. When the disease has reached this stage, of course stricture and most probably fistula will be present, as I have already mentioned ; and possibly, but not frequently, perforation into the bladder, the vagina, or the peritoneal cavity, may occur. The state of the patient is now most lamentable; his or her aspect resembles that of a sufferer from malignant disease, and no remedy short of lumbar colotomy offers much chance of even prolonging life. You may relieve these patients, but you can rarely do more; a cure can scarcely be expected. I have seen ulceration utterly destroy both the anal sphincters, so that the anus was but a deeply ragged hole. A low form of peritonitis is a not uncommon complication of ulceration and stricture. It is attended with considerable pain in the abdomen, often intense for a short period. There are generally one or more tender spots, tympanites, and often vomiting, especially on first assuming the erect posi- tion in the morning ; generally the pain is brought on by standing or moving about. These attacks are sure to end in diarrhoea. When making a post-mortem examination in such cases, I have observed effusion into the peritoneal cavity and often numerous old and recent adhe- sions between the intestines; the peritoneum is also thickened. In bad cases the whole of the rectum and even the sigmoid flexure may be involved in ulceration, and great thickening and contraction of the calibre of the bowel, caused by the attempts at repair, may be observed; in various parts, large bridges of indurated muscle are exposed, and the mucous membrane is strangely roughened. I have seen more than one case in which necrosis of the sacrum had taken place. In the treatment of these attacks there should be perfect rest in bed, with spare diet; opium may be given freely; fomentations relieve pain, but I have not seen any benefit result from counter-irritation, except by an ordinary lin- seed or mustard poultice. I have often found that calomel and opium, given for some time, are advantageous in these cases. From the notes of my cases in St. Mark’s Hospital, I find that out of 110 patients with ulceration and stricture, 92 were females and 18 males. Out of the 110, 49 had undoubtedly suffered from constitutional syphilis, while 9 had some syphilitic symptoms, but not such as were decisive, so that I think that this number should be deducted from the whole number, 110, before considering the statistics of the remaining 101; we then find 49 who were most undoubtedly syphilitic, and 52 who as undoubtedly had never contracted syphilis, and many of whom had never had any venereal disease at all. These statistics differ from those published in my work on Diseases of the Rectum, showing a less proportion of syphilitic patients; but this may be merely acci- dental, and a further series may again reverse the results. Many of my patients have been subjected to colotomy in the lumbar region, and for the most part have done well, and I believe several (eight or nine) are now alive. Two of the women have married since the operation, and one has borne a child. For the relief of stricture and ulceration I have performed colotomy thirty-five times. In sixteen cases I have performed Verneuil’s operation of linear rectotomy, but always with the knife, never with the ecraseur or galvanic cautery, as he has recommended. This is the essence of Prof. Verneuil’s operation : The whole stricture must be divided from its upper edge down to the coccyx, and through its entire depth. Thus a deep drain is made, from which all discharges freely flow, and as this heals up, the ulceration ceases, and the stricture is sometimes cured. 116 INJURIES AND DISEASES OF THE RECTUM. The patient being in the lithotomy position, the surgeon passes his finger through the stricture as a guide, then introduces a long straight knife, and, when its point is fully above the stricture, cuts firmly down right through it in its whole depth, even to the sacrum if necessary, and brings the knife out at the tip of the coccyx. By keeping to the median line the bleeding is but trifling, and the whole of the diseased structure will have been cut through. So rapidly beneficial is this operation that in forty-eight hours I have seen night-sweats arrested, and a patient who seemed about to die rally, and eat and drink, and get well from that moment; morbific discharges, instead of being absorbed, run out, and the patient is not poisoned. The wound should be well syringed, and the parts kept perfectly clean by injecting a very weak carbolic lotion (1 in 60). I always use dry absorbent cotton- wool as the dressing, sometimes carbolized, and I only want my patient washed at most twice in the day ; too frequent use. of any fluid, carbolized or not, soddens and weakens the granulations; dry dressings are those which I advise. Many of these patients have done well, and I have a record of at least fifteen permanent cures; but in others the operation has failed, and I have seen a return of the disease after even three or four years. In the after- treatment I often place a tube in the wound, keeping it in at night, which tends to prevent contraction. Many of my cases have been treated by dilatation, assisted in some instances by small incisions; stricture of the rectum, however, is a disease infinitely more uncertain, more prone to relapse, and more difficult to treat, than stric- ture of the urethra. In some few cases, immense good has resulted from the long-continued administration of iodide of potassium and percliloride of mer- cury ; but on the other hand, often when it has been expected to be of benefit, no curative result has followed. On the whole, therefore, I place no great faith in specific remedies, although I always use them with tonics when I feel that the ulcerations are of syphilitic origin. On summing up my own cases, hospital as well as private, I can in brief state that in women rather more than 50 per cent, have suffered from un- doubted constitutional syphilis, and that in men about 40 per cent, have been in the same position. Among the causes of the ulceration, etc., in those who showed no evidence of syphilis, I may mention tuberculosis (not so uncommon as is generally supposed); dysentery and diarrhoea, usually following prolonged residence in tropical climates; obstinate, long-standing constipation; injuries to the uterus and vagina in parturition; and operations on the rectum in per- sons of bad constitution; but will these causes account for all the cases? I am obliged to say that I do not think so, and to confess that in many of these cases I do not know the cause. If we could answer the question why ulcera- tion and stricture are so much more frequent in the female than in the male, w’e should possibly have a clue; but for my part I cannot see that any satis- factory reply has been given to this question, more than it has to another, viz., Why is epithelioma comparatively seldom found in the rectums of women? In connection with this part of the subject, I may say that I am altogether at variance with some French authorities, such as M. Gosselin, and some eminent American surgeons, such as the late Dr. Erskine Mason, who hold that the vast majority of cases of stricture and ulceration, not cancerous, result from contamination by the discharges from “soft sores” or “chan- croids.” I have gone very carefully and fully into the consideration of this matter, and I cannot too strongly and emphatically express my opinion that the ulceration which leads to stricture is the result of tertiary syphilis, and not of chancroid. My experience of soft sores near the anus is that they speedily heal under proper treatment, and I have seen many cases cured in a few days by clean- ULCERATION AND STRICTURE OF THE RECTUM. 117 liness and the use of a tartrate-of-iron lotion; and though these patients have been seen from time to time for other ailments, no ulceration or stricture of the rectum has been found to ensue. There are no maladies more baffling to the surgeon than ulcerations and strictures of the rectum, and, as I have before said, they are often quite in- curable, and nothing affords relief save colotomy. It is not quite impossible that, after this operation, the ulceration and stricture may get well, and that then the surgical opening in the loin may be closed ; this I have now in three cases successfully accomplished, but, on the other hand, I have frequently tried it and failed. In cases of circumscribed ulceration, I have great confidence in the efficacy of rest in the recumbent position, and of a wholly, or nearly, fiuid diet, and I consider that milk should be the essential element of food in these cases. When the ulceration is deep and contraction has commenced, the disease is much more serious, and a very doubtful prognosis should be given. Still, if only the patient will submit to proper treatment for a lengthened period, a good deal may be done in all cases. In these, rest is even more important than it is in the earliest stage of the affection. Often the ulceration induces such an irritable condition of the rectum that nothing will be retained—neither any injection, suppository, nor ointment; I have found that bismuth and char- coal, taken internally, will generally soon overcome this excessive irritability. Subcarbonate of bismuth may also be tried on the mucous membrane itself by means of insufflation. Iodoform also is a very potent remedy. This, when Fig. 1325. Rectal insufflator. continuously used, may soothe the rectum, relieve pain, and promote healing. As a rule, I prefer ointments to suppositories or injections. The improved American instrument for the application of ointments obviates all difficulties of introduction, and I am sure that this irritates less than other methods of Fig. 1326. Instrument for application of ointments to rectum. medication; all kinds of sedatives, opiates, and astringents may in turn be tried. I Lave seen the following formula most efficacious: Bismuthi subnitrat., 3ij; Hydrarg. subchloridi, 9ij ; Morphise, gr. iij ; Glycerinas, 3ij; Vaselini, %}; this is a very sedative application, and sores seem to be benefited by it speedily. Subacetate of lead and milk (3,j to fgj), with belladonna and opium, will be found serviceable; all sorts of astringents may be employed ; rhatany, friar’s 118 INJURIES AND DISEASES OF THE RECTUM. balsam, zinc (the permanganate), copper, iron, nitrate of silver, etc. The last, carefully used in not too strong solution, is one of the most admirable appli- cations, often inducing in an nicer a healthy appearance, and causing granu- lation ; so too, is the tartrate of iron in the proportion of ten grains to the ounce of water. Fuming nitric acid, and strong carbolic or chromic acid, applied under certain conditions, are potent remedies; they often allay pain and start healing processes afresh, but they are double-edged tools, and must be used with great discretion, and with a distinct object in view. In ulceration, when the least stricture exists, soft bougies may be always employed, but it must be remembered that to do any good they must be used with the greatest gentleness. A bougie of too large a size should never be employed ; no greater mistake can be made than to suppose that the larger the bougie that can be got in the better; the surgeon should keep below the size that can be well borne, rather than at all above it; in the one case good may ensue, in the other, irritation and retrogression are seen to take place; a patient should never be given an ordinary bougie to use for himself, always an India-rubber one, and conical, if the stricture is more than two inches from the anus. But if the constriction is only about an inch or an inch and a half from the anus, the patient may be given a vulcanite conical tube furnished with a collar, to which tapes are fastened to keep it in the bowel, and also to prevent it from going up the rectum; it may be passed and worn at night, if its intro- duction can be accomplished without any severe pain. When strictures are slight, and not very long, but annular in form, division in a few places with the knife, followed by judicious treatment with the tubes, may be very bene- ficial and even curative. The division I usually make at four points, and I take care just to cut through the induration, and reach the healthy tissues beneath, but not to go deeper; the bowel should be filled with well-oiled lint or wool for twenty-four hours, and then the tube introduced and worn, only taking it out for the bowels to act, and to wash out the rectum with some antiseptic lotion. I prefer Condy’s fluid or thymol, if the patient him- self applies it, as less dangerous than carbolic acid. I am of opinion that carbolic acid, if strong, is too irritant. In those cases in which the ulceration is extensive, and constriction so tight that a passage barely exists, or in which the lower part of the rectum is now merely a passive tube through which there is a perpetual leaking of semi-fluid feces, some relief may be afforded by dividing the tistulous pas- sages, which are nearly always present, with the elastic ligature. The knife is very likely to cause severe hemorrhage, as the divided vessels can neither retract nor contract in the hardened tissues. Constitutional treatment here is of no avail. Lumbar colotomy is the patient’s only chance. Stricture of the rectum without ulceration is a somewhat uncommon affection. Its pathology corresponds to that of organic stricture of the urethra; that is to say, there is an inflammatory deposit in the submucous tissue, and an accompanying spasm of the muscular coat. I have seen stric- tures of the rectum so tight that I could not get the end of my little finger into them; but when the patients had been brought well under the influence of an anfesthetic, I have been able to pass one or two fingers through easily. IIow inflammation and thickening are set up in the connective tissue of the bowel, it is difficult to say. It may be that straining to evacuate the con- tents of the bowel forces down the upper part of the rectum into the lower, thus causing an intussusception, and bringing the part within the grasp of the sphincter muscles; and I have often thought that this condition might be the starting point of the irritation. I have in some few cases had a suspicion 119 ULCERATION AND STRICTURE OF THE RECTUM. that long-continued pressure of the child’s head in labor has been the exciting cause, bruising of the bowel having perhaps taken place. Possibly, also, in- flammation may be induced by the passage of very dry and hardened feces, though doubtless this condition may obtain for years, as it often does in old people, without producing stricture. I have seen one case in which the frequent and rather rough use of an enema-pipe produced a stricture. It is stated in some works that the stools in stricture are thin, long, and pipe-like. According to my experience, such stools occur far oftener in spasm of the sphincter, enlarged prostate gland, enlarged retroverted uterus, and tumors of the pelvis generally. In true stricture, on the other hand, the stool is in very small broken pieces, the feces having no actual form, and looseness often alternating with this lumpy condition. The discharge in simple stricture is like the white of an unboiled egg, or a jelly tish, and is passed when the bowels first act. There is no discharge looking like coffee-grounds, such as is constantly seen in ulceration, nor is there the morning diarrhoea which we find in that complaint. The pain is generally referred not to the bowel itself, but to distant parts, notably the penis, the perineum, the lower part of the back, the thighs, under the but- tocks, and occasionally the stomach. A stricture of the rectum, resulting entirely from muscular spasm, is a thing that I am very much disinclined to believe in. I am of opinion that these stric- tures exist only in the mind of the surgeon, who has been misled by the bougie catching in a fold of the gut, or against the promontory of the sacrum. If in doubt as to the existence of a stricture, the surgeon should use a long and very elastic enema-tube, and inject fluid as he passes it, so as to distend the gut and remove any intussusception of the upper part of the rectum. This condition,! think, has often been mistaken for stricture, as unless the bougie goes directly into the aperture of the invaginated portion of the gut, it gets into the sulcus at the side, which is a cul-de-sac, and which prevents the in- strument from passing. In exploring the rectum, I use vulcanite balls, olive-shaped bodies of different sizes, mounted on pewter stems, with flattened, roughened handles. Fig. 1327. Instrument for detecting rectal stricture. They bend easily to any form ; and by their use I can be certain of detecting a stricture. For when they pass, or on quietly withdrawing them, the ball is felt to come suddenly, and perhaps with some difficulty, through the constriction. Fig. 1328. Rectal syringe. Iii cases of stricture where there is great spasm with a small amount of organic disease, much good may be done by the use of conical bougies. Opium or belladonna with oil should be injected previously, and the bougie should be smeared over with blue ointment, which is tenacious and lubricates 120 INJURIES AND DISEASES OF THE RECTUM. well. If the instrument cannot be quickly passed, it is better not to persevere, as irritation will be set up and damage done. I strongly disapprove of forcible dilatation, such as that produced by Todd’s dilator, as obstinate ulceration only too often results; the amount of pressure made cannot he gauged. The only kind of stricture without ulceration which in my opinion should be divided, is that in which the constriction is semicircular or annular, and feels to the touch as though the bowel were encircled by a cord. These strictures are so resilient that, even if dilated to their fullest extent, they will very soon return to their previous state of contraction. All other strictures without ulceration I treat by gentle dilatation with conical bougies, very gradually increasing the size of the instrument. I pass a bougie twice or thrice a Aveek, or daily, but not often the latter, being guided by the nature of the case; that is, I, never set up irritation if I can possibly avoid it. As all strictures of the rectum show a marked tendency towards return, patients should be warned never to be long without having the bougie passed, and, as soon as any of the old symptoms recur, at once to obtain treatment; if this advice he acted upon, but little fear need be entertained of a dangerous relapse, and I have now a very large number of patients who have been in this way kept for ten years and upwards in perfect comfort. Stricture of the rectum cannot be quickly and permanently cured by any means; an experience of nearly twenty-live years has never shown me a single case quickly cured, which has not as speedily relapsed. Cancer of the Rectum. Cancer of the rectum usually runs its course in about two years. In many instances the duration of life is much less. I have watched a case of encephaloid which terminated fatally at the end of four months from the appearance of its earliest symptoms. Colotomy was performed by me when I first saw the patient, two months before death; but I do not think that it delayed the progress of the disease one day, although it afforded relief from excruciating pain. On the other hand, I have seen many cases of scirrhus and epithelioma where the patient lived quite four years and a half (and even longer) without any surgical interference. Cancer is commonly a disease of middle life, but I have seen encephaloid rapidly fatal in a boy of seventeen ; and some years ago there was in St. Mark’s Hospital, under the care of my colleague, Mr. Cowhand, a boy, not thirteen, with cancer of the rectum. Scirrhus and epithelioma in old people usually run a very slow course, which may be accounted for by the fact that in old people the vital forces are sluggish in disease as in health. It has been said that cancer is more frequent in women than in men. As regards the rectum, this is directly the reverse of my experience. In my statistics many more men are victims than women. From my experience, too, there seems to be no ground to consider cancer of the rectum as a heredi- tary malady. Some varieties of cancer may in their early stage he only and purely local. But this stage is of very short duration, and the above statement is hardly, certainly not practically, true of the more malignant forms. By this I mean that as soon as a growth exhibits itself, so as to be noticed by the patient, the disease is commonly already constitutional, and the system is infected. As a rule, cancer of the rectum during some part of its course is most horribly painful, the function of the part enhancing the suffering; hut I have seen patients in whom there has not been excessive pain, particularly in CANCER OF THE RECTUM. 121 the early stages. In the more advanced periods of the malady the pain often becomes unremitting, from the fact that many nerves become involved, and are pressed upon or stretched, the neighboring organs thus becoming seats of separate pain, even if they are not actually touched by the growth. I had a patient with cancer, which, commencing in the rectum, involved the whole cavity of the pelvis, and pain down the right sciatic nerve was one of his most distressing symptoms. The forms of malignant disease usually described as occurring in the rectum are epithelioma, scirrhus, encephaloid, colloid, and melanosis. I think that I have placed them in their order of frequency. I have never seen a mela- notic tumor of the rectum. I have seen many colloid tumors, but I am not sure that encephaloid may not be colloid, or pass into it. From my own clinical observation I should be inclined to say that in cancer of the rectum it is often very difficult, if even possible, to make any distinction between broken-down scirrhus and epithelioma. I have seen cancers of the rectum stony hard at one part and quite soft at another. Malignant growths are commonly found seated within three inches of the anus, but often extend higher up, the most rapidly dangerous being about the upper part of the rectum and the lower portion of the sigmoid flexure. When cancer occurs near the anus, it may extend upwards beyond the reach of the Anger, but more frequently it does not, and the whole extent of the disease can be ascertained. If epithelioma begins at the anus itself, it may extend upwards for a variable distance, usually, however, not so far as to put excision out of the question. There is in cancer of the rectum a peculiar odor, which one cannot describe, but which once recognized will rarely be forgotten. In my opinion the odor is pathognomonic. In scirrhus and encephaloid, the mucous membrane may for a time remain quite smooth and unaffected, though adherent to the growth below. In epithelioma, the mu- cous membrane seems to be implicated from the first throughout, and, even when the growth is considerable, will be found movable over structures beneath. Scirrhus is often found as a hard tumor seated in the rectum over the prostate gland, and, although it may not have arisen from the gland itself, nor invaded it at all, yet it is remarkably adherent to it. The more malignant forms of cancer do not exist long in the rectum before secondary deposits occur in the lumbar glands, groin, liver, etc. The aspect of countenance which so often attends the cancerous cachexia is very usual, and is seen earlier in cancer of the rectum, I think, than in similar disease of other parts. When the cancerous growth is high up, vomiting, frequent and severe, is an early symptom, even when not much obstruction exists. The onset of cancer in the rectum is often marked by very trivial symptoms. A patient may come into the surgeon’s consulting room complaining of no more than a little diarrhoea in the morning, or even of only a little uneasi- ness in the bowel. He may look thoroughly healthy and strong, and may really think himself well in every respect save for the slight local trouble; yet, on making an examination, it may be found that the disease is advanced beyond all possibility of doing any good. When cancer attacks the upper- most portion of the rectum, or the sigmoid flexure, it runs a more rapid course, and is much more dangerous ; indeed, sudden death is not uncommon, as total obstruction takes place quickly, and, unless colotomy be promptly performed, the intestine gives way above the obstruction, and death ensues. Cancerous stricture of the upper part of the sigmoid flexure, or of the de- scending colon, is not so immediately dangerous, although the obstruction may be total. I have seen cases of this kind in which life has lasted eight weeks or longer. 122 INJURIES AND DISEASES OF TIIE RECTUM. Iii regard to treatment, I have never seen any benefit result from the appli- cation of caustics to growths within the bowel, but when a cancerous mass protrudes, which, however, is a somewhat rare occurrence, I have relieved pain and got rid of a good deal of the growth by using the arsenite of copper with mucilage as a paste; it does not cause bleeding, and, as far as my experience goes, is free from danger. The treatment in the majority of cases of cancer resolves itself into an attempt to assuage the sufferings of the patient. Pain is mitigated by the recumbent position, and by sedatives, which should be used externally and internally, opium in its several forms being the most effective agent which we possess. It may be used as a suppository, in which case the best formula is morphia with glycerine and gelatine (three of glycerine to one of gelatine), as this melts very soon, and does not feel like a foreign body in the sensitive bowel. Injections of Battley’s sedative, nepenthe, or black drop, in starch, afford great relief. Probably most patients obtain the greatest comfort from hypodermic injections of morphia, but no opiate can be used long without inducing a state of mind almost as unendurable as the pain of the disease; therefore great care should be taken to husband the remedy as much as pos- sible, never using a larger dose than is absolutely necessary, and bearing in mind that it may be necessary to rely upon it, more or less, even for months. I have tried the Chian turpentine, recommended by Mr. John Clay, of Bir- mingham, but have not been satisfied with its results, and have discontinued its use. When cancerous growths approach the anus, considerable relief may be obtained by dividing the sphincter muscles; defecation is thus rendered easier, and no possible compression can be exercised. When diminution of the calibre of the bowel is induced by cancer near the anus, Professor Verneuil has proposed free division of the gut in the dorsal median line; this operation I have frequently practised, thereby affording great temporary relief to my patients. In encephaloid of the rectum, much relief from pain and some advantage may be obtained by tearing out the growth by the fingers or the scoop. This must be done boldly, and the whole growth enucleated quickly and resolutely. If only the superficial portions are torn away, hemorrhage may occur to a considerable extent, which must exhaust the patient, and no real benefit will accrue. In the cases in which I have adopted this plan of treatment, I have been surprised to observe that, after the removal of the cancerous growths, the facial appearance of the patients has improved immensely ; in fact, they have all lost the malignant aspect, and not until the growths have gradually returned, and with it the poisoning of the blood and tissues, has the countenance reassumed its worn, haggard look. So, also, in respect of health, strength, freedom from pain, appetite, and capacity for sleep, this change for the better has been remarkable. Two operations have been practised for the relief of rectal cancer: The one is extirpation of all the diseased portions of the rectum; the other is colotomy; lumbar or inguinal, which only professes to relieve pain, and possibly to extend the term of the patient’s life. Extirpation of the rectum may be undertaken in any form of cancer which does not necessitate the removal of more than four and three-quarters or five inches of the rectum in the male, and about one inch less in the female. If found closely adherent to the base of the bladder and prostate gland, or to the neck of the uterus in women, the operation is probably not admissible, and certainly not desirable. Again, if any enlarged glands exist in the inguinal or lumbar regions, the operation cannot be recommended. Lastly, I should say that the patient ought not to be so exhausted as to render it doubtful whether the rather severe shock, consequent on the operation, may not greatly endanger life. 123 CANCER OF THE RECTUM. The partial removal of the circumference of the bowel is in my opinion most unsatisfactory. In all the cases in which I have removed only part of the wall, there has been either a return of the disease in the rectum, or in the glands in the groin, or in some internal organ, mostly the liver. Up to the present time I have excised the rectum in its entire circum- ference in 36 patients. In my early cases my success was less than it has been since ; increased experience has taught me better ways of operating and more skill in arresting hemorrhage. I am not nearly as long in com- pleting the operation, and consequently my patients sutler less shock; they rarely lose more than four or live ounces of blood, and are in the average not under ether more than thirty minutes—in many cases, indeed, much less time than .that. I never stop to tie bleeding vessels as I go, but put on forceps and leave them hanging. I use an eeraseur with whipcord, not wire, for cutting through the bowel. I prefer it because it can be more easily applied, and more accurately adjusted. It might be expected that in my long career I should have excised the rectum in many more cases than I have, but the fact is that few really good cases for the operation present themselves. Cancer often commences high up in the bowel, and only comes into reach after existing for some months. I have seen so many patients with cancer of the rectum who had recently been examined by eminent surgeons, and no disease found, that I have come to the conclusion that the disease existed, but had only very recently come within reach of the linger. Moreover, I have myself examined patients who had very marked symptoms of malignant disease of the bowel, but in whom I could not detect any disease in the rectum, and in less than three months these patients have again presented themselves, and the growth has been felt two inches from the anus. The mode of operating which I prefer in all serious cases, that is, when more than three inches of the rectum has to be removed, is that which has found most favor with French writers. The surgeon commences the operation by making a deep dorsal incision, beginning just in front of the tip of the coccyx, and carried high up the bowel. I consider this the “ key” to the operation; it affords plenty of room and wonderfully facilitates the details, such as securing vessels quickly, and performing delicate dissections of the parts adherent to the prostate and base of the bladder, or to the vagina. Further, it forms a deep drain through which all morbilic matters run away, and through which the whole wound can be easily washed out with weak carbolic lotion, or some other antiseptic. In operating upon the male, a silver catheter should always be passed to steady the urethra and render the deep dissection safe and more rapid. I often keep a large tube in the rectum, after the operation, to favor the escape of flatus, which if retained sometimes causes the patient great pain. In women, an assistant’s finger should be introduced into the vagina to afford the surgeon timely warning of his approach to the mucous mem- brane. If obliged to take out a portion of the recto-vaginal wall, I am not anxious about it, as in all my cases in which this has been done I have repaired the damage at the time of the operation, and in nearly all success- fully. In cases where the disease does not extend very high up the rectum, it is possible to leave the sphincter muscle, and bring down the bowel so as to suture it to the skin. I certainly have not had the success some surgeons claim in such cases. I have several times found the traction so great as to tear out the sutures, and at other times fecal matter has got into the wound, and the sutures have had to be taken out to clear away pus, etc. In two patients only have I had good results, the skin uniting with the mucous membrane very securely; both patients were women, thin, and very good subjects for the operation. 124 INJURIES AND DISEASES OF THE RECTUM. When small portions of the rectum have to be removed, there are several ways in which this can be done, and the surgeon may avoid the dorsal in- cision and use a horse-shoe one around the dorsal circumference of the anus ; getting into the connective tissue, the flap may be turned forwards, the growth removed, and then the flap brought down and sutured to the bowel without sacrificing the sphincters. I have not myself met with a single case in which I could attempt this operation with any chance of success, and I much doubt if it is very practicable. Mr. James Adams, late of the London Hospital, has suggested that colotomy should be performed prior to excising a cancer of the rectum. His arguments in favor of such a step are as follows: “ That in cases of any but the slightest degree the operation might prove incomplete, and the disease speedily return ; that after complete removal of the lower part of the rectum, the subsequent contraction is often very great, and even at times quite intractable; and that in any case the healing of the wound would be much expedited and the local recurrence diminished by diverting the course of the fecal matter.” I have not yet tried the combined operation of colotomy followed by excision, but I am disposed to think that there is much to commend it. I have found in all cases of excision of the rectum, in those of others as well as ill my own, that by the third month after the operation very great contrac- tion will have taken place, unless certain precautions have been practised. The contractions once formed are most difficult of cure, and in fact some are never thoroughly rectified. In all my cases, for years now, I have made my patients, after the expiration of ten or fourteen days from the operation, wear a vulcanite tube in the bowel. This is taken out daily while the bowels are acting, but at other times is constantly retained for some months; the result is that no stricture or contraction of the anal orifice takes place, and that the patients are quite comfortable. In one of my cases a man has been compelled to wear a plug ever since the operation ; if he leaves it out for a couple of months, the parts re-contract. I use tubes of three or four inches in length, one end conical to render the introduction easy, and the other ending in a broadish flange to prevent its accidentally slipping into the rectum, and also to enable it to be stitched to a bandage which keeps it in place. !N"ow what has been my success in the 36 cases in which I have operated since March 2,1874? Unfortunately, with the very best intentions, accuracy in all particulars cannot be insured in answering this question. Patients, particularly those attended in hospital, go away, and are lost sight of, but I have done all that I could to follow up my cases, and have-fairly succeeded, as I know the result in 26. Of the 26 patients, 1 died about 4 years after the operation. 1 “ “3 “ 2 “ “2 “ 5 “ over 18 months “ 7 “ about 1 year “ 5 “ from the direct consequences of the operation. 5 I know to be still alive. Of the 5 living patients, one was operated upon more than seven years ago; the rest within two years. Of the 5 who died from the direct consequences of the operation (that is, within 14 days), 1 died by carbolic-acid poisoning— an assistant unwittingly injecting a strong solution to wash out the wound— the peritoneal cavity being open ; 1 from secondary hemorrhage on the 10th or 12th day; 1 from peritonitis, a few days after the operation ; and 2 from erysipelas. There still remain the ten patients lost sight of; of these I can only say that they all went from my care after two months, when the early CANCER OF THE RECTUM. 125 dangers attending the operation had passed away; two I saw after six months, and their cases bade fair to be very successful. I must contend that the operation in properly selected cases is one likely to afford excellent results, and I am sure that with increased experience the direct mortality may be decreased. Properly, my deaths from the operation per se may he reduced to 4, as the carbolic-acid poisoning was absolutely an accident. As to the prolongation of life and the amount of comfort afforded, I think it quite sufficient to justify my recommending the operation in all cases in which the growth can be fully removed. In two of my cases, which did well, I opened the peritoneum and removed a hard mass of glands, and in another case one gland; and I am fully confident that if due precautions are taken, the opening the cavity of the abdomen does not greatly add to the danger. Since writing the above paragraphs I have performed three more excisions of the rectum, and all of the patients are, so far, doing well. I shall only quite briefly touch upon the question of colotomy, as the sub- ject has been fully considered elsewhere. Generally, I will say that colotomy is justifiable when an obstruction existing in the rectum, sigmoid flexure, or in the descending or transverse colon, places the patient’s life in peril. Also, when an opening has taken place between the rectum and the bladder, or even the vagina high up, the distress in these cases being often exceedingly great. When cancer of the rectum is rapidly advancing, and all treatment fails to relieve pain, then also colotomy may be performed even if no ob- struction exists. I must, however, protest against colotomy being performed simply because a cancer exists in the rectum. Often neither pain nor obstruction will ensue for months, or they may never occur, and the patient may die of some other malady. Of course, if a surgeon at once persuades all his patients who have malignant growths of the rectum to submit to colotomy, under the promise that life will be much prolonged and suffering averted, he will have many cases to report and very good statistics, but I maintain that such statistics are really valueless. In one case, another surgeon performed colotomy three days after the patient had consulted me; there was a growth, but no pain and no obstruction, and the patient was in fair health; he died four months after the operation. In all probability, had he not been operated upon, he might have lived for years. I was once called to Eastbourne, to see a gentleman whom I found suffering from constant diarrhoea; he was wasted to a shadow, and his skin was dry and furfuraceous. I found superficial ulceration in the rectum as far as I could reach, and the mucous membrane was studded with small elevated bodies. I said that the patient was suffering from tuber- culosis of the bowel, and that he would die in a few days. I was then asked if I did not think that colotomy was necessary, and was told that a surgeon was coming the next day to colotomize the patient. I fortunately succeeded in stopping the operation: the patient died in three days, and the post-mortem examination showed tuberculous deposits through the whole intestine. I saw a gentleman not long since who came to consult me about the trou- ble which he experienced from an opening that had been made in his right lumbar region for the relief of obstruction in the bowel. I found a con- siderable portion of the descending colon coming out of the wound. He said that the operation had been done two years before, and that he had been said to have cancer. He said that he had never had any severe obstruction in the bowel, but that the surgeon thought that while his health was fair it was better to do the operation, so as to avoid difficulty that was sure to arise in the future. On carefully examining the patient’s rectum, I found a very 126 INJURIES AND DISEASES OF THE RECTUM. moderate syphilitic stricture, through which a bougie, as thick as my fore- finger, was easily passed. Hemorrhoids. External hemorrhoids may be divided into two varieties: the first includ- ing all hypertrophies or excrescences of skin around the anus; the second, san- guineous venous tumors outside of the external sphincter. These are in fact either coagulations of blood in dilated veins, or coagulated extravasations into the connective tissue. The first variety of external hemorrhoids is often a sequel of the second, as, when a coagulum is absorbed, a small flap or tag of skin remains behind, marking its site and liable to give further trouble by accidentally becoming inflamed at a future period. Should this happen, the tag of skin becomes swollen, cedematous, and shiny, and exceedingly painful to the touch; sometimes it ulcerates, or suppuration may take place if the inflamma- tion runs high, and thus a small but painful little fistula may arise. At times the oedema is so considerable as to extend into the bowel, forming a large swollen ring of skin and everted mucous membrane all around the anus. With regard to the second variety, the sanguineous venous hemorrhoids, they are swollen, ovoid or globular, bluish tumors, very hard and exquisitely painful; they can be pinched up between the finger and thumb from the tissues beneath, and they feel as if a foreign body were present there. Some- times, but rarely, they can by gentle pressure be emptied of their contents ; but this process is not followed by any benefit to the patient, as in a few hours they become more painful and larger than before. By irritation they set up spasm of the sphincter and levatores ani muscles so that they are drawn up and pinched, thus adding much to the patient’s suffering. Just as he is falling to sleep, a spasm takes place and wakes him up; in addition there is constant throbbing, and the sensation as if a foreign body were thrust into the anus ; this excites the desire every now and again to attempt to expel it by straining, which, if indulged in, of course aggravates the pain. Often the patient cannot sit down, save in a constrained attitude, nor can he walk; and when he coughs the succussion causes acute suffering. When the bowels act, and for some time afterwards, the distress is greatly increased. Accompanying all this there are general feverishness, furred tongue, and usually constipation. Such then are the symptoms of an acute “ attack” of external piles, and it must be remembered that one invasion predisposes to another. Now what are the causes of external hemorrhoids, remote and exciting? Amongst the former must be included, obstructions of the liver or portal system, fecal accumulations, and anything rendering the return of blood from the rectum difficult. Therefore, whatever induces constipation of a chronic type, may also be regarded as a predisposing cause of external hemorrhoids. Too good living—especially the consumption of large quantities of meat—free indulgence in alcoholic drinks, excessive smoking, sedentary occupations, etc., are such causes. Among the exciting causes, exposure to wet or cold, friction from clothing, and the use of printed paper as a detergent (especially the cheap papers from which the ink comes off on the slightest friction), the neglect of proper ablutions, and straining, however induced, are in my experience the most common. Not unfrequently a little unusual eating and drinking, with- out any absolute excess, is the exciting cause ; an indulgence in effervescing wines or full-bodied ports or new spirits, being especially dangerous. The earliest symptom is a sensation of fulness or plugging up, and of slight pulsa- tion in the anus ; there is also a tendency to constipation, inducing a little HEMORRHOIDS. 127 straining; this is frequently followed by itching of a very annoying character, coming on when the patient gets warm in bed, keeping him awake for some time, and inducing him to scratch the part. In the morning he finds his anus a little swollen and tender, and if he be an observant person with regard to himself, he will notice after a motion a slight stain of blood. The treatment in such a case should be abstinence from active exercise, with rather spare diet, embracing well-cooked vegetables and fish, but not much meat, and no beer or spirits; even wine is not desirable. If a smoker, the patient must cut down his usual allowance ; smoking often causes a sympa- thetic irritation of the throat and rectum. He may take a warm or a Turkish bath, and should wash the anus night and morning with warm water and Castile soap, after this applying some glycerine and tannic acid, or some calo- mel ointment, or a lotion composed of one teaspoonful of the liq. plumbi diacetatis added to a wineglassful of fresh milk, which is very soothing. As to medicines, he may take a Plummer’s pill, with a little taraxacum and belladonna, for two or three nights at bed-time; and in the morning, f'asling, some effervescing citrate of magnesium, phosphate of sodium or sulphate of potassium and sodium, or this draught, which I have found very useful on many occasions : R.—Liq. magnes. carb. flss ; potassii bicarb. 9j ; syr. seu tinct. sennse f3ij; spt. sether. nit. f‘3ss; aquae purse ad One third of a tumbler-full of Friedrichshall water, taken fasting with twice as much warm water, or Carlsbad salts, will also have a good effect. If the case be neglected, and advice be not sought until active inflammation has set in, and the symptoms I have described are in full force, the surgeon will save his patient much time, pain, and after-trouble, by snipping off the inflamed cutaneous excrescences, or, in the case of the sanguineous tumors, by laying them freely open by transfixion with a bistoury, and turning out the clot. The incision should be made in the direction of the radiating folds of the anus. A little absorbent cotton-wool should be laid into the wound, which will readily heal. It is always well in these cases to ascertain, by means of an injection, whether there be any internal piles associated with the external; if so, they must be attended to, or the patient will probably be made worse by any operation on the external hemorrhoids. If the patient will not submit to operative treatment, the swollen parts should be well smeared with extract of belladonna and glycerine in equal parts, and a warm poultice applied. Sometimes cold is found by the patient to be more soothing; ice should then be constantly applied, or, if this be unattainable, Goulard water with extract of belladonna. I have never seen much benefit derived from leeching, and often much ill. After having experienced one attack of hemorrhoids, a patient should guard himself against a repetition by simple living, plenty of exercise, abstin- ence from stimulants and excessive smoking, great cleanliness of the anus, and absolute regularity of the bowels. If medicinal aid be required to insure this, he will find equal parts of the confections of black pepper, sulphur, and senna, a capital remedy; or the German licorice-powder, one teaspoonful of which, two or three times a week at bed-time, generally suf- fices to keep the bowels acting daily ; lastly, the mineral waters, such as Friedrichshall, Pullna, or Hunyadi-Janos, are often of great use. A steady perseverance in the line of treatment which I have suggested will in all pro- bability eradicate the hemorrhoidal tendency. A favorite prescription of mine to stave off attacks is the following: R.—Magnes. sulpli. 3ss ; acid, nitric, dil. ni x ; succi taraxaci f‘3j; infus. calumbse f,lj. This should be taken twice in the day. This medicine acts gently on the liver and bowels, and at the same time is a tonic. After taking it for a week, the patient generally feels wonderfully better. His 128 INJURIES AND DISEASES OF THE RECTUM. appetite is good, his bowels are regular, and he is capable of bearing fatigue and enjoying exercise. Internal Hemorrhoids. — Although during pregnancy external venous hemorrhoids are frequent, and usually pass away after labor, the reverse is the case with regard to internal hemorrhoids ; these most frequently make their appearance after parturition, when all the parts are relaxed and uterine involution is going on. I will not attempt to give any reason for this pecu- liarity ; I only state a fact which I have repeatedly observed. As regards the other causes of internal hemorrhoids, they are practically those which also produce external hemorrhoids. In addition, hereditary influence, and diseases of the genito-urinary system, must be included. I do not share M. Verneuil’s view that the boutonnieres musculaires, de- scribed in the section on anatomy, play an important part in the etiology of the disease which we are now considering, mainly on two grounds: first, because the presence of arteries in hemorrhoidal growths is not thus accounted for ; and secondly, because it seems to me that the contraction of the circular and longitudinal muscular fibres of the bowel favors, and does not retard, the upward flow of the blood ; the button-hole apertures through the muscular walls of the rectum really play the part of valves to support the column of blood going to the liver, and in place of causing stasis pre- vent it, by opposing regurgitation in congested states of that organ. As regards the structure and appearance of internal hemorrhoids, three broadly-marked kinds may be observed : viz., the capillary hemorrhoid, the arterial hemorrhoid, and the venous hemorrhoid ; at times all perfectly dis- tinct, at other times united in the same patient. Hemorrhoids of the first variety I should describe as small, florid, raspberry- like looking tumors, having a granular, spongy surface, and bleeding on the slightest touch ; these piles are often situated rather high in the bowel. Al- though so small, the quantity of blood lost from them may be very consider- able. In structure they consist almost entirely of hypertrophic capillary vessels and spongy connective tissue, and therefore I think a good name for them is the capillary hemorrhoid. They resemble arterial nsevi very closely indeed in their microscopic structure, except that they are covered externally by a very much thinner membrane, and consequently are readily made to bleed. Ultimately, the main vessels feeding the growth increase in diameter, and the areolar tissue becomes thickened and more abundant. An exudation of lymph obliterates the capillaries, and so arrests bleeding from the surface. These changes I believe to be the result of slow processes of inflammation. In this way most commonly hemorrhoids of the second variety, arterial in- ternal hemorrhoids, are formed. They may be thus distinguished: The tumors vary in size, attain sometimes very considerable dimensions, glisten on their surface, are slippery to the touch, hard, and vascular, and if scratched bleed freely, the blood being bright-red and issuing by jets. If the finger is passed into the bowel it will feel entering into the upper part of each hemor- rhoid an artery, pulsating with as much force as the radial, and in many cases of a calibre but little less. On dissecting one of these tumors, it will be found to consist of numerous arteries and veins, freely anastomosing, tor- tuous, and sometimes dilated into branches, and of a stroma of cell-growth and connective-tissue, the latter most abounding. The third variety is the venous internal hemorrhoid, and in this the venous system predominates. The tumors are often very large. I have seen them quite the size of a hen’s egg. They are bluish or livid in color, and they are hardish; the surface may be smooth and shiny, or pseudo-cutaneous; they prolapse very readily, and are often constantly down; they do not usually HEMORRHOIDS. 129 bleed much, but, if pricked, the contained blood may be either venous or arterial. This form is commonly found in women who have borne children, and who have enlargement or retroversion of the uterus; they often occur about the period of change of life. This form may be called the “passive” kind, and is frequent among spirit drinkers. I never hesitate to operate on these cases, but I observe certain precautions before doing so; if the liver is in fault, I prescribe careful living and a course of Carlsbad waters, together with shampooing and the cold douche. In women, any uterine complication should be attended to. In men, after the operation, extreme moderation of living should be enforced, the bowels should be kept acting regularly, daily, and stimulants should be interdicted. Some- times venous hemorrhage occurs a week or ten days after the operation, from the surface of the unhealed wounds; if it be not extensive, it should not be interfered with. The ordinary symptoms of internal hemorrhoids are bleeding at stool, which may continue for some little time afterwards; constipation ; a feeling of discomfort and heaviness about the anus and lower part of the rectum ; and, lastly, protrusion of the hemorrhoids through the anus. The bleeding is usually the first symptom which attracts the patient’s attention to the fact that there is something wrong with his rectum, and its amount and character vary considerably. At first usually slight, it may soon become so severe as to blanch the patient, causing one to hesitate about operating, and making it desirable, if possible, to improve the patient’s condition by the enforcement of rest, and by the use of tonics and astringent injections, iron and ergotine being especially useful. Should, however, the hemorrhage not cease very soon, the only thing to do is to operate at once, being most careful while operating to avoid any needless loss of blood. In these cases of great blanching the blood is quite watery, will not clot, and runs out freely from the slightest prick; the operation must therefore be executed very rapidly. I often ligate four hemorrhoids in less than one minute; and in such severe cases the ligature is, in my opinion, the only method that can be safely adopted. Some few months back I was present when, in one of these formidable cases, an operator, contrary to my advice, attempted to remove the piles by the clamp and cautery. The result was that the patient nearly lost his life. I was able to temporarily stop the bleeding by pressure on the abdominal aorta, while ligatures were put on around all the diseased mass; a moderate estimate of the amount of blood lost was three quarts. The character of the bleediug may be arterial, venous, or mixed. The older the hemorrhoids, as a rule, the more venous is the hemorrhage, but, on the other hand, when they have reached a very advanced stage hemorrhoids frequently do not bleed at all, but exude a sero-mueous fluid. Even from the first, a patient with internal hemorrhoids may never have lost a drop of blood, or, what is more probable, may not be conscious of ever having done so. The feeling of discomfort and heaviness in the rectum hardly ever amounts to pain. If there is pain, there is probably inflammation or an ulcer. When the hemorrhoids come down, and are compressed by the sphincters, there will of course be pain, which is relieved by the patient’s returning them into the bowel. This protrusion is what annoys the patient most, and urges him to undergo an operation. At first the piles come down during stool, but return spontaneously; afterwards, the patient has to return them by pressure; and lastly, although returned,'they will not remain in place if the least exertion be made. Constipation, which usually precedes the advent of hemorrhoids, is nearly always rendered much more obstinate through the mechanical obstruction which they afford to the free evacuation of the bowels; yet patients will tell 130 INJURIES AND DISEASES OF THE RECTUM. the surgeon that they go regularly to stool every morning, and only on cross- questioning them will he elicit the fact that, although the bowels may diur- nally respond to the call of nature, their action still leaves much to be desired, and at the best is very protracted and attended with violent straining and loss of blood. A useful question to ask these patients is, “ You go to stool every morning, you say ; how long do you remain there ?” In old-standing cases with protrusion, there is frequently a difficulty in retaining wind or loose motions; this is partly due to relaxation and weak- ness of the sphincter, partly to the loss of acute sensitiveness of the mucous membrane at the lower part of the rectum. This sensibility in the healthy subject gives timely warning to the sphincter ani to contract, when necessary. Before describing the modes of operating which I employ, I may say a few words as to the cases which in my opinion are not well suited for operative interference. The older I get the more convinced do I become that the only really reliable way of treating hemorrhoids is to remove them; the only exception I would make, and that is a very partial one, is in those cases in which, together with hemorrhoids, there is found an ante-flexed or retro- flexed uterus. Here, I would say, the uterine displacement should be first corrected, and then the surgeon should use his judgment, being of course influenced by the urgency of the case and other considerations, as to whether he will operate or not. Even if the wounds heal satisfactorily, the distressing symptoms, bearing down, etc., may continue as before the removal of the piles. So, too, when there are vesical complications, the wounds heal slowly, and with a tendency to ulceration; and when they have at last healed, the patient, as far as his symptoms are concerned, is not much, if at all, improved. A question often put by the patient to his surgeon is, “If I have my hemorrhoids removed now', w'ill they return ?” This query is, in my opinion, best answered in the following way: “ If after the operation you will follow the few simple rules of life wffiich I shall give you, you ma}r rely upon it that there will be no return of your hemorrhoids ; but if you give full play to the causes which produced them before, there may be such a return.” But I am bound to say that, in my own practice, the cases in which I have operated a second time for hemorrhoids have been so fewT that I could count them on my fingers. As the result of my experience I may safely say that the tendency to the fresh formation of hemorrhoids has been greatly overrated, and that if patients, after operation, will but attend to their bowels and live simply and rationally, with due regard to the necessity of taking exercise regularly, they need never fear a return of their old trouble. An exception may be made wdth regard to patients living in tropical climates. Unless great abstinence from alcohol be observed, piles will return. And now as regards the operation: The night before, and in some cases in vdiich the liver is congested, for two or three nights before, I order a couple of pills, six grains of the pill of colocynth and hyoscyamus, and two of blue pill, to betaken; and the next morning, an hour before the operation, a copious soap-and-wrater enema should be administered, to make sure that the bowels are empty. I prefer operating early in the morning, as then the patient has the wdiole day before him in which to shake off the unpleasant effects of the ether and get rid of all pain, and as a consequence a quiet night will be insured, and refreshing sleep. The different modes of operating are briefly the following: I shall describe only those fully which I myself employ or think w'ell of:— 1. Excision with knife or scissors. HEMORRHOIDS. 131 2. Mr. Whitehead’s method of excision, combined with torsion and bring- ing together the divided mucous surfaces. 3. Removal with the ecraseur of Chassaignac or the wire of Maisormeuve. 4. The application of various acids and caustic pastes. 5. The injection of carbolic acid or other caustic or astringent fluids into the body of the pile. 6. Punctuate cauterization of Demarquay, Reeves, and others. 7. Linear cauterization of Voillemier. 8. Removal by the galvanic-cautery wire. 9. Removal by the clamp and scissors, applying the actual cautery to arrest hemorrhage. 10. Dilatation of the sphincter muscles. 11. Ligature. 12. Removal by means of the screw-crusher. Excision is an operation which was much practised in the early part of this century. In cases in which the hemorrhoids are not very large or very numerous, it is in my opinion one of our best modes of procedure, as it is followed by very slight pain only, and rapid recovery ensues. I have had cases in which the wounds were soundly healed on the sixth day. In performing excision I first gently but fully dilate the sphincter muscles, and employ a retractor to keep the anus well open ; I then seize the bowel deeply, above the pile, and cut the latter off at its base, not letting the bowel escape from the volsella until all bleeding has been arrested by torsion of the arteries. Rarely more than two vessels spirt and require twisting. I wait for a little while to see that all hemorrhage has ceased, and then I treat the other piles in a similar manner. After all the arteries have ceased to bleed, I place a piece of cotton-wool, previously saturated in a solution of tannin and water (strength, one ounce of tannin to one ounce of water), within the anus as high as the scissors have cut. In no case has any recurrent hemorrhage taken place. This operation must be done slowly and carefully, and therefore occupies far more time than either ligature or crushing, which is a decided drawback to its employment, as I hold that prolonged anaesthesia is if pos- sible always to be avoided. About five years ago, Mr. Walter Whitehead, of Manchester, introduced a modification of this old method of excision, which he believes to be more in harmony with the principles of modern surgery. I will give his own description :— After it had been decided to excise the hemorrhoids, a day in the following week was fixed for the operation, and in the mean time the patient was very carefully pre- pared by diet, aperients, and rest. The operation was conducted under chloroform, with the patient in the lithotomy position. As a preliminary measure, the function of the sphincter was suspended by forcible dilatation. Two thumbs were introduced into the rectum, and the circumference steadily kneaded in every direction until all resist- ance was overcome, and the sphincter rendered absolutely passive. The patulous con- dition of the rectum thus obtained, enabled the whole mass of piles to be extruded from the anus by introducing two fingers into the vagina and depressing the recto-vaginal wall. The hemorrhoids in size and appearance resembled an average ripe tomato, and were mapped on the surface into four irregular and unequal lobes. The lobes were next divided into four segments by longitudinal sections in the axis of the bowel and in the furrows marking the intervals between the several lobes. This was accomplished without the loss of any blood. Each portion was then secured in succession by Lund’s ring forceps, and dissected with scissors; first transversely from the anal margin, and then upwards in the cellular plane to the highest limit of the he- morrhoidal growth, in this case about an inch and a half. Each segment was thus con- verted into a quadrilateral, wedge-shaped mass, the base below consisting of the hemorrhoid, and the apex above of the healthy mucous membrane of the bowel. 132 INJURIES AND DISEASES OF THE RECTUM. The mucous membrane at the highest point was next transversely divided, leaving the hemorrhoid simply attached by loose cellular tissue and by the vessels, proceeding from above and supplying the mass below. The forceps containing the hemorrhoid were then twisted until all connection was severed and the hemorrhoid removed. The divided surface of the mucous membrane was next drawn down, and attached by several fine silk sutures to the denuded border at the verge of the anus. The other portions having been treated in the same manner, the operation was com- pleted. The sections throughout were made by scissors. The loss of blood during the operation did not exceed a couple of ounces. The patient made a complete recovery, and regained the full capacity to discharge her domestic duties and social engagements. This operation Mr. Whitehead seems to have since modified, and he now cuts out a ring of the bowel commencing at the junction of the skin and mu- cous membrane; he dissects the piles upward, and then by a circular incision removes the mass (and a portion of the bowel also, I suppose); the cut edges.are then brought together. Primary union, Mr. Whitehead says, always takes place, and the patient gets speedily well; he avers that in a large number of cases (200 and upwards), no contretemps has taken place, and by implication no death. Moreover, stricture has never resulted, nor ulceration. I fancy that in small excisions of the bowel for malignant disease, when the mucous membrane and skin have been brought together, such satisfactory results have not been obtained. The method of Mr. Whitehead deserves a full and fair trial, and it shall have it at my hands very shortly; one objection I feel called upon to make, viz., that in inexpert hands much time must be occupied, and considerable loss of blood must take place. I am quite sure that the frequent failures which are said to take place in other operations for piles, are the result of the very perfunctory and imperfect way in which they are conducted. I have constantly coming to me patients who have only been free from the surgeon for six months, and in whom the piles have returned; this is clearly because real removal has never been per- formed; a slight clamping, a little burning, removing only the mucous surface of the hemorrhoid, is all that has been done; hemorrhage is only for a time arrested, and the disease continues to advance, having indeed been only very temporarily checked by the means used. The next seven in the list of operations which I have given, I will pass over, because they have little to recommend them ; when they are not uncer- tain methods they are dangerous, and occasionally they combine both danger and uncertaint}r of result. Take, for instance, the “ clamp and cautery” method. Mr. Henry Smith, who advocates this plan, lost four cases in 530 operations. Out of 195 patients Fig. 1329. Clamp for hemorrhoids. with whom I followed his recommendation, 2 died in consequence of the operation. On the other hand, in 1800 cases of ligation I have had but one HEMORRHOIDS. 133 doubtful death. In this case the patient, who was old and very bronchitic, succumbed in 36 hours after the application of the ligature, from acute pneu- monia. The “ post hoc” here should not I think be considered the “ propter hoc,” but I record the case. In over 500 cases treated by crushing, I have not had one death from any cause whatever. I will pass on to dilatation of the anal sphincters, so strongly advocated by Messrs. Verneuil, Fontan, Panas, Gosselin, and Monod. The method is as follows: The patient being fully under the influence of an anaesthetic, the surgeon inserts both thumbs into the rectum and dilates gradually, first in the antero-posterior and afterwards in the opposite direction, using an amount of force sufficient to overcome spasm. He continues to manipulate the sphinc- ters until the muscles feel reduced to a thoroughly pulpy condition, so that he can easily insert his whole hand and even draw it out as a fist. The result is that paralysis of the sphincters is fully induced, and this condition will last certainly for four or live days, and possibly for even more. The patient must be kept recumbent for about a week. In all my operations for internal hemorrhoids I invariably make dilatation a prelude to whatever else I do. This I do for two reasons: first, the rectum is thus rendered so patent that all disease can be seen and dealt with by knife, scissors, or crusher, without making any undue traction on the part; second, all spasm is done away with, and the great element in all such operations, viz., pain, is reduced to the minimum. The removal of piles by the screw-crusher is in my judgment a very valu- able operation. Very safe as regards hemorrhage, and almost paiidess, the recovery is more rapid than is effected by most other methods. Mr. George Pollock was, as far as I know, the first to describe and practise the operation by means of a powerful crushing apparatus, and his success was very great; but when I came to try this plan, I found that the instrument he used, which was one designed by Mr. Benham, like a large pair of pincers, was very defective ; it was too large, heavy, and clumsy, and did not after all, in severe cases, make enough pressure to insure the thorough destruction of the base of the hemorrhoid. My son, Mr. Herbert W. Allingham, then designed for me an instrument on a totally different principle; it was small, light, and easy of adaptation to the pile, and its power was enormous, being worked by direct screw action and not by lever movement, as in Mr. Benham’s pincers. After many trials, Messrs. Krohne & Sesemann, of Lon- don, made me a perfect instrument, which I use with much satisfaction and great success. The crusher is made of solid steel, forming an open square at one end, between the sides of which a second piece of steel slides up and down. The bar is connected with a powerful screw, which drives it firmly home against the distal end of the square, first by a sliding, and lastly by a screwing motion, and thus exerts a great crushing power from which the hemorrhoid cannot escape. By removing a pin, the screw and piston can be easily taken out for the purpose of cleaning. (Fig. 1330.) To aid in the adjustment of the crusher, the hemorrhoid is seized with volsella forceps (Fig. 1331) and drawn through the open square of the instrument. Treatment of Internal Piles by Ligature.—Although I now almost invari- ably employ the crushing operation, there are still some cases for which I elect ligature: those, for instance, in which the hemorrhoids form a continuous ring with no division into lobes. In these cases the crushing operation has drawbacks. At the sides of the crusher, hemorrhage may occur from laceration of the adjacent portion of the hemorrhoid ; the part crushed is not likely to bleed more than any other crushed hemorrhoid, 134 INJURIES AND DISEASES OF THE RECTUM. Fig. 1330. KROHNE& SE5EMANN LONDON. Z1 Screw-crushing instrument for hemorrhoids. Fig. 1331. Forceps for grasping hemorrhoids. but the hemorrhage proceeds from parts wounded in the application of the crusher. In these cases I always adopt ligation as being the best and safest procedure. The method of operating is as follows: The patient must lie on his right side, on a hard couch, with his knees drawn well up to his abdomen. When he is fully anaesthetized, I gently but completely dilate the sphincter muscles. I then seize the hemorrhoids one by one with a volsella, and with a pair of strong, sharp, spring-scissors (Fig. 1332) separate the pile from its connection Fig. 1332. Spring-scissors for hemorrhoids. with the muscular and submucous tissues upon which it rests ; the cut is to be made in the sulcus or white line which is seen where the skin meets the mucous membrane, and this incision is to be carried up the bowel, and parallel to it, to such a distance that the pile is left connected by an isthmus of vessels and mucous membrane only. There is no danger in making this incision, because all the larger vessels come from above, running parallel with the bowel, just beneath the mucous membrane, and thus enter the upper part of the pile. A well-waxed, strong, thin, silk ligature is now to be placed at the bottom of the deep groove which has been made, and, an assistant then drawing out the pile with some decision, the ligature is tied high up at the neck of the tumor as tightly as possible. Great care must be taken to tie both knots of the liga- ture, so that no slipping or giving way can take place. I myself always "tie a third knot; the secret of the well-doing of the patient depends greatly upon this tying—a part of the operation by no means easy. 135 HEMORRHOIDS. If the pile be very large, a small portion may now be cut off, taking care to leave sufficient stump beyond the ligature to guard against its slipping. When all the hemorrhoids are thus tied, they should be returned within the sphincter ; after this is done, any superabundant skin which remains may be cutoff; but this should not be too freely excised, for fear of contraction when the wounds heal. I always place a pad of wool over the anus, and a tight T bandage, as it relieves pain most materially and prevents any tendency to straining. It is advisable to commence by operating upon those piles that are situated interiorly, as the patient lies, in order that the others may not be obscured by blood, but when the hemorrhoids are numerous, and there are small piles, either anterior or dorsal, it is better to tie the small ones first, as otherwise they may be overlooked. After the operation, the bowels should be confined for three or even four days. I find a solid one-grain opium pill, given as soon as the vomiting after the ether has ceased, and repeated twice, at inter- vals of two hours, the best article to begin with; afterwards a draught containing laudanum may be substituted. The diet, until the bowels have acted, should be light—spoon-diet in fact. After the bowels have operated, a more liberal allowance of food should be made; I usually begin with fish, followed by meat the next day. I always advise entire abstinence from wine, beer, or spirits, unless there is some special condition indicating the necessity for their use. On the third or fourth night after the operation I order a mild aperient, such as the German licorice-powder, followed the next morning by a hot Seidlitz draught. The first action of the bowels is gene- rally rather painful, and sometimes exceedingly so. A hot linseed poultice applied to the anus immediately after the stool, mitigates the pain and comforts the patient. The ligatures separate about the sixth or seventh day. I generally give a gentle pull at them daily, commencing the day after the bowels are first relieved; by this plan the ligatures always separate on the fifth or sixth day. The patient should be kept lying down during this period; in fact, the more he observes the recumbent position until his wounds have healed, the better. This usually occurs a fortnight after the operation; in very severe cases it may of course be longer before the wounds cicatrize. The dressing which I employ is of the simplest: a small piece of cotton-wool saturated with oil, or smeared with zinc-ointment, suffices—but it should be introduced with the greatest care and gentleness through the anal orifice. On the night of the ope- ration, the patient may be unable to pass urine, owing to reflex spasm in his urethra; the urine must then be drawn off with a soft catheter, or he will pass a restless night. During the second week after operation, I always make a point of introducing my finger, well anointed, into the patient’s bowel, to make sure that there is no tendency to contraction. Should there be such ten- dency I daily introduce the finger, and, if need be, tell the nurse in charge of the patient to repeat the act at night. Such contraction is of no serious moment, as it only affects mucous membrane, and in any case would pass away in time. But it is as well avoided, as it alarms the patient, who may think that he has got a stricture in place of his piles. The most common complication of internal hemorrhoids is fissure or small painful ulcer; pain, continuing long after the bowel is relieved, is its most certain sign. Fistula is a less common accompaniment of piles. When examining a case of hemorrhoids, the surgeon should never omit to pass the finger well into the bowel, to ascertain that no stricture, ulceration, or malig- nant disease is present. Impaction or accumulation of feces in the rectum or colon, is another complication worthy of mention. Lastly, polypus is some- times found in conjunction with hemorrhoids. 136 INJURIES AND DISEASES OF THE RECTUM. The preliminary dilatation usually suffices to cure a fissure or painful ulcer. It is rarely necessary to divide the muscular fibres at the time of an opera- tion by ligature, since dilatation has come into use. A fistula must of course be laid open. An accumulation or impaction of feces must be broken down and got rid of before the day of operation, as otherwise the wounds will not heal kindly. A few words must be said as regards the treatment of hemorrhage after operations in internal hemorrhoids. Primary hemorrhage, if the operation be carefully done, is very rare; occa- sionally, when large and very vascular hemorrhoids are ligatured, and there is also much superabundant skin cut away, a small vessel will bleed when the patient recovers from shock. This is a trivial matter, and a ligature is easily applied. Secondary hemorrhage is of more serious import, and occurs generally in elderly people of broken-down constitutions, or in those who have been very free livers. As far as my experience goes, this hemorrhage is usually more venous than arterial, and occurs at or about the time of the separation of the ligatures. I have found it utterly futile in cases of secondary hemorrhage to try and place a ligature around the vessels; it is usually the large veins or venous sinuses which are opened by sloughing or ulceration, and when the surgeon introduces a speculum and tries to find the source of bleeding, he can only see that the whole rectum is filled with blood, and on passing his finger will feel a quantity of clots. The best mode of arresting this form of hemorrhage is as follows:— Pass a strong silk ligature through and near the apex of a cone-shaped sponge, and bring it back again, so that the apex of the sponge is held in a loop of the silk. Then wet the sponge, squeeze it dry, and powder it well, filling up the lacunae with powdered subsulphate of iron. Pass the fore- finger of the left hand into the bowel, and upon that as a guide push up the sponge—apex first—by means of a metal rod, bougie, or penholder, if nothing better can be got. This sponge should be carried up the bowel at least five inches, the double thread hanging outside of the anus. When it is so placed, fill up the whole of the rectum below the sponge, thoroughly and carefully, with cotton-wool well powdered with the iron. When the bowel is thus completely stopped, take hold of the silk ligature attached to the sponge, and while with one hand the sponge is pulled down, with the other push the wool up. This joint action will spread out the bell-shaped sponge like opening an umbrella, and will bring the wool compactly together. This plug may remain in from a week to a fortnight or more. A male catheter passed through the centre of the sponge, with the wool packed around it, is a great improvement, as it enables the patient to pass flatus. Retention of urine will occur after this packing, but may be relieved with a catheter. Stimulants are best withheld until reaction has set in. Opium should always be freely exhibited after the introduction of the plug, as otherwise straining will be set up. As soon as it can be taken, nourishment is to be given, and Liebig’s cold soup, which can be quickly prepared, I have found a wonderful restorative. Hot liquids, I need scarcely say, are to be avoided. As soon as a patient can take solid food, he should have it, but it should be nourishing and easy of digestion. The drugs which I prefer are the tinctura ferri percliloridi and the liquor ferri peracetatis, as these are not only haemo- statics but also blood-repairers. PROCIDENTIA and prolapsus of the rectum. 137 Procidentia and Prolapsus of the Rectum. True procidentia is the descent of the upper part of the rectum, in its whole thickness, or all its coats, through the anus. True prolapsus is a descent of the lowest part of the rectum, the mucous membrane and submucous tissue being turned out of the anus. A third variety consists of an intussusception, the upper part of the rectum descending through the lower part. It is easily diagnosed from ordinary procidentia by there being a more or less deep sulcus around the inner column of the intestine; so that there are, as it were, two cylinders of rectum, one inside of the other. The expression prolapsus ani is often loosely applied to protruding in- ternal hemorrhoids, thus giving rise to unnecessary confusion. Internal hemorrhoids come down as distinct and separate tumors, with a smooth and shiny surface, and are hard to the touch. True prolapsus has no folds, except one towards the perineum (which indeed may be absent), and feels to the finger soft and velvety. But the most common cause of prolapsus is un- doubtedly the presence of internal hemorrhoids. I have seen it also as the result of straining, in fissure, and in conditions of the urinary tract accom- panied by difficulty of micturition, such as urethral stricture, the presence of a stone in the bladder, enlarged prostate, cystitis, etc. In children, diarrhoea, often the result of strumous inflammation of the bowels, worms, and phimosis, are responsible for a great many cases. Polypus may be the cause of either prolapsus, procidentia, or intussusception. It must be well under- stood that, as procidentia is only a more advanced degree of prolapsus, all the causes above mentioned will, if they act long enough, produce it also. When procidentia occurs conjointly with internal hemorrhoids, removing them by either crushing or ligature will almost certainly cure it. Procidentia of the rectum is more often seen in children than in adults, although it is by no means a rare affection in women—particularly those who have borne many children—and in men advanced in years. Procidentia in children is much favored by the formation of the pelvis, the sacrum being nearly straight. Moreover, all infants strain violently when their bowels act, even when their motions are quite soft; there appears to be some phy- siological necessity for this, which I do not pretend to explain or understand. But these facts are not quite sufficient to account for the proneness of children to this malady ; there must be, in addition, some inherent weakness or ex- traneous source of irritation present, by which excessive straining is produced. There are many cases, however, in which we can assign no special cause, where the child is not manifestly unhealthy, and where no source of irritation can be detected. I am sure that the very bad custom of placing a child upon the chamber-utensil, and leaving it there for an indefinite period, as practised by many mothers and nurses, is a fertile cause of procidentia. In children the treatment is generally successful: it should first be addressed to the removal of any source of irritation; this accomplished, a cure is speedily effected. Where no source of irritation can be discovered, the general health must be attended to. The child should never be allowed to sit and strain at stool; the motions should be passed lying upon the side, at the edge of the bed, or in a standing position, and one buttock should be drawn to one side, so as to tighten the anal orifice while the feces are passing; this device I have found to be very useful. When the bowels have acted, the protruded part ought to be well washed with cold water, and afterwards a solution of alum and oak-bark, or infusion of matico, should be thoroughly applied with a sponge; the bowel must then be returned by gentle pressure, and the child should remain recumbent for some little while, lying upon its face on a 138 INJURIES AND DISEASES OF THE RECTUM. couch, before running about. If there be any intestinal irritation, I order small doses of mercury with chalk, and rhubarb, at bedtime, and steel wine two or three times in the day. When the child is very ill-nourished, cod- liver oil does much good; the diet should be nutritious and digestible. If these mild measures do not succeed, I find the application of strong nitric acid the best remedy. The child should be anaesthetized, and the protruded gut well dried. The acid must be applied all over it, care being taken not to touch the verge of the anus or the skin. The part is then to be oiled and returned, and the rectum thoroughly stuffed with wool; a pad must after this be applied outside of the anus, and kept firmly in position by straps of plaster, the buttocks being by the same means brought closely together; if this precaution be not adopted, when the child recovers from the anaes- thetic, the straining being urgent, the whole plug will be forced out and the bowel will again protrude. When the pad is properly applied, the straining soon ceases, and the child suffers little or no pain. I always order a mixture of aromatic confection, with a drop or two of tincture of opium, so as to con- fine the bowels for four days. I then remove the strapping, and give a tea- spoonful of castor oil. When the bowels act the plug comes away, and there is no descent of the rectum. In procidentia in the adult the mass is sometimes very large; I have seen it in a woman larger in circumference than a foetal head, and seven or eight inches in length. I have had, in my own practice, many cases of procidentia in which there was a hernial sac in the protrusion, and in all it was situated anteriorly, as from the anatomy of the part, of course, it must be; the intes- tine could be returned from the sac, and it went back with a gurgling noise. As soon as the bowel protrudes, a hernia can be recognized by the fact that the opening of the gut is turned towards the sacrum ; when the hernia is reduced, the orifice is immediately restored to its normal position in the axis of the bowel. I have never found such a hernial protrusion in a child. In very old and bad cases of procidentia, more or less incontinence of feces always exists, owing to loss of tone in the sphincters and loss of sensitiveness in the altered mucous membrane. Thus when fecal matter reaches the lower part of the rectum, the sphincters are not stimulated to action, nor is the patient aware of its presence. The most satisfactory operation for proci- dentia in the adult with which I am acquainted is that recommended by Van Buren, which I perform as follows :— The patient is etherized, and the procidentia is drawn fully out of the anus by the volsella; I then make four or more longitudinal stripes, from the base to the apex of the protruded intestine, with the iron cautery at a dull red heat. I take care not to make the cauterization as deep towards the apex as at the base, because near the apex the peritoneum may be close beneath the intestine, while a deep burn near the base is not dangerous. I take care to avoid the large veins which can be seen on the surface of the bowel. If the procidentia is very large, I make even six stripes. I then oil and return the intestine within the anus ; having done this, I partially divide the sphincters on both sides of the anus with a sawing motion of the hot iron, and then insert a small portion of oiled wool. From the day of operation 1 never let the patient get out of bed for anything ; the motions are all passed lying down, and consequently the part never comes outside. If the wounds have not all thoroughly healed in a month, I continue the recumbent position for two weeks more, by which time it very rarely happens that cicatrization is not complete. The patient can then arise and get about, but still for some time I enjoin that evacuation of the motions should be accomplished lying down. The reason for the success of the treatment is simple enough. When the burns are all healed, the bowel by contraction of the longitudinal stripes is drawn 139 PRURITUS ANI. upwards, and circumferential diminution also takes place. In these cases, before operation, the sphincter muscles have quite lost power, and the anus is large and patulous ; by sawing through the anus with the iron, the muscles contract and regain their power, the patient having strength to cause the anus to close at will, and even to some extent to squeeze the finger when introduced. Sometimes when a large portion of the bowel comes down, there is much difficulty experienced in returning it. I have found that the passing up the bowel of a large flexible bougie, so as to carry before it the upper part of the descended gut, is of great service; gentle taxis should at the same time be practised. A tiresome diarrhoea is very commonly present, and there is often a dis- charge of mucus which keeps the linen damp and adds not a little to the general discomfort. One teaspoonful of powdered acorns in a tumblerful of milk, every morning, answers better than anything else that I know of, as a remedy for this. The frequent and bountiful application of cold water in these cases is to be most strongly recommended, as it fulfils the same purpose as astringent lotions, and quite as effectually. Pruritus Ani. Pruritus ani, or painful itching of the anus, is frequently induced by habits of too free eating and drinking ; it occurs thus in subjects of the lithic-acid diathesis. I am bound to say, however, that there are exceptions to this rule, as I have seen a most ascetic clergyman sutler dreadfully, as well as a lady who had been all her life a total abstainer, and a remarkably small eater. Hepatic affections with constipation, disorders of the stomach, and uterine diseases, are prolific causes of pruritus ani; and gout, especially latent gout with its accompanying eczema, is responsible for a great deal of suffering from this troublesome affection. Amongst local causes, the presence of in- ternal hemorrhoids, vegetable parasites, pediculi, and ascarides, are the most frequent. Doubtless there are many cases of pruritus for which we are unable to assign any cause, and it may then be considered as a pure neurosis. On examining the part, a distinctly eczematous rash is often seen, which is moist from exudation ; or the anus may be dry and rugose, with bright redness consequent upon scratching ; occasionally there are numerous minute scales to be seen, forming irregular rings; often there are cracks radiating from the anus and even extending up to the sacrum ; but what I consider the characteristic condition—which may always be noticed when the disease is severe and has lasted for any length of time—is the loss of the natural pig- ment of the part. To such an extent does this loss often occur, that patches around the anus, extending backwards as far as the sacrum and fonvards to the scrotum, are of a dull-white, parchment-like character, and have lost all the normal elasticity of healthy skin. When considering a case as to the question of treatment, it is always important to discover the cause of the irritation. I once had a patient who invariably got an attack of pruritus from eating lobster or crab, and another in whom salmon produced the same effect. There is but little doubt that excesses at table, combined with a want of active exercise, form not only a predisposing but also an exciting cause. Excessive smoking is another excitant of the disorder. When a tendency to the malady exists, over indul- gence in smoking may be immediately followed by an attack of pruritus. The surgeon should investigate closely the habits of his patient, and 140 INJURIES AND DISEASES OF THE RECTUM. should recommend a plain, sometimes even a low diet. lie should interdict both beer and spirits, and should restrict the drinking to a little light sherry, or to claret and Vichy or Seltzer water. Coffee should be given up, and weak tea substituted. A walk of three or four miles, at such speed as to induce slight perspiration, should be taken daily, and every morning a sponge-bath is strongly advisable, with, once a week, a warm or, better still, a Turkish hath. The anus and parts around it should he washed every night when retiring to bed with warm water and tar or Castile soap. The bowels must be well opened daily ; the following prescription will be found beneficial: sulphate of magnesium, 9j; powdered carbonate of magne- sium, gr. v; wine of colchicum, v ; syrup of senna, f3j ; compound tincture of cardamom, f3ss; infusion of cinchona, f§j, twice or thrice in the day ; and I also often order two grains of Plummer’s pill with three grains of compound rhubarb pill, to be taken every other night for a week. I likewise frequently prescribe the mineral waters of Carlsbad, Friederichshall, Vichy, Hunyadi- Janos, etc. After washing the parts at night, let the patient apply this lotion on a piece of lint fixed with a T bandage: Sodse biboratis 3ij; morphiae hydrochlor. gr. xvj ; acidi hydrocyan. dil. f§ss. The lint may be kept moist with this lotion by dabbing it through the bandage. Calomel ointment and chloroform locally (chloroform, f3ij, glycerinse flss, ung. sambuci .?iss), sulphide of calcium inter- nally and externally, liquor carbonis detergens when there is much eczema, and carbolic glycerole, are all admirable remedies, and may well be tried in obstinate cases. When the surgeon has made up his mind that the disease is a nervous one, as I think it often is in spare and delicate, excitable people, he should give arsenic and quinine freely, and be prepared to push them to their physiolo- gical effect, at the same time of course using local means to allay irritation. In obstinate, old-standing cases, I usually commence treatment by rubbing the parts thoroughly with a solution of nitrate of silver, 9ij to f3j ; this softens the skin, and induces a more healthy action and secretion. The dis- order is much more common among men than among women ; it is not often met with in young persons. When an attack of pruritus comes on after mental overwork, bromide of potassium is very advantageous. Opium given internally increases the disorder. I have for years past recommended the introduction into the anus, at bed- time, of a bone plug, shaped like the nipple of an infant’s feeding-bottle, with a circular shield to prevent it from slipping into the bowel; the nipple should be about an inch and a half in length, and as thick as the end of the fore- finger. I presume that it does good by exercising pressure upon the venous plexus and nerve-filaments close to the anus. At any rate, it stops the itch- ing and insures a good night’s rest. I advise it to be worn every other night. Pruritus caused by a vegetable parasite is readily cured by a lotion of sul- phurous acid, one part in six. Polypus of the Rectum. By the word “ polypus” I mean a pedunculated growth attached to the mucous membrane of the rectum, and generally situated not less than an inch from the anus. Polypi may be attached two inches up the bowel, but only occasionally more than that distance. Polypi have been usually described as of two kinds: the soft or follicular, and the hard or fibrous, the former being found in children and the latter in POLYPUS OF THE RECTUM. 141 grown-up persons. I am of opinion, however, that the soft polypus is not always the one found in young children, and consider the true fibrous variety rare even in the adult. In fact, this rough division is very far from express- ing the pathological truth, for the true fibrous polypus is in its anatomy an almost perfect counterpart of the fibroid tumor of the uterus, that is, a myoma. The few which I have myself seen have been nearly as large as wal- nuts ; they creak when cut, and the incised surface is of a pale color. The peduncle is about an inch and a half long, and is always attached above the sphincters ; the tumors do not usually appear outside of the anus; they do not bleed, but when they protrude they cause pain, irritation, and spasm, and often set up ulceration of the bowel. The discharge from them is of a very ichorous and ill-smelling character. The polypi usually found in the adult are smaller than the mucous polypi of children ; they are multiple. I have often found two growing from opposite sides of the rectum; there may also be two stems with only one head. The pedicle may be an inch or a little more in length, and is not uncom- monly hollow ; the polypi are neither very hard nor soft, and are easily com- pressible; they are sometimes cystic; a large vessel runs up the stem, and in some cases can be felt to pulsate. In women rectal polypi are almost always soft, with remarkably long and rather slender stems. The polypi of children are small, vascular tumors, with peduncles often two inches long. They resemble small, half-ripe mulberries more than any- thing else. They bleed very freely at times, and occasion in the young great debility. They are said to be hypertrophies either of the glands of Lieber- kiilm, or of the mucous follicles of the rectum. They may be dangerous when high up, by occasioning intussusception of the bowel, with total obstruction and death. When the peduncle is more than an inch in length they usually protrude at stool, and require to be returned after the bowels are relieved. The general symptoms in children are: frequent desire to go to stool, accompanied by tenesmus; occasional bleeding, with discharge of mucus; and the protrusion from or appearance at the anus of a fieshy mass when the bowels are acting. In the adult, the history of polypus is curious. Without any previous discomfort of any kind, the patient suddenly finds a substance protruding from the anus after going to the closet. This is characteristic of the malady. Until the peduncle becomes long enough to allow the polypus to be extruded and grasped by the sphincter, no inconvenience is felt, and therefore the patient speaks of a sudden onset; this is quite different from the history of hemorrhoids. In examining a patient, an injection should be administered before intro- ducing the finger; even if the polypus slips away, the surgeon will always be able to feel the pedicle at its point of attachment. The only treatment to be recommended is the removal of the growth. This is best done by seizing the peduncle close to its base with the German catch-forceps, and gently twisting the polypus around until it comes away. There is no danger of hemorrhage, no pain, and scarcely any necessity for resting more than one day. If a ligature is used, the patient should rest until it separates, as otherwise abscesses may follow. The rarer kinds of polypi are the dermoid, the cystic, the sarcomatous, and the disseminated ; the latter are adenoid as a rule, and the mucous membrane of the rectum and of the colon may be closely studded with them. Another very rare tumor of the rectum is the villous. This consists of a lobulated, spongy mass, with long villus-like processes studding its surface; it resembles exactly, though its villi are much larger, the growth of the same name found in the bladder. Usually it has a stem, broad rather than round, which I think is an 142 INJURIES AND DISEASES OF THE RECTUM. elongation of the mucous membrane rather than a new formation. These tumors may become malignant. I have seen two cases in which epithelioma replaced the villous growth. Impaction of Feces. By this expression is meant an accumulation in the pouch of the rectum, immediately above the internal sphincter. It occurs in females more com- monly than in males; old women, and women shortly after their confine- ments, being especially liable to it. I have seen it in children, and call to mind a little boy, only three years of age, who had a veritable impaction which gave a good deal of trouble; but when it was removed the bowel re- gained its tone quickly, and regular action was afterwards easily kept up. The cause of the accumulation I believe to be nearly always, primarily, a loss of power in the muscular coat of the rectum. Constipation is its inva- riable forerunner, and this may be due to spasm of the sphincter. In impac- tion, sphincter-spasm always exists, so that when the patient strains the anus protrudes like a nipple. The symptoms of impaction may be obscure, and I have known it mistaken for neuralgia of the rectum, gout of the rectum, and malignant disease of the caecum or sigmoid flexure. I once attended a gentleman who had been be- lieved by his physician to have incipient disease of the brain, so much nervousness and hypochondriasis resulted from a very loaded colon and impacted rectum. In another case, phthisis had been diagnosed by several medical men on account of a constant cough, with hectic at night, and much emaciation. But the most common error is the mistaking of impaction for diarrhoea with tenesmus. In many of these cases the patient complains of a tendency to diarrhoea, liquid motions being frequently passed, especially after taking an aperient, but without any sense of relief; and on assuming the erect position, straining—severe, continuous, and irresistible—takes place. On lying down this generally passes away. In the history of these cases it is not rare to find that severe pains have been experienced in the right lumbar and left inguinal regions ; this symptom points to the fact that the caecum has been the seat of obstruction and dis- tension, and that when this has been removed, the feces have again lodged in the rectal pouch. Dyspepsia, irritability of temper, nervousness, and despon- dency—the patient supposing herself to be suffering from an incurable malady ■—a very muddy, yellow, skin suggestive of malignant disease, morning vomit- ing, loathing of all food, and excessive thirst, are among the common symptoms of this disorder. A peculiar, ringing cough, particularly in women, and also night-sweats, are not uncommon. In both men and women obstinate reten- tion of urine may be caused by impaction. When examining a patient, tumors may be felt in the caecum, the transverse colon, or the sigmoid flexure. The anus will be found nipple-shaped, and the sphincter muscle as hard as a piece of wrood. On introducing the finger into the bowel (no easy, matter), a ball of hardened, clayey feces will be found filling up the rectal pouch. This ball I have seen as large as a foetal head, and quite movable, so as to admit of liquid or thin fecal matter passing around by its sides, thus giving rise to the impression that diarrhoea rather than constipation existed. So deceptive is the feeling wThieh this mass gives to the fingers, that I have more than once thought that I must be touching a tumor. In bad cases the sphincters must be dilated under an anaesthetic, and then the mass broken up with the finger or a lithotomy scoop, or the handle of a silver spoon. After having thoroughly disintegrated the impacted mass, NEURALGIA OF THE RECTUM—IRRITABLE RECTUM. 143 injections of soap-suds and oil may be administered to get rid of the enor- mous quantities of feces that will come down from the colon. It often takes time before the rectum can recover its power after its great distension, and therefore reaccumulation must be guarded against by injecting cold water, kneading the abdomen, and giving nux vomica with decoction of aloes. Exercise in the open air should be taken daily, and the diet should be moderate and simple. In the diagnosis between impaction and malignant disease, two points are of extreme importance. The first is, that in impaction the tumor differs in size and shape from time to time. The second, that the tumor in impaction has a decidedly doughy feel, and is irregularly soft. When the tumor is in the rectum, the introduction of the finger will at once clear up the doubt, if there be any. Concretions in the bowel are rarer than impactions. They are usually formed around some foreign body. I have seen a quantity of human hair form the core of a concretion, the patient having swallowed the hair in a fit of mania. Biliary calculi are often found in the centre of these concretions. The strangest case that I have ever seen was one in which a sovereign, swal- lowed fifteen months before I removed the concretion, was found to be its nucleus. It is curious that large bodies, such as a set of false teeth with gold mounting, may not be arrested anywhere in the intestines, while a small body, such as a sovereign or a date-stone, may fail to traverse the alimentary canal safely, and may indeed set up ulceration of the bowel and perforation. Neuralgia of the Rectum. A pain in the rectum or sphincter muscles may be called neuralgia, when not the slightest lesion, sign of inflammation, or discharge of any kind can be discovered, and when the pain is not aggravated by action of the bowels. This last is a most important point in diagnosis. I have more than once considered pains to be neuralgic which I afterwards discovered to originate from a structural lesion. Patients with rectal neuralgia are mostly delicate, irritable or nervous people, who have been subjected to neuralgic pains in other parts. I have noticed the attack to follow direct exposure to wet and cold, by sitting upon damp grass. One attack predisposes to another. Usually in these cases there is general debility with disorder of the digestive organs, mainly the liver. In treatment, the abdominal viscera must be first unloaded and put into condition, and then quinine, iron, strychnia, and hypodermic injections of morphia may at once cure the patient. In some instances, however, treat- ment only does temporary good, and nothing appears to be of permanent use. When the sphincter is the seat of pain, there is always spasmodic contrac- tion. Dilatation of the anus answers best here, followed by an injection of morphia. Irritable Rectum. This I believe to be really the result of a chronic inflammation of the mucous membrane, as it is accompanied by much heat in the bowel, and by tenesmus, as well as by a discharge of mucus. These cases are best treated by the administration of gentle laxatives and of alkalies with bitter infusions, and by insufflation of bismuth and charcoal into the rectum. When the irritability is allayed, injections of rhatany and starch, with small doses of the liquid extract of opium, will render the cure permanent. 144 INJURIES AND DISEASES OF THE RECTUM. [Inflammation of the Rectal Pouches. Under the names of Encysted Rectum (Physick) arid Sacciform Disease oj the Anus (Gross), has been described an inflamed or ulcerated state of the rectal pouches or lacunae, which sometimes, particularly in old persons, become enlarged, and serve as receptacles for fecal matter. The symptoms of this affection are intense itching and often severe pain, but without spasm of the sphincter. The diagnosis may be made by exploring the gut with a bent probe or blunt hook. The treatment consists in drawing down the affected pouches and excising with curved scissors the folds of mucous membrane at their base. Recto-vesical Fistula. An abnormal opening between the rectum and bladder may be due to con- genital defect,1 to ulceration, usually malignant in character, or to a wound, as occasionally happens in the operation of lithotomy. As a result, urine escapes into the bowel, and, if the opening be large, fecal matter may enter the bladder, causing great pain and irritation. In some cases, an attempt may be made to close the fistula by the application of caustics or the galvano- cautery, or by a plastic operation analogous to that employed in cases of vesico-vaginal fistula, but in cases of malignant ulceration palliative meas- ures are all that can ordinarily be recommended, though colotomy (preferably by Amussat’s method2) may be occasionally justifiable. Recto-urethral fistula will be considered in the article on Injuries and Diseases of the Urethra.] 1 See page 99, supra, 2 See page 78, supra. HERNIA. BY JOHN WOOD, F.R.S., F.R.C.S., PROFESSOR OF CLINICAL SURGERY IN KING’S COLLEGE, AND SENIOR SURGEON TO KING’S COLLEGE HOSPITAL, LONDON. Hernia in General. In its more extended meaning the term hernia is applied to any protrusion of a vise us through its containing walls, as seen in Hernia cerebri, Hernia pul- monum, Hernia testis, etc. In its more restricted and usual sense, it means a protrusion of some abdominal viscus through the abdominal walls, beneath the integuments and fasciae ; and in this sense it is used in this article. Most frequently the opening is constituted by the enlargement of a natural aper- ture between the muscles and fasciae. Such protrusions are named accord- ing to their situation: Hernia, inguinalis, Hernia cruralis vel femora,lis, Hernia umbilicalis, Hernia obturatoria, Hernia sacro-sciatica. All these pass through dilatations of natural openings, and are covered by the integuments and abdominal fasciae varying with their position. In the same category must be named the unusual forms of diaphragmatic hernia passing through the oesophageal openings into the thorax. But abdominal rupture is sometimes found as the result of wounds, or tearing of the abdominal walls. This most usually results in a ventral hernia, occurring through openings in the mus- culo-tendinous parietes, produced by distension and forcing, such as occurs in pregnancy and childbirth, and in excessive corpulency, peritoneal dropsy, etc. Another form of traumatic rupture, as it may be called, follows pene- trating wounds in the same regions—as in the case of diaphragmatic pro- trusion through a spear wound into the pericardial cavity, protrusion after laparotomy, etc. Beneath and in addition to the coverings already mentioned, hernise are also usually furnished with a sac or covering of the serous membrane—the parietal layer of the peritoneum; but the caecum may protrude without a sac, and in cases of congenital umbilical hernia, and of traumatic rupture, the only sac to be found may be composed of cicatricial tissue. This containing pouch soon contracts adhesions to its hernial coverings, and cannot after a time be returned within the musculo-tendinous walls of the abdomen. It increases with the size of the protrusion, partly by growth, partly by distension with slight unravelling of its fibres, but mainly by fresh protrusion of the loose peritoneum. It may be so thin as to be distinguished with difficulty, or so thick as to be divisible into layers. The dilated end is called the fundus ; the narrow constricted portion is the neck of the sac. In an old rupture, the latter is usually puckered, thickened, and more or less rigid, sometimes forming a strangulating band. Sometimes two sacs are found in an old hernial tumor, a fresh protrusion existing within, or by the side of, the hernia. primary sac; or the sac may be constricted into two narrow, neck-like aper- tures (hourglass contraction), each resisting and capable of strangulating its contents. In the sac may be found almost any portion of the abdominal structures, even parts of the liver, kidney, or ovaries. The contents vary with the higher or lower position of the protrusion. In the greater number of cases, the intestine and omentum, or epiploon, form part of the contents (entero-epiplocele); but sometimes, in inguinal and crural hernia, the omentum forms the sole contents (epiplocele), or the intestine only may be found in the sac (enterocele). Frequency of Hernia.—Abdominal hernial protrusions are very common. According to Malgaigne, one out of every 13 males, and one out of every 52 females, are affected with some kind of rupture; that is, about one in every 20 individuals. Of these, more than half are found between 40 and 80 years of age. In Kingdon’s tables, from reports of the Truss Society, farmers and farm-laborers are most subject to hernia of some form; next come porters and gardeners, then carpenters and house servants. It is significant that all these occupations necessitate the frequent use of muscular power with the body in a bent position on the legs. * General Causes of Hernia. In by far the greater number of cases of inguinal and umbilical hernia, the occurrence of protrusion is preceded by a condition resulting from arrest or delay of development, delaying the descent of the testicle beyond the time of birth—when the body of the child becomes reversed from an inverted to a more or less upright position—and retarding the complete formation of the transversalis, internal oblique, and cremaster muscles, the closure of the deeper opening being imperfectly effected, or the omphalo-mesenteric and allantoid openings being later in closing up than usual. Then the first efforts of the new-born infant, in crying and breathing, force out the smaller intestine, while undistended with food, into the patulous passage, and retard or prevent its normal closure. In many cases in which the formative tendencies are rather more effectual, but still not complete, a bulgy condition of the groins, or of the umbilical dimple, remains during life, although the absence of other exciting causes may not effect a complete hernial condition. An important predisposing cause was pointed out by Richter, in an abnormal elongation, or low attachment, of the mesentery and omentum. This operates in the case of inguinal and femoral ruptures by allowing the omentum, mesentery, and in- testine, to reach further down than is normal, and gives them liberty to force open the inguinal and femoral openings under pressure of the muscles. And it must be admitted that such a condition forms a powerful aid to the pro- duction of hernia in these situations. But that a normal formation and nor- mal connections of the mesentery and omentum will not prevent the protrusion of intestines, is witnessed in the performance of the operation of abdominal sec- tion, or in accidental penetrating wounds just above the pubis, where the opening is quite as far clown as the inguinal opening, and yet where protrusion occurs immediately upon contraction of the abdominal muscles. And on the other hand, such abnormal connections and elongations are frequently found in the post-mortem room, in persons of advanced years, in whom no hernia is found. These crucial instances show that when the abdominal parietes are normal, the pressure of the abdominal contents, however unrestrained by the connections of the viscera, are not sufficient of themselves to cause hernia, although they may constitute an important subsidiary element in its produc- 147 GENERAL SIGNS OF HERNIA. tion when the abdominal apertures are weak or patulous. When a rupture is established, the downward traction tends of course to produce or increase such an elongation, and results in the development of the various tail-like forma- tions which are so often found in the omentum lodged in an inguinal or femoral rupture. All these causes are more or less the result of hereditary formation of the belly and of its contents. Bulgy groins, late-descending or retained testicles, and inguinal, crural, and umbilical hernial protrusions, can be traced so fre- quently in the several generations of the same family, as to set this beyond a doubt. Another powerful factor in the production of hernia, operating earlier and more easily in individuals predisposed as just described, and later and with more difficulty in those who are perfectly formed, lies in the nature of their pursuits and occupations. Forgemen, strikers, carpenters, and colliers are all especially liable to ruptures, as are those who inordinately practise such athletic exercises as rowing, lifting heavy weights, etc. In some cases the debilitating effects of a high temperature in the working atmosphere, helps the predisposition by causing relaxation of the skin and other tissues. In others, the position of the body, as in bending, crouching, or sitting, while making great muscular exertion, prevents the lower abdominal muscles, the oblique and transversalis, from giving the proper support over the openings during the supreme effort. Very commonly, the constant and great expulsive efforts in a chronic cough, violent sneezing, straining at stool, or during mic- turition, result in a rupture. Again, the excessive distension produced by corpulency, and still more that caused by pregnancy, followed by the violent expulsive efforts of parturition, frequently causes a hernia, usually of the umbilical or ventral variety. General Signs of Hernia. One of the most characteristic signs is the sudden appearance of a tumor near one of the openings just enumerated—a tumor which shows itself on assuming the erect posture, increases on making any muscular effort, disap- pears on lying down, and is usually absent after rest in bed. The tumor gets larger, tenser, and more elastic on coughing; and this cough-impulse, felt by the fingers firmly grasping the tumor, is one of the pathognomonic signs most relied upon. A hernia containing omentum only, feels inelastic, flabby, and uneven to the touch. It is returned into the abdomen with more difficulty than one con- taining bowel, and may easily be mistaken for a varicocele, but is less elastic. When reduced, if the finger is kept pressed upon the hernial opening, and the patient stands up, no return of the swelling occurs; but in a varicocele the pressure promotes the quick return of the swelling by obstructing the venous circulation. A hernial tumor can usually be squeezed back into the abdominal cavity by the proper application of the fingers {taxis): except in cases to be mentioned hereafter, it is compressible and reducible. Vone of the signs mentioned can, however, be relied on singly in any doubtful case. Any fluid accumulation lying within the influence of the abdominal muscles, will become more pro- minent on standing, will have a distinct cough-impulse, and may be pressed back. This sign ceases, for example, to be a distinguishing mark in the diagnosis of femoral hernia from psoas abscess, or in that of inguinal hernia from abdominal abscess or from hydrocele of the cord. But if added to the above signs we have a ventral resonance on light percussion over the tumor, 148 HERNIA. from the presence of air in the contained intestine, we have an important verifying evidence. But this corroboration will not be found in hernise containing omentum only, or any other of the solid viscera, and so cannot help to distinguish them from an enlarged gland or a tumor. So that in many cases the concurrence of signs, aided by the method known as diagnosis by exclusion, will be the only safe guides to an operative procedure, and some cases can only be made certain by careful explorative dissection. In hernia containing intes- tine, the occasional occurrence of the croaking, gurgling, or squeaky sounds of air mixed with fluid (technically known as borborygmus), especially heard and even felt when pressing back the contents, will make clear the diagnosis. Again, interference with the known functions of any viscus which is impli- cated, such as flatulence, nausea, or constipation of the bowels, and signs of irritation of the bladder or ovaries, or absence of the testicle from the scrotum, may throw light upon the case. In the formation of a rupture, pain is usually, but not always, felt—a sud- den and violent pain when fibres give way or strangulation is threatened, a dull, aching, intermittent, and recurring pain, or soreness, when the distension of a natural canal is occurring. When the bowel is fairly engaged in the hernial opening, to these are added a dragging pain felt in the lumbar region, or about the umbilicus, flatulent eructations, uneasiness after eating, constipa- tion, and even nausea and vomiting, from traction on the stomach. These symptoms, in ordinary cases, gradually disappear on the patient lying down, but increase in intensity if the case goes on to complete strangulation. In some slow cases, no pair, whatever is felt in the part during the formation of the hernia, and the attention of the patient is first attracted to it by the appearance of a tumor. In most cases, the commencement of the rupture is due to a portion of omentum being first forced through the deep ring, and gradually preparing the way for the entrance of the bowel; and in some cases, a small tubular formation of the peritoneum (the persistent remains of the canal of Nuck) favors the entrance of the omentum. Such cases are usually unattended with pain, or have but little, in their formation. In other instances, the small intes- tine may be the first to force open the deep ring, producing a good deal of aching and acute dragging pain in the groin, and symptoms referable to irri- tation and irregular contraction of the intestines, such as flatulence and alter- nating diarrhoea and constipation. The increase of an epiplocele is slower and more gradual than that of an enterocele. This variety is less commonly observed in femoral than in ingui- nal, umbilical, or ventral hernia. It is less easy to detect and to differentiate from other tumors, is doughy and inelastic to the touch, and dull on percus- sion, while enterocele is elastic and resonant; the cough-impulse is less marked and evident, and its reduction is effected more slowly, and without gurgling or borborygmus, such as we usually have in enterocele. Most cases have, however, mixed contents of both omentum and bowel, and sometimes in the lower part of the sac the hernia has the characteristics of an epiplocele, and in the upper part those of an enterocele. The protrusion of a hernia is brought about by violent efforts of expiration by the diaphragm and abdominal muscles, pressing outwards the contents of the abdominal cavity. The investing structures give way at their weakest part, wherever that may be at the moment. The protrusion is often favored by the position of the body at the time of the supreme effort. If the thighs are bent on the trunk, the tendinous structures in the groin are relaxed, and the muscular fibres which are attached to them operate at a disadvantage, and leave unsupported the openings which they should cover and protect. The irreducible hernia. 149 result is some form of inguinal or femoral hernia. If in addition there is a congenital or traumatic imperfection in the development or position of the abdominal muscles and fasciie, the result is more easily effected. So if the abdominal recti be imperfectly developed, and separated by a broad linea alba, while the umbilical cicatrix is large, weak, and feebly resistant, the result is an umbilical or ventral hernia. Or if any other of the natural aper- tures of the abdominal cavity are looser and less compact than natural, or if by the infliction of an injury a cicatricial tissue has been formed which is more yielding than the normal walls, the protruding force operates in the manner of fluid pressure, and the weakest part gives way. In some of these cases, where no parietal peritoneum is opposed to the opening, there may be no serous sac formed for the protrusion, which is covered only by the enveloping fascia of the part. The forces above indicated operate alike in all cases of abdominal hernia. The particular form which it may assume is determined by the condition of the several abdominal apertures. In some cases met with, the tendency is so extensive that several hernise may occur in the same person, more or less closely following each other, or even produced at the same time. Thus, it is not uncommon to find a double inguinal rupture, associated with a femoral or an umbilical one, or even both. In such cases, it is found that the mesenteric and omental connections are long and loose, or that the patient, after having been stout and corpulent, has become suddenly, by illness or other causes, thin and relaxed. The fat which helped to fill up the apertures is removed before it disappears in the mesentery and omentum, where it increases the protrud- ing force. Another condition which predisposes to the formation of rupture, is irregular contraction of the large or small intestine, as from flatulent colic, with distension of one part of the bowel, and spasmodic contraction of the neighboring part. The former distends the abdomen, and helps to force the smaller contracted portion through the hernial aperture. This is perhaps most frequent in children, from the same causes which may eventuate in intussusception of the bowel or prolapse of the rectum. Reducible Hernia. If the contents of a rupture can be returned into the abdomen by pressure (taxis), or go back of themselves, it is called a reducible hernia. Usually the reduction may be effected by simple posture, as by lying down for a greater or less time, and especially if the pelvis be raised above the upper part of the trunk, as by inversion of the patient. Under these circumstances the con- tents are drawn into the abdomen by the simple force of gravity, facilitated by the smooth, moist, and slippery surfaces of the peritoneum. Frequently we see the hernia thus reduced by the peristaltic contraction of the longitudi- nal muscular bands of the intestine, or by the flatulent or other distension of the gut in the close neighborhood of the contracted part which lies in the hernia, or by the rolling movement of the stomach and large bowel, acting through the great omentum. In some cases reduction seems to be effected or aided by the bracing and compressive action of the cremaster and dartos fibres, when stimulated by a dash of cold air or water, or by the application of ice. Irreducible Hernia. When the hernial contents cannot be returned by the above means, although there be no impediment to the passage of feces through the bowels, or to the 150 HERNIA. circulation of blood through its vessels, the rupture is said to be irreducible. This condition may be produced 1, by the adhesion of the contents to the sac, or to each other, so as to prevent the serous surfaces from sliding over each other, or by the formation of membranous bands; 2, by the enlargement of the omentum or mesentery by deposition of adipose tissue, or from fibroid or glandular change in these structures, usually resulting from truss pressure (incarcerated hernia); and 3, in the case of omental hernia, by atrophy of the upper part which lies in the neck of the sac, causing it to double up easily on force being applied. Irreducibility produces dragging pain in the abdo- men, and sometimes nausea and vomiting, flatulent distension, and constipa- tion from irregular peristaltic action, all increased by corpulence and preg- nancy. The protruded parts are also exposed to injury, and are in constant danger of strangulation and inflammation. Irreducible ruptures may sometimes be made reducible by keeping the patient in bed for some weeks or months, and by reducing the diet so as to cause absorption of the fat. And when this has been done in the course of a long illness, irreducible ruptures have sometimes spontaneously disappeared. A large enterocele may be rendered temporarily irreducible, by an accumu- lation and impaction of hardened feces in the contained intestine preventing the progress of the intestinal contents wholly or in part (infarcted hernia). This condition is invariably attended by more or less constipation of the bowels, and may even give rise to the more severe symptoms of obstruction, such as nausea, and vomiting, even of a fecal character. Copious enemata of gruel, olive oil, and turpentine, regularly administered three or four times daily, with the recumbent position aided by the topical application of hot fomentations, will usually help the taxis to a successful issue in such cases. The regular use of laxative enemata, with the application of ice-bags and elastic, compressing apparatus to the tumor, will help to relieve all these forms of irreducible hernia. Sometimes it happens that the patient is made so uncomfortable and ill by the return of an old irreducible hernia, that the reproduction of the protrusion is desirable to relieve him. Efforts at reduc- tion are most likely to succeed in the omental forms. But when there are adhesions, it is evident that the measures above described cannot succeed, and if the sufferings or disability resulting from an irreducible rupture jus- tify the risk, the modern practice, hereafter described, of opening the tumor under the carbolic spray, and antiseptic dressing, may be had recourse to. The palliative plan of applying a bag truss to receive and support the rup- ture, may be sufficient to relieve the patient whose physical condition or age forbids such an operation. Strangulated Hernia. A hernia is said to be strangulated when it is constricted at the neck with such force as to obstruct the circulation of the blood in the vessels and to paralyze the nerves, as well as to stop the passage of secretions and feces through the contained bowel. The former condition may exist, and set up its characteristic symptoms, in cases of omental and other hernise which do not contain bowel. The results depend upon the severity of the constrict- ing force. If it be so complete as to stop all the circulation in the compressed parts, either by its immediate pressure, by the progressive coagulation of the blood, producing thrombosis in the vessels less immediately compressed, or by the results of inflammatory stasis, the result is complete gangrene or mortification of the parts engaged. If it be less complete, the result may be linear ulceration of the parts immediately compressed, and progressive sepa- STRANGULATED HERNIA. 151 ration of the tissues. If any part of the bowel be included, it may thus become perforated, and may give exit to the alvine matter or mucus which it contains. This may, according to its position, either escape into the peri- toneal cavity and set up local or general peritonitis, or be retained in the sac, causing it to suppurate. General Symptoms of Strangulation.—These may be separated into the symptoms of obstruction, which indicate the stoppage of the passage of the intestinal contents, and those of strangulation proper, which indicate arrest of the local circulation and pressure upon the nerves. Both are common to hernia and to various other pathological conditions. The former are usually slower in development, and more chronic in continuance, while the latter are more acute, intense, and alarming to the patient. Thus the symptoms of obstruction may result from intra-abdominal pressure by various tumors, from adhesions, from impaction of feces, or from calculi. They can occur only where the intestinal canal is directly implicated. Those of strangulation may result also from intra-peritoneal causes independently of rupture, such as the sudden entanglement of the bowel in bands of adhesion, forming loops or openings in the mesentery or omentum, through which the bowel may be suddenly thrust. On the other hand, they may occur without complete obstruction of the bowels in ruptures, as where the omentum only is present in the sac, and is strangulated without implication of the bowel in the constriction. The signs of obstruction are persistent constipation, and eventually total cessa- tion of the alvine evacuations. One or more costive evacuations of the contents of the bowel below the obstructed part may occur, after the first symptoms have manifested themselves, and are usually attended by tenesmus and strain- ing. If these evacuations are in fair quantity, the position of the obstruction may be localized as being somewhere above the large intestine. Gradu- ally the abdomen becomes distended, and flatulent eructations and borboryg- mus occur, the flatus rarely if ever passing downwards by the anus. The distension of the bowel may, in thin persons, often be traced on the surface of the abdomen, and is slowest and most pronounced in obstructions low down. Colicky pains, more or less severe, follow from spasmodic peristaltic move- ments. These ultimately become reversed in order of occurrence, and project the fecal matter towards the mouth. Then occurs vomiting, at first of the just taken and unaltered food, then of the chymous ingesta and the acid, gastric secretions, then of chyle more or less tinged with bile, and finally of matter possessing a decidedly fecal smell and appearance. In cases of acute strangu- lation, the vomiting and sickness take place almost immediately, attended with much pain from the sympathetic irritation of the gastric nerve-centres. As a rule, the vomiting occurs earlier in the sequence of symptoms the higher the point of obstruction. The pain increases in intensity, is not referred with certainty to a particular spot, but follows rather the curve of the bowel around the umbilicus, to which it is vaguely referred. The secretion of urine may be limited, and this has been said to indicate a high position of the obstruction; but the amount of urine depends so much upon that of the per- spiration, and upon the quantity of fluids swallowed, that the indication is of little practical value. In the earlier stages, the temperature of the patient is usually normal; after- wards it may rise somewhat at night, to fall in the morning often below the natural average ; and at the same time the pulse quickens and is more com- pressible. In the later stages the temperature often falls considerably, and may remain below the normal standard, while the pulse quickens to 120 per minute or more, and becomes more feeble, and at last irregular and intermit- tent. The respirations are quick and shallow, and entirely thoracic. The 152 HERNIA. vomit becomes more constant, and is darker from admixture of extravasated blood, and at last looks entirely like coffee-grounds; the secretions fail, restless sleeplessness ensues, the pain ceases, the countenance becomes pallid, sallow, and sunken, a cadaverous smell mingles with the fecal odor of the breath and body, and the pa ient dies from exhaustion at a period varying from a few days to many weeks. Post-mortem examination usually reveals more or less of the results of peritonitis, general, or limited to the region of obstruction. The symptoms of strangulation may in great part be referred to those of peritonitis, at first local in extent, finally general. If the constriction be severe, or near the upper part of the canal, the pain and distress are quickened and intensified on the first onset by the pressure upon the numerous nerves of the part, and by sympathetic irritation of the epigastric nerve-centres. There may be very early and severe symptoms, causing speedy death—apparently by the impression of the pain upon the nervous system generally, resulting in exhaustion—without any extensive post-mortem appearances of peritonitis. In these cases the pain and distress come on directly after the occurrence of strangulation, and soon become intense, the temperature and pulse rise to- gether, the countenance is pale and very anxious, and the decubitus dorsal, with the knees drawn up to relax the pressure of the abdominal muscles. The respirations are short, quick, shallow, and entirely thoracic; and there is usually an unequal, one-sided, spasmodic contraction or catch in the abdominal mus- cles. The pain is attended by a dragging sensation, and is referred constantly to one spot. In cases of hernia it directs the surgeon to one of the usual her- nial openings, where a hard, elastic, tense, and very tender lump, of greater or less size, is found. The cough-impulse in the tumor is wanting when tested. The less common, deeper-seated hern he, such as the diaphragmatic, sciatic, and obturator, where the tumor cannot be felt, may be suspected from the position of the pain, and from the effect upon the action of the diaphragm, or upon the nerves, sciatic or obturator, pressed upon by the tumor. In other respects than the latter, they resemble obscure cases of intra-perito- neal strangulation. The inflammatory symptoms of strangulation consist of the constitutional, feverish symptoms—such as a rise in the temperature, quickened pulse and respiration, diminution of the secretions, and foul tongue —which characterize pyrexia. The temperature rises in the evening, and falls in the morning, after daybreak. The rise does not usually reach as high as in traumatic injuries of the head; from 102° to 105° F. is the usual limit, with exceptional cases ; and the fall is usually proportionate to the rise. The pulse reaches its danger point at 120, and increases in quickness as the case approaches a fatal end. It is always soft and compressible, a peculiarity which seems to be caused by the impression made on the extensive abdomi- nal nerve-centres, and secondarily upon the cardiac plexuses. To the same cause must be attributed the constant vomiting, the stomach rejecting all food, and the retching commencing earlier and more violently than in mere obstruction. The anxious face is often yellow or jaundiced, the decubitus dorsal, with the knees drawn up, and the breathing short, quick, and thoracic. The local symptoms are great pain, commencing in and usually referred to one spot, but ending in a twisting and dragging pain around the umbilicus, as the inflammation extends to the coils of intestine. There is general abdominal tenderness, especially acute as the pressure nears the strangulated point. Very soon, swelling of the abdomen and tympanites on percussion, evidence paralysis of the intestinal muscles and accumulation of flatus and liquid excretions, attended by the borborygmus and other signs of obstruction already described. The symptoms are less severe when the omentum only is strangulated hernia. 153 constricted: there is then no total obstruction, but rather irritation of the bowels. When the vessels of the constricted part are completely obstructed, and its nerves of sensation paralyzed, it becomes mortified, the pain ceases, and the patient becomes easier and less restless. But the temperature falls suddenly ; the pulse becomes quicker, weaker, irregular, and intermittent; and the breathing is more shallow, as the abdominal swelling increases and prevents the descent of the diaphragm. The face is still anxious and pale,and becomes more and more livid, and covered with a cold, clammy sweat; the eyes film over, and are glassy; the voice is hollow; the tongue and mouth are dry, cracked, and covered with a brown sordes, and sometimes an eruption forms on the lips. The breath is cold, and the smell of the patient cadaverous. All these signs indicate, and are speedily followed by, death. The post- mortem examination shows great distension and softening of the bowels above the strangulated part; congestion of all the peritoneal vessels, most intense in the neighborhood of the strangulation ; frequent and extensive ecebymosed patches ; effusion of pus, and often of putrid fluid, with flakes of lymph, and more or less extensive adhesions of the coils of intestine to each other, and to the mesentery, omentum, and parietal peritoneum. These adhesions, usually soft and recent, are sometimes continuous near the site of strangulation, so that the loop of bowel often cannot without difficulty be separated from the constricting part, and the intestinal walls are so softened as to be easily torn in attempting it. Sometimes an ulcerated opening may be found at or near the constriction, permitting the escape of the intestinal contents, when a fecal smell tinges the putrid exhalations. The strangulated loop of intestine, or omentum, is dull-looking, black, soft to the touch and easily torn, flabby, cedematous, and often spotted with flakes of lymph, or sloughs, or with patches of black ecchymosed blood, or of greenish or ash-colored spots of sphacelation, easily broken down. There is also oedema of the tissues in the neighborhood, and an emphysematous crispness around. The sac in these cases contains dark colored blood, or fetid serum, sometimes fecal in smell from extravasation of the intestinal contents. General Diagnosis and Treatment of Strangulated Hernia.—The first duty of the surgeon in all cases where there are signs of obstruction or stran- gulation, is to examine carefully all the usual sites of abdominal rupture, and to continue his researches also, in case of not finding a cause, into the unusual positions of hernia. In searching for the causes of symptoms of intestinal obstruction, it must not be forgotten that a hernial tumor may be found at one of the usual out- lets, and tTiat yet it may not be the cause of the obstruction. In such a case, reduction by the taxis, without relief of symptoms, will prove that the cause must be sought for elsewhere. If there be two or more hernial tumors, they must be in turn reduced, and the effect upon the symptoms observed. If one of them be irreducible, it will probably be the offender. If strangulated, it will be tense and tender, and the pain will be more or less referred to it. In all cases of multiple hernia, with symptoms of strangulation or obstruction, the irreducible hernia must be the first chosen for operation; and if all are irre- ducible, the one which is hardest, most tense and tender, to which pain is most referred, or which came the earliest. Again, a tumor, which yet is not a hernia, may exist at one of the hernial openings, and may coexist with symptoms of intestinal disturbance, nausea, vomiting, and constipation. In the scrotum and region of inguinal hernia, such a tumor may be a cyst con- nected with the cord; a fatty tumor; a sarcocele, complicated with thicken- ing of the cord; a large hydrocele of the tunica vaginalis; a haematocele; a 154 HERNIA. varicocele ; or a pelvic abscess. In that of crural hernia, the tumor may be an enlarged, and, perhaps, inflamed gland; and this last is, from the local pain and tenderness, and from the constipation and sickness frequently coex- istent, the most perplexing to the surgeon. Or here we may have also a cyst, an abscess (psoas), a fatty tumor, or a varicose enlargement of the femoral or saphena vein, or one of their branches. In cases of other varieties of hernia, especially in the umbilical, a fatty tumor or an abscess may simulate hernia by its impulse on coughing, or by its general appearance and feel. A sarcomatous, or other tumor may also present some appearance of rupture. Measures of relief should be adopted without loss of time. When a rup- ture is found, the indications are to return the strangulated parts into the abdomen by manipulation, if possible, aided by other secondary measures. If this is not successful after a fair trial, then the tumor must be operated on. Moreover, in cases in which the peculiarity of the symptoms leads to a strong doubt as to the nature of a tumor, an exploratory operation under the spray should be resorted to, to make quite certain that the patient either can or cannot be saved. The term taxis is a Greek word applied to the proceedings of manipulation. The taxis should be employed with the least force and the greatest gentle- ness possible: much damage may be done by misdirected, hurried, or vio- lent efforts. It should be gentle, but firm and persistent. If the rupture be large enough, the fundus of the tumor should be grasped by one hand and gently squeezed, to press out the blood from the engorged vessels, any serum which may be in the sac, and the fluid or gaseous contents of the bowel which may be present. The finger and thumb of the other hand should then be applied to the neck of the sac, and kneaded gently all around with the object of returning those parts which lie in the orifice, and which were the last to come down. If the rupture be small, the points of the fingers only can be used, and the skill to use. these successfully lies in a combination of grasping, pressing, and kneading motions, which can only be acquired by long experi- ence. The direction of the force applied should be that of the protrusion above the most superficial hernial opening, and varies with the kind of hernia, as will be seen in considering the anatomical details of the various special kinds of rupture. The first hopeful result is usually a diminution in the total size of the tumor, a feeling of motion in the interior, and a slight gurgling croak, indi- cating the movement of the contained gases if bowel be present. The kneading motion and the compressing force must then be kept steadily applied, and the rupture-tumor, if containing bowel, will usually suddenly disappear into the abdomen. If omentum be present in any amount, its complete reduction is somewhat slower and more gradual, and there may be a little difficulty in passing up the whole of it if it be lumpy. Or a portion may be adherent and irreducible, although the return of the more vital intestine may have placed the patient in safety. The position of the patient during the taxis should be recumbent, with the shoulders low, the hips raised, and the knees bent up to the body and as close together as may be convenient to the operator, who stands on the affected side of the patient, with one hand and arm between his knees in cases of inguinal and femoral, or obturator rupture. In cases of difficulty, the patient should be placed during the continuance of the taxis, more or less in an inverted position. This is best and most quickly accomplished by drawing the patient, with the upper part of the mattress, bed, and bedding, off the side of the bedstead, and placing them on a low stool or upon the floor, keeping the patient’s hips on the side of the bedstead with the knees still drawn up. The effect upon the bowel and omentum is to allow STRANGULATED HERNIA. 155 them to gravitate towards the diaphragm and away from the hernial point, and thus to draw the hernial contents into the abdominal cavity. This action may be aided considerably by an assistant pressing gently with his hand on the abdomen near the rupture,- sliding it slowly in a direction from the strangulated part, while the patient makes a long and deep expiration and slowly repeats it. Baron Seutin stated that he could sometimes relieve strangulation by insinuating the point of a finger into the tightened opening and stretching the constriction, but common sense and experience tell us that when the point of a finger can be introduced from without, there cannot be much strangulation present, and that if there were much, such a forcing in of the finger could not but be disastrous to the distended, tense, and softened tissues, and might easily burst the bowel. The most powerful auxiliary to the taxis is undoubtedly the influence of anaesthetics, and of these, chloroform, from its greater influence in para- lyzing the muscles without much previous spasmodic contraction, is better than ether alone. The best of all is a mixture of chloroform, ether, and alcohol, one part of the last with two of the first, and three of the second. An anaesthetic should, in all cases in which there is no serious objection to its use, be employed as soon as it is found that the rupture does not return by the simple taxis. All other so-called auxiliaries, such as hot baths and fomenta- tions, blood-letting, antimony, opiates, and enemata, especially those of tobacco or other active drugs formerly employed, cause dangerous delay or injurious hindrance. In cases of the less acute kind, however, such as of large hernise which have become infarcted, where the symptoms are not acute and point rather to obstruction than strangulation, the application of ice-bags to the tumor for a few hours, with the administration of enemata through a long rectal tube, to remove flatus, etc., sometimes aid the taxis to a successful issue. Ice, as a rule, however, should not be applied to small crural hernbe occurring in aged women with thin tegumentary coverings. In such cases it may, if kept long on the congested bowel, produce mortification. Such cases, if the taxis fails, call imperatively for operative procedure within forty- eight hours of the time of strangulation. If much force is used improperly in the taxis, the tumor may sometimes be made to disappear into the abdominal wall without release of the strangu- lation. This is called reduction “ en bloc” or “ en masse.” It most readily occurs when the strangulation is effected by the neck of the peritoneal sac itself, either from inflammatory thickening, with internal bands or adhesions, or from external bands in the closely investing “ fascia transversalis.” By a disproportionate exercise of the pressing over the kneading process, the sac with its strangulated contents is pushed into the loose sub-peritoneal tissues, or between the abdominal muscles and fascia on one side of the hernial canal, tearing asunder the tissues to make a lodgment for the sac. In some instances, the sac has been found burst near its neck by the force applied, and the contents forced through the torn aperture into the connective tissue between the layers of muscles and fascia, or under the peritoneum. Here the sac is often found filled with blood, and there is extravasation in the areolar tissue and sometimes within the peritoneum. In such cases the symptoms of strangulation of course continue, and in an aggravated degree, especially the pain and tenderness at the part; the collapse is more marked; and a close manual examination of the hernial canal will reveal the presence of the hidden tumor, deep down, close to the abdominal cavity. Under these conditions the only rational remedy is immediate exploration by ope- ration. This proceeding requires much care, since the anatomical relations of the parts are greatly altered, and the tissues may be torn, bruised, ecchy- mosed, and matted together by adhesions. The sac, or even the bowel, may 156 HERNIA. be found burst by the force used. In all operative proceedings of this nature, the antiseptic method should be carefully observed so as to diminish the effects of the subsequent exposure to air. Inguinal Hernia. We now proceed to consider in detail the special forms of hernia, com- mencing with the most common, viz., Inguinal Hernia. Frequency of Inguinal Hernia.—Out of 93,355 cases, in the statistics collected by Bryant, there were 7 inguinal to 1 femoral. In upwards of 3000 cases seen by myself, the proportion of inguinal hernia has been rather more than this, viz., about 8 inguinal to 1 femoral. In a considerable number of cases a rupture is more or less developed on both sides, double crural hernia being rather more frequent than double inguinal. Often the rupture is crural on one side and inguinal on the other, and occasionally three ruptures have been present, an umbilical one in addition to the other two varieties. This last condition has been most commonly seen in infants, occasionally associated with undescended testis, and all resulting from slowness or arrest of develop- ment in the parts. Hernia is more common in males than in females in about the proportion of 4 to 1. In the male sex the inguinal variety is more frequently found than in the female. In the former the proportion of the inguinal form of hernia to the crural is at the rate of 50 to 1. Inguinal hernia is found more frequently on the right side of the body than on the left side, in the proportion of about 3 to 2. In about twenty-five percent, of cases it is found on both sides. The greater frequency on the right side is due mainly to the lower position of the root-attachment of the mesentery on that side, and to the pressure of the liver above. Something may be due also'to the more frequent use and stronger muscles of the right arm and leg. Parts involved in Inguinal Hernia.—These are situated in the groin just above the groove which indicates Poupart’s ligament, which is a strong band of tendinous fibres forming part of the insertion of the tendon of the external oblique, and reaching from the anterior superior spine of the ilium to the spine of the pubis. On removing the skin and the two layers of superficial fascia, it is seen (Fig. 1333) that two small vessels pass upwards and inwards from the common femoral, and cross Poupart’s liga- ment and the inguinal canal. They are the superficial epigastric and the superficial external pudic, the first lying external, almost over the position of the deep ring, and the last internally placed, and crossing the cord near the superficial ring; crossing in the same direction inwards, below this, is another branch, the deep external pudic artery. The deeper layer of superficial fascia is attached loosely to Poupart’s ligament, and is continuous with the deeper layer of perineal fascia continued over the spermatic cord. The nerves are branches of the ilio-inguinal and ilio-hypogastric, offsets of the lumbar plexus, the former (n) emerging from the superficial ring (at i). The lymphatics pass downwards to the superior inguinal glands (c), which are arranged between the two layers of fascia on a line parallel to and above Poupart’s ligament, and join the femoral or crural glands placed directly below them. Then is exposed the aponeurosis of the external oblique muscle of the abdomen, commencing at the termination of its muscular belly, near the anterior superior iliac spine, passing downwards and inwards, in flat bands of fibres, to be inserted externally into the pubic spine as Poujmrfs INGUINAL HERNIA. 157 ligament, and internally into the front surface of the pubic angle and sym- physis, sending some fibres to join the ligamentum suspensorium penis vel clitoridis. These bands are separated from each other a little below the cen- tre of Poupart’s ligament, where they form what are called the internal and Fig. 1333. external 'pillars of the external abdominal ring. The inner one is flat and ribbon-shaped; the outer, triangular, rounded below and grooved above, for the lodgment of the spermatic cord. They afford an opening for the passage of the spermatic cord or round ligament, the opening being placed directly above the pubic spine, and being obliquely triangular in shape, with its base downwards and its angle upwards and outwards. It is closed in by a band of fibres (b) lying superficial and closely adherent to the tendon, springing from the centre of Poupart’s ligament, and curving spreadingly downwards and inwards, so as to cover by a connecting layer of tough fascia the fibres of the tendon and its triangular opening or ring. These fibres are continued downwards (i) as one of the coverings of the cord to join the scrotal fascia. They convert the triangular opening into an irregularly oval or circular one. The opening thus formed is the superficial or external abdominal ring. Of the fibrous bands or pillars of the ring which bound the opening laterally, the inner is placed above, and the outer below the opening, in an oblique direction. The curved bands of fibres which bind these together and form the upper boundary, are the arciform fibres (b); the fascia between the pillars is the intercolumnar fascia; and the prolonged fascia over the cords is the external spermatic fascia (/'). Internal to the ring, and extending quite behind it at the lower part, can Superficial dissection of the inguinal and crural regions. 158 HERNIA. be seen the outer border of the rectus abdominis muscle, lying behind the aponeurotic sheath derived from the conjoined tendons of the internal oblique and transversalis muscles, blended here, also, to a considerable extent, with the tendinous fibres of the external oblique muscles. Some fibres reach across the linea alba, from the opposite side, are placed obliquely across the lower part of the superficial ring, and are attached to the crest of the pubis as far as the pubic spine, fortifying at this place the hinder wall of the inguinal canal. These are known as the triangular fascia. (See Fig. 1334 g.) On turning aside the oblique aponeurosis (a), the lower muscular fibres of origin of the internal oblique (b) are seen arising from Poupart’s ligament as far down as the inner third, covering and fortifying the upper part of the front wall of the inguinal canal and the deep ring (/). The muscular fibres of origin are continued along the lower third of Pou- part’s ligament as the cremaster muscle, the scattered fibres of which, con- nected by the cremasteric fascia, pass through the superficial ring—some, the Fig. 1334. Deep dissection of the inguinal canal and abdominal wall. outer ones, to be lost on the tunica vaginalis testis; the middle ones passing up so as to form loops, to become inserted into the fascia near the superficial ring; while some pass again into the ring to become implanted upon the con- joined tendon and triangular fascia. Thus is constituted in the perfect specimen the cremasteric fascia, recognizable to the surgeon by its muscular fibres, but very frequently feeble and indistinct in cases of congenital hernia. On dividing longitudinally the fibres of the internal oblique, it will be seen that they are deeply more or less blended with those of the transversalis INGUINAL HERNIA. 159 abdominis, arising from the upper third of Poupart’s ligament, closely skirt- ing the upper part of the deep ring, and separated externally by a thin fascia with the small hypogastric nerves, and with the communicating branches of the deep circumflex iliac and epigastric arteries. Internally, the two mus- cles become implanted upon a common tendon, the fibres of the transversalis occupying the outer border, while those of the internal oblique are implanted upon its surface. This conjoined tendon (d) covers the origin of the rectus muscle, but is continued beyond its outer border in a downward and outward direction to become inserted into the spine and pectineal line of the pubis, where it blends with the triangular fascia and Ginibernat’s ligament, at tfye margin of the crural ring; and it is loosely attached by its deep surface to the transversalis fascia (/), which covers the deep surface of the muscle of that name, and separates it from the sub-peritoneal adipose tissue. If the finger be now pushed behind the internal oblique and transversalis muscular fibres, it will be seen to raise the conjoined tendon (d) as an oblique border, which can be felt by the finger curving behind the cord to form the lower two-thirds of the hinder wall of the inguinal canal. On dividing the muscular fibres of the transversalis, the arrangement of the fascia prolonged over the deep ring and spermatic cord is exposed to view. The best view of the deep or internal ring is to be had from within, by making a transverse incision along the fascia above the centre of Poupart’s ligament, and a longitudinal one to join it at the margin of the rectus muscle. Then, on lifting it from its deeper connections, the deep ring will be seen to form an oval opening (see Fig. 1335 6), about half or three-quar- . ters of an inch above and a little inter- nal to the centre of Poupart’s ligament. The opening has its long diameter directed upwards and inwards, with the inner edge sharp and prominent, and it gives oft' from its borders a sleeve-like prolongation over the sper- matic cord, called the fascia infun- dibuliformis, fascia propria, or fascia spermatica interna. The fascia is con- tinuous with the fascia transversalis, as the sleeve of a coat with its body, and it narrows downward in a funnel-like manner. The vas deferens turns round its lower edge on its way to the pelvis, crossing the iliac vessels, while the spermatic nerves and vessels pursue a backward, upward, and inward course. There is thus a somewhat loose inter- val formed on the inner side of this sleeve-hole, which permits of dilatation under the pressure of a protruding bowel or omentum. And when a rupture is formed, the tightened fascia becomes thickened and stretched, and forms the most common seat of strangulation, either outside of, or in combination with, the sac. Below this, the sac is usually loosely connected with the fascia by adipose tissue. On the inner side of the deep ring, usually placed within a quarter of an inch, the deep epigastric artery (Fig. 1334/) ascends inwards towards the umbilicus, to enter the sheath of the rectus, lying in the loose subperitoneal tissue. It is a vessel of considerable size, with a vein on each side of it, and at this point gives off a branch to the cord—the cremasteric— which lies in the cremasteric fibres, supplying them, and anastomosing with Fig. 1335. The internal abdominal ring. 160 HERNIA. the spermatic and pudic arteries. It arises from the external iliac, just above the crural and below the deep inguinal opening. It is subject to some irregu- larities which will be mentioned in relation to crural hernia. Crossing the posterior inguinal wall, upwards and inwards to the navel (see Fig. 1335 d,), internal to this, and lying behind the border of the conjoined tendon, is the obliterated hypogastric cord, the remains of the foetal placental artery. It gives oft’ before its point of obliteration the superior vesical artery to the bladder. Internal to it passes out an inguinal rupture, when it assumes the direct form, emerging between this obliterated artery and the outer edge of the rectus muscle, which form the two sides of the triangle of Uesselbach, the base being formed by the inner end of Poupart’s ligament. The perito- neal investment behind this is loose and movable, and a direct rupture either passes through, or is covered by, a prolongation of the conjoined tendon, which is placed here, filling up the triangle. (See Fig. 1334.) The inguinal canal is thus an oblique, valvular opening, in the layers of the muscles and fascia placed above the inner half of Poupart’s ligament, its anterior wall being composed of the integuments, aponeurosis of the external oblique, intercolumnar fibres, lower fibres of internal oblique, and cremasteric muscle. It is from one to two inches long, and half an inch wide—wider in the male than the female, but longer in the female. The spermatic cord, consisting of the vas deferens, with its artery, and the spermatic vessels and nerves, loosely connected together by an areolar invest- ment, traverses the oblique inguinal canal in a direction more directly upwards than that of the canal itself. Thus it is separated above from Poupart’s liga- ment by an interval of from half to three-quarters of an inch, where a groove can be felt with the finger, formed by the junction of the fascia transversalis with the deep surface of the ligament. This groove it is important to recognize in operating for the radical cure of the oblique kind of hernia. At the lower end of the canal, at the superficial ring, the cord crosses obliquely the inser- tion of Poupart’s ligament, grooving it deeply just outside the pubic spine, which thus acquires an important internal relation to the cord. Lying upon the cord, under cover of the cremaster muscle and its fascia, is the genital branch of the anterior crural nerve, sending off its filaments to the loops of the cremaster muscle, and, finally emerging from the superficial ring to sup- ply the dartos scroti, and so communicate with the perineal branches of the internal pudic nerve. Coverings of Inguinal Hernia.—An oblique or external hernia (so-called because it passes outside of the epigastric artery), traverses the deep ring and inguinal canal, and is covered by the structures forming the anterior wall of the canal, viz., the integuments, the aponeurosis of the external oblique, with its arciform or intercolumnar fibres (fascia spermatica externa), by the lower fibres of the internal oblique and the cremasteric fibres and fascia, and by the infundibular prolongation of the fascia transversalis or fascia propria. Then comes the peritoneal sac, covered by adipose tissue separating the contents of the rupture from the constituents of the cord and their investing areolar tissue. The hernia lies on the hinder wall of the canal, this consisting of the triangular fascia, the conjoined tendon, and the fascia transversalis, covering the epigastric vessels and hypogastric cord. A direct or internal hernia is wanting in the covering of the infundibuliform fascia, and may have an investing layer from the conjoined tendon and fascia transversalis, and sometimes from the cremasteric fascia. In a case of inguinal hernia of long standing, and originally and essentially an oblique or external hernia, where the neck of the sac is wide and large, the epigastric vessels may be dragged inwards by the weight and traction of INGUINAL HERNIA. 161 the hernia, and may closely invest the lower and inner, and sometimes a portion of the upper part of the circumference of the peritoneal opening. In such cases, the rupture will assume the appearance of a direct hernia, and the edge of the rectus muscle may be felt to form the inner margin of the deep opening of the sac. The inguinal canal will be very short, and the two openings almost directly opposite to one another, as in internal or direct hernia. The most common seat of strangulation in an oblique inguinal hernia, is at the inner edge of the fascial opening of the deep ring, thickened it may be into bands, or adherent to the neck of the sac. Or in old ruptures the strangulation may be placed in the thickened neck of the sac itself, or in ad- hesions placed entirely within the sac. In some large cases the stricture may be from muscular spasm of the internal oblique, and lastly, and most rarely, at the margins of the fascia or pillars of the superficial ring. The two last forms are usually most amenable to the use of the taxis. The most common seat of strangulation in a direct hernia, is the opening in the triangle of Hesselbach, where the fibres of the conjoined tendon encircle the neck of the sac, or, as in oblique hernia, in the neck of the sac itself, or in its contents. An oblique hernia mostly depends upon some deficiency in the develop- ment and arrangement of the parts concerned in the descent of the testicle, which causes them to yield at an early or later period of life, and more or less quickly, to the internal pressure. A direct hernia is most frequently produced in muscular men by tearing of the tissues by violent efforts in lifting, etc. To the latter cases, the term rupture is more appropriate than to the former. A hernia of either kind, when it has forced its way through the deep opening into the canal, lifting forward the front wall and bulging backward the hinder wall, and while it is protruding between the pillars of the super- ficial ring and dilating its inclosing fascia, is called a bubonocele, the name signifying a tumor or rupture of the groin. It is for a short time often arrested in its downward course into the scrotum by the contraction at the upper part of the latter, which indicates the commencement of the clartos muscle, where the loose adipose tissue ceases. And this may form, after complete descent, a sort of oblique, hour-glass contraction, which is also seen in cases of large hydrocele, making their way upwards in the opposite direction. Descent of the Testicle.—This gland, originally developed from the Wolffian body below the kidney, as an abdominal organ, makes its way downward between the seventh and eighth months of intra-uterine existence. To effect its descent, a cylindrical mass of unstriped muscular fibre, the gubernaculum testis, developed and blended with the dartos scroti, and connected with the bottom of the scrotum below and with the peritoneum and lower part of the epididymis above, is aided by a portion of the cremasteric fibres to draw down the testicle till it reaches the middle of the canal, where those fibres are attached. The farther downward movement is accomplished by the gubernaculum and dartos alone, while the fibres of the cremaster, according to Mr. Curling, become invested with it, forming the invested loops characteristic of that muscle. The sac of peritoneum, which is destined in the male to form the tunica vaginalis, precedes the testicle, and is sometimes found in the female, reaching with the round ligament into the labium, which represents the cor- responding half of the scrotum. This is the canal of Nuck, the most usual cause of oblique inguinal hernia in the female. Now, sometimes, by the occur- rence of peritonitis in the foetus during its intra-uterine existence, adhesions form between the testicle and the bowel, omentum, or iliac wall of the abdomen, or with the kidney itself, causing arrest of development, and, if these adhesions 162 HERNIA. be strong and extensive, detention of the testicle within the abdominal cavity. If the adhesions are capable of elongation, the force of the gubernacular trac- tion is sufficient to allow the testicle to reach into the inguinal canal, or to the top of the scrotum, immediately outside of the superficial ring. Some- times this force is sufficient to draw down the sac of peritoneum, and even the epididymis (which may become unravelled and elongated), while the testicle itself remains within the abdominal cavity, or in the canal. We may then have one of those troublesome forms of hernia which are complicated with non-descent of the testicle. In all these cases, there is usually a deficiency of development in the cremaster and gubernaculum, as well as in the lower fibres of the internal oblique muscle, leaving a characteristic bulging of the groin. The scrotum and dartos also participate in the deficiency, and on the affected side, or on both sides of these structures, are shrunken and undevel- oped. The testicle should be found in the foetal scrotum in the last month of intra-uterine life, and of course at birth, and it is one of the duties of the accoucheur to observe if this condition be fulfilled, since the first cries aud struggles of the infant tend powerfully to force down the thin intestines along the unclosed and unprotected canal of Nuck. Thus we have formed a congenital hernia (Fig. 1336), the sac of which is formed by the tunica vagi- nalis itself, or its representative sac of peritoneum. In this form, the bowel descends into the scrotum so as to touch and pass in front of the testicle, or even below its level, so that the gland is obscured as in common hydrocele. This variety of hernia is usually easily reducible, leaving the testicle distinct and evident to the touch. The canal of Nuck, or channel of communication between the tunica vaginalis and the peritoneum, becomes closed, first at the deep ring, leaving Fig. 1336. Fig. 1337. Diagram of congenital hernia. Diagram of infantile [or encysted] hernia. a cicatrix which is always more or less traceable. The obliteration extends down the cord to within half an inch of the testicle. The serous mem- brane degenerates and is transformed into connective tissue, which more firmly binds together the elements of the cord. Sometimes the oblitera- tion extends only to the parts near the deep ring. Then, while the cicatrix INGUINAL HERNIA. 163 is still weak, some violent crying or coughing efforts of the child protrude the bowel, pushing and dilating the cicatrix before it, and a fresh sac of peritoneum is invaginated from above into the upper part of the large tunica vaginalis, which is pushed before it into the scrotum. We have thus formed that kind of children’s rupture with a doubled sac which is called infantile [or eiicysted] hernia. (Fig. 1337.) In this there are three layers of serous mem- brane placed in front of the bowel in the scrotum, viz., two layers of the in- vaginated tunica vaginalis, and one of the fresh, or real sac of the hernia. This may, like other forms of rupture, become strangulated, and may cause per- plexity to the operator. Here also the testicle may be covered and obscured by the hernial protrusion, which is usually less easily reducible than in the strictly congenital form, when not complicated by adhesions within the sac. The direction of the long axis of all forms of oblique inguinal hernia is obliquely upwards, outwards, and slightly backwards, and this must be care- fully borne in mind both in diagnosis and in the application of the taxis. In .direct inguinal hernia the long axis corresponds more to the axis of the body, with a more decided backward tendency at the neck of the sac. This backward direction is scarcely ever needed, however, in the manipulation of the taxis, as when the strangulated part moves under the pressure of the upper fingers, the contents slip inwards spontaneously. The application of the taxis in inguinal hernia, in infants and little children, especially when they cry violently, is powerfully aided by lifting up the pelvis from the bed by grasping the heels with the feet a little separated. This takes off the abdominal pressure in the violent, expiratory, crying and coughing efforts, and does no harm whatever to the child, if the shoulders and head be left resting on the bed. A slight shake of the body in this position aids also the pressure of the fingers, by the inward drag upon the engaged bowel and omentum. Diagnosis of Strangulated Inguinal Hernia.—Inguinal hernia in a state of strangulation is usually easy to detect, by the association of a tumor in the region of the groin with general and abdominal symptoms of obstruction and strangulation. It is of practical importance to know, however, before pro- ceeding to the taxis or to operative measures, first, whether the hernia is inguinal or crural, and secondly, whether, if inguinal, it be oblique or direct. In very stout persons, especially in females, this is sometimes by no means easy. The fold of skin in the groin is deflected downwards in fat persons, so that the long axis of the hernia may seem higher in crural, or lower in inguinal rupture, than it is in reality. The first means of diagnosis, and the most important, is by observing the relative position of the pubic spine and of the attachment of the inner end of Poupart’s ligament. This can usually be made out even in the fattest subject. Then, if the tumor be felt to lie upon the pubic spine with its central axis above and internal to Poupart’s liga- ment, while the opening of the external ring is blocked by the tumor, and the saphenous opening is free, we may be sure that the hernia is inguinal, and, if the reverse, that it is crural. The long axis of both of these hernise, when fully formed, is downwards and inwards, but the inguinal is relatively higher and more internal. In oblique inguinal hernia, the neck-tumor is more pyriform, and extends more upwards and outwards along and above Poupart’s ligament than in the direct variety, producing more obscuration of Poupart’s ligament and of the spermatic cord, which may be felt to dis- appear behind it. In the direct form, the root or neck of the tumor, which is globular, seems to spring out of the abdomen immediately and suddenly above the pubic spine, the fulness not being traceable along the canal, but closely skirting the outer border of the rectus muscle. In old and large 164 HERNIA. cases of oblique hernia, however, the structures internal to the neck of the sac are so dragged inwards by its pressure, that the latter is placed close to the rectus muscle, with the epigastric artery winding round its inner side, and it is often impossible to distinguish the two forms until incisions have been made in operation. In all, however, the direction given to the taxis should be in the line of axis of the tumor—upwards, outwards, and back- wards—the latter direction earlier in the direct form than the oblique. In dividing the stricture at the deep ring, in operations in doubtful cases, the incision should be made directly upwards. Operation for Strangulated Inguinal Hernia.—After failure of a full trial of the taxis, and the symptoms of strangulation continuing unabated, the patient should be moved to the operating table,and an anaesthetic administered, and a final effort with the taxis and inversion then tried. Frequently, when the anaesthetic has full influence, the rupture will pass up. If it does not, the parts should be shaved after anointing them with carbolized oil, and washed with a 1-20 solution of carbolic acid, taking care to thoroughly cleanse the pubis, penis, and scrotum. If possible, the carbolic spray should be used. An incision is then made through the integuments along the axis of the tumor, from the site of the deep ring to the fundus. One or two arterial branches, the deep and superficial external pudic, may require small catgut ligatures; then the inter-columnar fascia and arciform fibres are divided to the same extent, when the muscular fibres of the cremaster are brought into view. A director may now he used to divide these and the internal spermatic or infun- dibuliform fascia. Now the yellowish streaks of adipose tissue which indicate the sub-serous fascia, will be seen lying upon the grayish-blue sac. A pinch with the forceps will raise this about the centre, and the scalpel applied hori- zontally will open the sac, which must then be slit up upon the finger or straight director as far as the neck. Now the contents of the sac may be carefully examined and turned over. The forefinger, passed upwards to the strangu- lated point, will feel the inner edge of the deep ring, or the opening in the con- joined tendon (according as the case is an oblique or a direct one). The point of the curved, deeply-grooved hernia-director is now carried along the fingei and insinuated between the sac and the bowel, and the hernia knife passed along the groove, with its edge directed upwards. If the case be clearly one of direct hernia, an inward direction may be given to the cut in order to avoid the epigastric artery. If an oblique hernia, an outward direction should be given for the same end. If the case be doubtful (as it may be), a directly up- ward and forward cut is the safest. The cut should be limited to the actually constricting fibres, and, if necessary, further room can be got by dilatation with the director or the finger. The omentum, if present, should now be drawn down so as to permit a careful examination of the constricted portions. If it be found sphace- lated, as may be known by its having a dull, dark appearance, and by its fetid smell, it should be cut off with a pair of blunt scissors, and all the bleed- ing twigs tied with thin catgut. The loop of bowel should then be drawn down for an inch and examined on all sides. If the bowel look healthy, retain- ing its glistening surface look, and if no ulceration be found at the constricted portion, although it may be congested and chocolate-colored, it should be carefully returned into the abdominal cavity after the omentum, which should be put up first. The edges of the wound are then brought together with sutures, sufficiently close, a drainage-tube being placed along the bottom and out at the lower end of the wound, and the parts dressed and well padded with carbolized gauze, tow, or cotton-wool, the whole secured with a spica bandage and a support to the scrotum. The patient is then put to bed, with INGUINAL HERNIA. the shoulders raised and a bolster put under the knees. Opium should be given to allay pain and maintain rest; milk and beef-tea, iced, to allay any remaining sickness or retching; milk-diet, and no stimulants, unless the patient show signs of sinking. The bowels may be left to themselves for four or five days, purgatives in any shape being contra-indicated. After this, mild enemata with olive oil may be administered, if required. If the gut be sphacelated and black, and have lost its lustre, with gray or ash-colored spots and a putrescent smell and foul secretion in the sac, the parts should be well washed with the spray; the bowel should then be opened longitudinally at the sphacelated part with scissors, and the sides of the opened bowel stitched to the skin by three or four points of suture. The spray may then be discon- tinued, and the wound dressed with lint soaked in 1-40 carbolic lotion, and covered by a large, loose lump of carbolized tow in the groin and perineum, held on lightly by a spica bandage. If the condition of the bowel be doubt- ful, the parts may be left in situ after free division of the stricture, and cov- ered with lint dipped in warm water, the warmth being kept up by a hot- water sponge placed over all. The bowel may thus recover itself, and may slowly be drawn into the abdomen. It should be watched and examined twice daily, to see if the signs of mortification increase in certainty, and, if so, stitches should at once be placed on the bowel to prevent retraction into the abdomen and subsequent fatal extravasation. The bowel should be freely opened, and an artificial anus formed, as just described. The same expectant treatment should be followed in cases where a small aperture has ulcerated through the strangulated part, and permitted the escape of fecal matter into the sac. This should be first well washed out by carbolized sponges and the spray. If the bowel be clearly ulcerated or sphacelated beyond recovery, it may, in favorable cases occurring in otherwise healthy individuals, be entirely removed by sections through the gut, including the diseased and damaged loop of bowel between them. The mesenteric attachment may then be divided, the arteries and veins tied with small catgut ligatures, the cut sections of the bowel brought together, and stitched round by a continuous or glover’s suture, with small catgut, taking care to double inwards the serous edge so as to get the two serous surfaces in contact. It may then be returned into the abdom- inal cavity, after thorough cleansing with weak carbolic lotion, and the external wound closed with antiseptic dressing, with a drainage-tube passing into the abdomen at the lower angle of the wound. Patients treated in this way have occasionally made good recoveries. If a portion of the omentum be thickened into a mass which cannot be re- turned, this should be removed, and all bleeding vessels tied with catgut liga- tures cut oft' short. Any soft, recent adhesions of the bowel or omentum to each other, or to the sac, should be carefully separated by the fingers or forceps, and any oozing of small vessels staunched by pressure. In favorable cases with little damage to the hernial contents, I have for many years been in the habit, at the end of the operation for relief of stran- gulation, both in inguinal and crural hernia, of taking away the sac after tying it with catgut, and closing the tendinous hernial opening by my wire operation, and with the best results, both without and with the spray and gauze treatment. A description of the modes of proceeding in these cases will be given presently. Diagnosis of Inguinal Hernia when not Strangulated.—When symp- toms of strangulation or obstruction are absent, an inguinal bubonocele may be mistaken for encysted hydrocele of the cord. It may be easily distinguished, if the cyst be placed below the superficial ring, by feeling the canal and cord 166 HERNIA. above the tumor, free from swelling and hernial impulse. If the cyst be within the canal, the diagnosis is more difficult. A cyst, however, is less changeable in size and position than a rupture; it is more tense, less com- pressible than hernia, whether omental or intestinal, and when it possesses a cough-impulse, it is not a dilating impulse, but a communicated one from above downwards. If not adherent, the hernia disappears when the patient lies down, and reappears on his standing up; whereas a cyst, although less prominent, is persistent in the recumbent posture. A scrotal hernia may be mistaken, when irreducible, for a hydrocele or hydro- sarcocele. Its history aids the diagnosis; a hernia descends from above, and at first comes and goes with the change from the standing to the lying position, whereas a hydrocele begins below and grows upwards, reaching the inguinal canal by its pyriform prolongation only when very large, when it may be more easily detected by its translucency, fluctuation, and more heavy weight. It also more completely obscures the testicle to the sight and feel. A con- genital scrotal rupture may also do this, if adherent, and if its contents are altered by inflammatory effusion, either solid or fluid, and it is in this latter condition that it is most likely to give rise to doubt, especially when some fluid effusion is present in the sac, or in the contained bowel. The condition of the cord at the superficial ring, and that of the inguinal canal, will help the surgeon to distinguish such perplexing eases. If the cord be free from swell- ing, and of normal size, and the canal undistended, the case cannot be one of hernia. In cases of sarcocele, or of malignant deposit in the testicle and cord, however, the cord in the canal may be thickened and hard,.but its feel will be in these respects different from the large, soft, cylindrical swelling due to the presence of omentum or bowel. The history of the case and the other symptoms will generally make the diagnosis clear under such circumstances, and, if necessary, the use of a small aspirator-tube to draw off any fluid which may be present, may justifiably be had recourse to. An elongated, irreducible, omental hernia may be hastily mistaken for a varicocele, or the two may coexist. The feel of the latter has been compared to the vermicular elasticity of a bag of live worms, while that of an omental hernia is doughy and lumpy, like that of a bag of dead worms. If reducible, the hernia, as well as the varicocele, disappears when the patient lies down. If then the finger be placed and kept on the cord at the superficial ring, and the patient be made to stand up, the omentum will be kept back, while the varicocele will slowly return and become even more distended than before. If the omentum be irreducible, it will not of course disappear on the assump- tion of the horizontal posture. The rare cases of diffused hydrocele of the spermatic cord, extending along the unobliterated canal of Nuck, present more difficulties, especially in chil- dren, where this condition assumes the form of what is often called a windy rupture. It is prominent in the erect posture, and disappears by the passage of the fluid into the peritoneal cavity in the horizontal posture. When the patient stands up and coughs, there is an impulse closely resembling that of hernia. By the aid of a candle, however, the great and uniform translucency of the tumor, and also its distinct fluctuation, distinguish it from hernia, and drawing off the fluid by a small aspirating needle at once clears up any remaining doubt. If the fluid be in the sac of a congenital hernia, with an unobliterated vaginal process, the intestine or omentum will then descend and occupy a position in front of the testis. The symptoms of hcematocele resemble those of hydro-sarcocele, or hydro- cele, except for the absence of translucency and, perhaps, of fluctuation, and for the presence of more pain, heat, and tenderness. Cases of acute hydro- cele, after injury, may simulate scrotal hernia under similar conditions, INGUINAL HERNIA. 167 and may require close observation and comparison of symptoms, and of the history of the case. Fatty tumors growing from the sub-peritoneal or connective tissue of the cord may closely resemble irreducible omental liernise. If they do not increase, they should not be meddled with further than by the use of a truss in doubt- ful cases, as pressure will be of service in either condition. If they grow and give trouble, they should be removed, whether omental or sub-peritoneal, with antiseptic precautions. Chronic pelvic or iliac abscesses may point through the inguinal canal, guided by the vas deferens or round ligament, and may simulate, by the cough- impulse which they possess, the formation of a hernia. They are distinguished by the dulness of percussion in the iliac and inguinal regions, and by the fluctuation which is apparent when they protrude near the surface. The history of the case, and evidences of disease in the lumbar or pelvic region, will throw light upon their nature. Hydatid tumors in the inguinal region or in the spermatic cord, may also simulate inguinal hernia. They are not reducible, are often lobulated, grow slowly but uniformly larger, and never diminish or alternate in size. An aspiration-puncture will most clearly show their nature. Enlarged and inflamed inguinal glands may be attended with symptoms of disturbance of the alimentary canal, so as to simulate somewhat hernial con- ditions. When such glands are movable on their deep and superficial struc- tures, they can usually be felt to be of the characteristic glandular shape, sometimes multiple, and distinct from the abdominal rings or inguinal canal. When inflamed, or suppurating, the irregularity of the lump, and the redness, oedema, and other appearances of induration, adhesion, fluctuation, etc., will be sufficiently clear, and further light may be gained from the pre- sence of such affections of the scrotum and penis as give rise to sympathetic bubo. Radical Cure of Inguinal Hernia.—The question of the propriety of em- ploying methods for radically curing this troublesome and incapacitating condition of hernia, depends, first, upon the immediate risk to life of the steps proposed ; and, secondly, upon the permanence of the cure thus produced. Of these considerations the first is by far the most important. It will be seen that the prudence of incurring immediate risk depends much upon the severity of the inconvenience, pain, and danger endured. Some of the principles of insurance here come into play. If the pain, inconvenience and loss, and ultimate risk be great, it will be right and prudent to risk more to remove them. The same may also be said of the prospects of certainty of success or failure in the remedy. Many remedies have been at various times proposed and tried. With but few exceptions these have been relinquished, because their results have been too fatal, or not efficacious in producing a permanent cure. Space will not allow me here to consider the numerous and various ways in which a permanent cure has been sought for, from the earliest days of surgery to the present time. It will be sufficient to give those methods which my own experience has found to be most favorable for the desired end, and from the results of which we can most securely calculate the patient’s chances. We can then judge of the advisability of recommending a patient to seek the advantage of a radical cure, or to be content to suffer the evil that he has. In estimating the advisability of undertaking an operation for the radical cure of any hernia in which an operation is at all feasible, we must first consider the risks incident to the hernial condition. First, the risk to life. This amounts to the estimate usually made by the medical referee to a life- 168 HERNIA. insurance company, as to the premium to be paid by a hernial patient. If we take 25 per cent, as the proportion of reducible hernial cases, which sooner or later become subject to strangulation or other consequences which immediately endanger the life of the patient, we shall certainly not at all over-estimate this risk. In irreducible hernia the chances of such a result are at least trebled. The risks of an operation for strangulated hernia are again much increased by the unfavorable conditions of general health, etc., under which the operation must usually be undertaken; and this again is further greatly increased when the hernia is irreducible. The risk of strangulation is vastly greater if the patient is placed in circumstances under which the neces- sity for bodily labor or great muscular exertion is constant and recurring ; and its dangers are more serious if he is likely to be far from medical aid, and from opportunities of having efficient renewal and timely adaptation of trusses. Soldiers, sailors, travellers, colonists, sportsmen, and farmers in remote dis- tricts, far from medical advice and aid, all undergo greatly increased risks from strangulation. Death and physical disability in the struggle of life are in their cases more threatened than in the cases of those who live at home and at ease. The same may be said of strangulation occurring among strong and muscular men who are fond of, and otherwise best adapted to, athletic exercises and pursuits. We have also to estimate the pain, trouble, and inconvenience arising from the ditficulties of making proper and efficient truss-pressure, and its constant renewal; the danger resulting from blows or other external injuries; and the constant tendency of the rupture to grow larger and more unmanageable, or irreducible, and of truss-pressure to be less available, as the patient grows older and less able physically to endure the pain and danger of frequent stran- gulation. Again, there are to he considered the care and expense involved in the con- stantly recurring necessity for new trusses, or for repairing the old, especially in remote countries and in tropical climates, where the conditions of exis- tence render truss-renewals more frequently required, while the distance from instrument-makers renders them more tedious, and difficult. In irritable natures, the worry of unsatisfactory truss-pressure removes the slender possibility of a cure by this means, and often renders life a burden, and deteriorates the constitution so as to predispose to tendencies which shorten life. The trouble and risk are of course directly increased if there be local complications, such as non-descent of the testicle, or the supervention of a hydrocele or varicocele, as not uncommonly occurs in advancing years. Urethral stricture or enlarged prostate, a chronic cough, or an enlarged liver or diseased kidneys, causing, accompanying, or supervening upon hernia, also multiply to a variable and indefinite extent the troubles which it produces, its chances of strangulation, and the risks of dealing with it if strangulation occurs. It is, of course, difficult to give an exact estimate of the risk to life of the hernial condition as compared with that of the operation for its radical cure, but it is less so than that of estimating the pain, worry, suffering, and incon- venience of wearing trusses, generally more or less inefficient, and always liable to fail at the moment of greatest muscular effort, when their support is most urgently required. The risks and advantages of a radical cure for hernia vary of course with the method adopted, and the conditions of the rupture under which it is under- taken. So much in this respect depends upon the tact, judgment, experience, and manipulative skill of the individual surgeon, that I can only base my com- parison upon the results of my individual experience, which will be found in detail in a subsequent portion of this article. That an immense deal does depend INGUINAL HEKNIA. 169 upon such skill and experience, is shown in this, as in other operations, such as ovariotomy and laparotomy. In the history of those operations, as well as in that for the radical cure of hernia, it is distinctly shown that the mortality and failures of the earlier attempts of all surgeons are very much greater than when experience has brought the knowledge, cafe, and skill necessary to deal successfully with the conditions of each case. Much depends upon the choice of cases, but more upon the surgeon’s manipulative skill, the plan of the operation, and the after-treatment adopted. In the first hundred operations for the radical cure of hernia performed by myself, while trying various methods—such as plugs, ligature-threads, and compresses of various forms—and on all kinds of hernial cases in which success was at all likely to be obtained, the number of deaths was three. One of these was from pyaemia, and another from erysipelas—both dangers which the advance of antiseptic surgery has rendered so infrequent as to be prac- tically abolished. The third was from peritonitis, which, as shown clearly by the post-mortem examination, was set up by other causes than the opera- tion. In the last two hundred cases operated on by my subcutaneous-wire method, not one has been attended by any serious or unpleasant symptom. If all these cases are taken together, the risks of my various methods amount to one per cent. If the results of the perfected operation only are taken, the risk to life (as far as 200 cases go) is nothing. And this, I think, may be taken as the basis of calculation (allowing for the fallibility and imper- fection of individual surgical skill), in healthy subjects below the age of 40, affected with reducible inguinal hernia. The next most important consideration is the chance of failure in the pro- duction of a cure by operation. This may be set against the trouble, pain, and irksomeness of wearing a truss without an operation. The difficulty of exactly ascertaining the per- centage of failures, or of return of the rupture months or years after the ope- ration, is great. The results which I have been able to ascertain satisfacto- rily, will be given hereafter. In this place, it is enough to say that in favorable cases I estimate the successful results of the subcutaneous wire operation at 75 or 80 per cent., and in less favorable cases at 60 per cent. And, what is a very important element in the calculation of chances, in a great many of the cases in which a certain amount of reproduction of the rupture has occurred, a truss has been made available and successful in keeping up the remaining protrusion, and in making the patient comfortable, when it was not so before the operation. In some cases also, the groin, though at first weak, has improved under the sub- sequent pressure so much, and the usual contents of the rupture have been so completely kept out of the sac, that a firm cure has subsequently and finally resulted. Again, in not one of the cases operated on, as far as can be ascertained, has the patient’s condition been rendered worse by the operation. And this also is a very important consideration. In those cases in which a cure has resulted and endured for some years, and under extraordinary efforts or by accidental injury has again given way and reproduced the rupture, it must be considered that in the mean time the patient has had all the advantages of a sound groin, and has been relieved from the inconveniences of a truss. And the rupture in such cases must pro- perly be considered as a fresh rupture, produced by the giving way of fresh parts of a groin originally weak, and produced by a force which might have, and often does have, the effect of causing another rupture in a different part of the abdomen, just as a fatty or other tumor, after being removed in one place, 170 HERNIA, occurs in another from constitutional causes. No surgeon is thereby warranted in objecting to the removal of the original tumor, or even to a repetition of the operation, if necessary, although the mortality of such an operation may exceed that of the radical cure of hernia in reducible and favorable cases. The loss of time and the expenses attendant upon the radical cure of hernia are small in comparison to those of a life-long rupture, and can scarcely be seriously estimated. The mere money-value of the former must be greatly smaller than that of the latter, while the losses from disability for various callings, and from opportunities in life unavoidably neglected, must in many cases be very great. Again, when the radical cure is accomplished in early youth, when time is of little value and when the chances of success are cor- respondingly great, the risk amounts to nothing at all. Patients may thus he made strong and capable men and women, fitted for the wear and tear of labor and exertion, of pregnancy and parturition. Moreover, hernia can be with most certainty cured while it is yet small and manageable, and the cure by operation is more certain than that by the slow, tedious, and very uncertain treatment by truss-pressure, while it is certainly less irksome, painful, and inconvenient. Upon the principles of insurance, and in accordance with the maxims of prudence, the evils of a hernial condition are best counteracted, as a general rule, by an early recourse to the benefits of operative surgery in effecting a radical cure. Operations for the Radical Cure of Inguinal Hernia : The Subcutaneous Wire Operation.—This operation I consider to be the best for cases of perfectly reducible hernia, and especially for those in healthy children and young persons, in whom truss-pressure has been found to make no progress towards closing up the aperture, and particularly if they are likely to be called upon Fig- 1338. Fig. 1339. Instruments required in operation for radical cure of inguinal hernia. The scrotal incision. for a life’s work which will remove them far from instrumental and surgical assistance, or will render them incapable of meeting the necessary and recur- ring expenses, while at the same time it will test and try their physical powers of resistance. It is also applicable to those cases in which trusses fail in keeping up an increasing rupture, or cause, in some way or other, great discomfort to the wearer. INGUINAL HERNIA. 171 The patient being placed on the table, the parts shaved clean and purified, and an anaesthetic administered, so as to get the muscles relaxed, an oblique incision is made with a small, sharp-pointed tenotomy-knife, well washed in 1-20 carbolic lotion, in the front of the scrotum over the fundus of the rup- ture, three-quarters of an inch long, and through the skin and superficial fascia. (Fig. 1339.) The handle of the knife is then used to separate the integu- mentary tissues from the deeper fascial coverings of the hernia, or cord, so as to form a circle of detached integuments large enough to be invaginated into the hernial canal without drawing up the skin into the superficial ring. A stout handled needle (Fig 1338), equally curved in the segment of a circle, with a sharp point, blunt shoulders, and a large eye near the point, is used for carrying the wire. This should be well-annealed and flexible copper wire, silvered over, thick enough not to cut the tissues when drawn tight, but not so thick as to be at all inflexible. A piece about twenty inches long, briskly rubbed so as to render it flexible and clean, dipped in a 1-20 solution of carbolic lotion, and then in carbolized oil (1-5), should have each end bent into a hook three-quarters of an inch long, and evenly curved so as easily to pass the eye of the needle. The fore-finger, oiled, should then be passed into the scrotal puncture (Fig. .1340), and made to invaginate the fascia and sac into the hernial canal, as far up as it will go into the deep ring behind the lower fibres of the internal oblique muscle, which should be raised well upon the finger. To the inner side of the finger will then be felt the raised edge of the conjoined tendon, lying on the outer side of the rectus abdominis muscle. The needle must now be carefully and slowly passed along the finger until its point can be felt plainly by the bulb of the digit placed behind the con- Fig. 1340. Invagination of the fascia by the fore-finger Fig. 1341. Fig. 1342. The needle perforating the conjoined tendon. Introduction of the -wire. joined tendon. The point should next be directed inwards so as to take up the tendon, and to transfix it and the aponeurosis of the external ob- 172 HERNIA. lique which covers it. Its point will then be seen to raise the skin. The skin must next be drawn towards the median line, and the needle directed by its stout handle so as to bring its point out through the skin, one inch and a hall external to the puncture, through the deeper tissues (Fig. 1341). One end of the wire is then hooked on to the eye of the needle, and is drawn with it by a slight jerk through the tissues emerging at the scrotal puncture. (Fig. 1342.) The needle is next detached from the wire, and the linger again passed into the canal. Now the spermatic cord is to be felt for, lying in a groove formed by the union of Poupart’s liga- ment with the fascia transversalis. The cord is to be pushed gently inwards, and the point of the linger placed in the groove which it occupied, and lifted forwards, so as to elevate Poupart’s ligament at its centre, and with it the outer pillar of the superficial ring. The iliac artery may be sometimes felt behind the finger, which lifts up the tendinous structure from its immediate contiguity, and protects the vessels from injury. The needle, passed again along the front of the finger, a little to its outer side, is then pushed through Poupart’s ligament till its point raises the skin. (Fig. 1343.) The latter is now pulled inwards until the point of the needle can be made to pass through the same puncture in the skin of the groin which the wire already traverses. The opposite end of the wire is next Fig. 1343. The needle penetrating Poupart’s ligament. Fig. 1344. Fig. 1345. The wire twisted and locked. Needle crossing the sac. hooked on to the needle, drawn down as before through the scrotal puncture, and then detached. There is now a wire-loop at the groin, and two hook-ends at the scrotal puncture. Opposite the latter, the sac is then pinched up by the finger and thumb, in the same way that a varicocele is separated from the spermatic duct when submitted to operation. An assistant seizes it with INGUINAL HERNIA. 173 finger and thumb, also in the same way, at about two inches distance, both assistant and operator recognizing the situation of the spermatic duct. The needle is then passed at one corner of the scrotal puncture (Fig. 1344) across the sac, in front of the duct, and out at the other end of the scrotal puncture. The skin here is so elastic that the puncture stretches sufficiently to allow this to be easily done. The inner end of the wire—viz., that which traverses fehe conjoined tendon—is next hooked on to the eye of the needle and drawn across behind the sac. Care must here be taken, by dealing with the wire roundly, not to make an acute bend or kink, which would put a needless difficulty in the way of its subsequent withdrawal. The wire should be drawn down so as to get straight parts in the tissues, and to bring the loop an inch or so from the skin-surface. The two scrotal ends are then twisted twice or three times around each other, the operator observing the direction of the twist, so as to be able readily to untwist the wire when it is to be withdrawn. The loop of wire above is now seized and drawn firmly upwards, so as to invagi- nate the scrotal fascia into the hernial canal as high up as the deep hernial opening, and it is then twisted firmly down, in the same way and with the same precautions as the lower ends. The ends and loop are then bent over towards one another (Fig. 1345), the former cut off to a convenient length, passed through, and bent on to the latter. In very large cases, where the superficial ring is very patulous, the wires may be crossed in the canal, and the needle passed through the pillars near the pubis, after the sac is invagi- nated. Thus the lower opening of the hernial canal may be more effectively Fig. 1346. Modified operation for very large herniae. The compress in position. closed. (Fig. 1346.) In these cases a cylindrical pad of glass or boxwood may be used with advantage to secure the loop, and for the ends of the wire to be twisted over, as seen on the other side of the figure. A pad of lint, large enough to exercise compression, is fixed under the bight of the double wire loop which has been formed (Fig. 1347), a little carbolized tow is put over the scrotal puncture to catch any discharge, and a flannel spica bandage is applied, the ends of which, on being tied, should be made into a sling or suspender to support the whole of the scrotum and penis. The patient should be placed in bed, with the shoulders well raised and the knees tied 174 HERNIA. together and bent over a long bolster, with a prop for the feet to keep the body firm. The bowels should be opened on the morning of the operation, and then left until some discomfort is experienced. Opium should be given for the first twelve hours—one grain every four hours—until pain ceases oi sleep comes on. The diet should be of milk and beef-tea, with ice to relieve any nausea left by the anaesthetic. No stimulants are advisable. The pain usually passes off in twelve hours. The discharge is trifling and of a serous character. The bandage rarely requires to be touched till three days have elapsed, when it may be removed entirely, with the pad of lint. A lump of well-teased antiseptic tow placed under the wire will he sufficient dressing. The scrotum should be well supported. In a few cases the urine may require removal by a catheter, for the first day or two, on account of the patient’s dis- inclination to contract the abdominal muscles. The wire should be kept in for from eight to twelve days, according to the amount of reaction set up, the lower ends of the wire acting as an efficient drainage-conductor. At the end of this time the wire may be untwisted, and it will then he found that the two parallel, straight portions of the wire, which originally passed through different tracks, have by slow ulceration joined each other in the same track, and that they will come out together by cutting off their lower ends with pliers, and pulling upon the upper loop. If by reason of slight kinks there is any difficulty in this, the wire may be straightened by pulling at each end with pliers, and the ends may then be withdrawn together or singly. The upper opening usually closes soon after their with- drawal, and a truss may then be applied, with cotton-wool beneath it, and the patient may be allowed to get up and lie on a couch until the lower sinus heals. Sometimes a little swelling of the testicle, or effusion into the tunica vagi- nalis, shows that the spermatic cord is closely embraced by the wire, but this rarely calls for any special treatment, being entirely removed by the wire’s withdrawal. In only one case, in which a steel clamp was used to hold the ends of the wire instead of twisting them, has atrophy of the testicle fol- lowed the operation. I have met with no burrowing of matter since substi- tuting the wire for the ffempen ligature and compress. The straightened wires act as efficient and cleanly drainage-conductors, aided by the raised position of the shoulders and trunk. Yery little discharge is usually present throughout, and it only becomes puru- lent in the last few days. A large quantity of fibrinous effusion mats togtlier the walls of the canal with the inclosed, invaginated sac. The induration, however, soon disappears, and the cure depends not upon its plug-like formation, but upon the adhesion of the hinder wall of conjoined tendon (at a, Fig. 1348) with the front wall and Poupart’s ligament, adherent to and embracing the cord. The effect of this operation, when successfully accomplished, is to unite in one cicatrix the sides of the inguinal canal as far up as the deep ring, to- gether with the pillars of the superficial ring, the union of which supports the invaginated, twisted, and obli- terated sac, with its intimate coverings of external and internal spermatic and Cremasteric fasciae. All these are blended together in the fibrinous effusion consequent upon the gradual severance by the pressure of the wires. The conjoined tendon of the internal oblique and transversalis muscles is firmly connected with the deep part of Pou- part’s ligament, and upon this union depend, for the chief part, the success and permanence of the radical cure. Thus the valvular arrangement of the front and hinder wails of the canal is restored and Fig. 1348. Diagram of cured inguinal hernia. INGUINAL HERNIA. 175 strengthened by adhesion, and the rounded knuckle of bowel can no longer enter the deep ring, and thus, the most effectual preventive of the formation of a hernia in the healthy inguinal canal, is restored and even strengthened by the operation. Unless this is accomplished, the cure is not a satisfactory one; and one of the chief causes of failure in the hands of beginners is the want of dexterity and experience in obtaining a hold upon the conjoined tendon with the needle-point, at the first stage of the procedure. In some cases, no doubt, a want of substance and development in the con- joined tendon causes it to give way before the needle, and to tear under the traction of the wire. In other cases, where the hernial rings are large in diameter and close to one another, with no length of canal between them— as in direct hernise, and in old oblique hernise which have become, in effect, direct, and in which a patch or plug of invaginated tissue is necessary to supply an absolute deficiency of the abdominal wall—the inherent weakness will re- quire afterward,.perhaps, a longer, or even the continued use of a light truss. If care be exercised, however, in placing and keeping on a proper truss, such cases may be strengthened and fortified, so that the rupture may not return, and even if the groin remains weak and bulgy, and threatens to reproduce a rupture, ultimate success may be obtained. And in another class of cases, doubtless, adhesions, at first firmly resisting and efficacious (if not deposited when the patient is in robust health), may yield, under continued pressure, just as in other cases of operation for prolapsus of various kinds. In less aggravated cases, the truss may usually be left off after nine or twelve months, the patient being at first careful to put it on occasionally, when likely to be called upon for much muscular effort. A bulgy weakness of the groin may be apparent after the hernial canal is securely closed, from a want of development in the lower muscular and other fibres of the internal oblique and transversalis muscles; but this condition rarely requires more than the occasional use of a light truss, such as would be recommended for weak groins which had never been actually subject to hernia. When it is considered that in such cases, generally, no truss has been effectual in keeping up the rupture before the operation, the advantage gained by the latter becomes sufficiently convincing. By the method just described I have operated upwards of two hundred times consecutively, with not a single seriously bad symptom occurring. The average period of convalescence has been about a month, from the ope- ration to the healing of the lower opening; the average time in bed about eighteen days. Before adopting the use of wire, thread and compresses were employed, and while the steps of the operation were imperfectly understood and carried out, and when—perhaps still more important—-cases were ope- rated on somewhat indiscriminately, to see what could really be accomplished, three deaths occurred in the first 100 cases; one from pyaemia, one from ery- sipelas, and the third from peritonitis, all having been published at the time in the medical journals. Two of these cases were decidedly from hospital or other infection, while the third case was a peculiar one: the necropsy clearly showed that fatal peritonitis had been set up by a knuckle of intestine which had been involved in the sac before the operation, with the truss pressing upon it. The focus of inflammatory action was found around the damaged and congested loop of bowel, on the opposite side of the abdomen to that which was the seat of the rupture and of the operation. The sac operated on, and the peritoneum in its neighborhood, all around, were free from all traces or consequences of inflammation. In no case has any trouble arisen from hemorrhage, nor have there been any signs of injury to the epigastric, femoral, iliac, or other vessels. 176 HERNIA, Success and Durability of the Results of the Subcutaneous Operation.—It has been justly urged that the immediate success of such an operation as that under consideration is not as fair a test of its worth as the permanence of its results. Fully impressed with this opinion, I have, at the expense of much pains and trouble, kept notes of three hundred cases, and have obtained the results given in the accompanying Table and Statistics. It has of course been extremely difficult to follow the cases operated on, derived as they have been chiefly from the very migratory working classes during a considerable number of years. The first case given in the Table was one of very large scrotal rupture operated on at King’s College Hospital, in the presence of the late Sir William Fergusson, Professor Partridge, Sir Spencer Wells, Mr. Henry Smith, and many other distinguished sur- geons. Since the operation, the patient has been employed in very hard, laborer’s work, and has, moreover, been severely tried by a winter-cough and bronchitis. He has worn no truss whatever, except for a few months immediately after the operation. He has been shown at various metropolitan societies and surgical assemblages, from time to time, at intervals of some years, and is well known to London surgeons inter- ested in this operation. He has been shown at the London meeting of the British Medi- cal Association, in 1873 ; at the Royal Medico-Chirurgical Society ; at the Royal College of Surgeons, on several occasions ; and on numerous occasions, at intervals, in the ope- rating Theatre at King’s College Hospital. The seat of operation is sound and resisting, and is, in fact, better than the opposite side, which shows a slight bubonocele, from lifting and coughing. This circumstance serves to indicate the amount of strain that has been put upon the cured side during the twenty-four years that it has so successfully resisted, and the unyielding nature of the union when properly established. The total number of cases which I have been able to keep in view, noting their condition from time to time with much care and trouble, amounts to fifty-six. They are given for the sake of convenience in the accompanying tabulated form, with the date of the operation, and the date when last seen by the operator, or, in a few cases, heard of from some other surgeon. It has been thought most convenient to place them in the order of the dura- tion of time for which the rupture has been kept under notice and known to be cured. Many have been seen up to a late date, and many at various yearly intervals of which the last date is given. Two have been known to be cured up to the time of death from consumption; others have dropped out of observation. The earliest cases wrere taken without much selection as to size and difficulty, and from a class of persons mostly proverbially careless as to the due application of trusses. Many wore no truss whatever after the operation. In the later cases, after the operation had been tested and perfected, a more careful selection was made. INGUINAL HERNIA. Table of Results of the Subcutaneous Operation for the Radical Cure of Inguinal Hernia. No. Name. Age. Date of operation, or of last opera- tion. Date when last seen. Duration of cure about Remarks. 1 J. B. 25 Jan. 11, 1862 J une 6, 1881 19 yrs. Very large; Aard labor; no truss; shown at Med.-Chir. Soc. 2 H. H. 22 Oct. 6, 1860 Aug. 1, 1878 18 No truss for 15 yrs.; hard labor. 3 H. C. 28 Feb. 28, 1862 Oct. 1880 18 Heard of. 4 R. S. 6 Mar. 24, 1864 Nov. 15, 1881 17 Shown at College of Surgeons. 5 J. M. 25 June 25, 1860 Nov. 25, 1877 17 No truss at all worn. 6 H. W. 30 Nov. 1864 Dec. 1881 17 7 H. H. 16 Oct. 6, 1859 July 16, 1875 16 No truss ; seen by Mr. R. Bell. 8 C. C. T. 10 June 5, 1865 July 19, 1881 16 Passed med. exam, for artillery 9 H. W. 26 June 21, 1865 April 30, 1881 16 [at Woolwich 5 years ago. 10 M. B. 5 Oct. 1864 Dec. 1877 13 No truss worn. 11 G. P. 15 Oct. 5, 1861 Dec. 9, 1874 13 Operated on twice ; sailor. 12 W. A. 5 Oct. 1864 Oct. 9, 1877 13 Heard of again lately as well. 13 A. H. B. 40 Feb. 5, 1867 May 16, 1880 13 By letter from patient. 14 C. T. 18 June 28, 1862 April 1874 12 Seen many times. 15 J. B. 17 June 20, 1859 Oct. 5, 1870 11^ 16 J. C. 25 April 1, 1858 Oct. 20, 1868 104 Slight bulging after a fall. 17 T. L. 18 Sept. 5, 1863 May 7, 1873 10 Double rupture. 18 F. H. 27 Nov. 8, 1871 Dec. 20, 1881 10 Operated on 3 times ; sailor. 19 D. W. 34 Sept. 5, 1862 June 10, 1871 9 No truss worn ; hard work. 20 W. R. 19 May 31, 1862 Jan. 1870 8 No truss. 21 C. T. 18 June 28, 1862 Feb. 1, 1870 8 No truss. 22 G. H. R. J. 28 Oct. 19, 1872 Mar. 5, 1880 8 No truss ; India. 23 L. D. 26 Mar. 1866 .^an. 1873 7 24 T. N. 7 July 4, 1863 Dec. 28, 1869 H l Brothers. 25 G. N. 9 Oct. 3, 1863 Dec. 28, 1869 6 $ 26 J. P. N. 24 Dec. 13, 1870 April 5, 1876 6 27 M. S. 8 Nov. 15, 1872 July 1877 5 Both sides operated on same time successfully. 28 G. V. 21 June 2, 1860 Oct. 1865 5 29 W. B. 32 Mar. 12, 1862 May 1867 5 30 J. H. L. 4 June 22, 1871 Oct. 20, 1875 4£ 31 W. A. 24 Oct. 3, 1863 Nov. 7, 1867 4 No truss. 32 H. R. 23 Nov. 26, 1864 Nov. 28, 1868 4 No truss. 33 H. P. 23 Nov. 1864 Nov. 28, 1868 4 34 H. C. 20 Oct. 5, 1868 Died 1872 4 Consumption; no return. 35 G. R. A. 26 June 19, 1868 June 10, 1872 4 36 J. D. Aug. 28, 1862 Oct. 1866 4 Truss 9 months ; seen often. 37 L. E. 26 Feb. 13, 1877 Oct. 1881 4 38 J. A. T. 16 Oct. 5, 1872 Feb. 24, 1876 3£ Large scrotal. 39 E. B. 5 Dec. 20, 1873 Jan. 14, 1877 3 Very large; congenital. 40 C. C. 40 Mar. 1864 April 1867 3 41 E. P. 3 June 1877 June 19, 1880 3 Very large scrotal. 42 C. K. 8 April 1876 June 20, 1879 3 43 J. S. 22 May 18, 1872 June 30, 1875 3 44 W. S. 22 Mar. 29, 1862 July 9, 1865 3 Dolible scrotal. 45 G. T. 18 Dec. 1, 1869 Dec. 1872 3 46 M. D. 18 Jan. 6, 1874 Jan. 1877 3 Passed army examination. 47 C. K. 8 April 1, 1876 May 20, 1879 26, 1867 3 48 J. B. 26 Feb. 27, 1864 May 3 Female; no truss. 49 R. H. 30 July 2, 1862 1865 3 Heard of. 50 J. P. 19 Mar. 30, 1878 June 1881 3 Both sides operated on same time. 51 D. S. 21 Julv 2, 1865 May 1868 3 52 J. P. 19 Dec. 30, 1865 July 10, 1868 24 53 J. L. 13 Mar. 14, 1863 July 8, 1865 2I Female. 54 H. C. 25 Mar. 1, 1878 July 1880 H 55 A. H. 22 Feb. 9, 1878 June 12, 1880 24 56 A. F. L. 20 Oct. 18, 1878 Oct. 1880 2 All the patients of the foregoing table, it will be noticed, had remained cured for over two years before they were last seen. 178 HERNIA. In 62 other cases, the patients have been seen and kept under observation for periods less than two years, during which time the cure has remained satisfactory—in many without any supporting truss-pressure whatever. Most of these however, have, for the sake of security, worn trusses during the first twelve months after operation. In 48 cases, I have ascertained that, at various periods from a few months to two or more years, the ruptures have returned. In most of these cases, however, trusses have been made available and efficient, which was not the case before the operation. The patients have been, in fact, made comfortable by the proceeding. In no instance, as far as is known, has the case been made worse by opera- tion. Although in many cases the operations have been failures, in a strictly scientific sense, they have by no means been so as far as the patient’s satisfaction and comfort have been concerned; and the operation can scarcely be put down, therefore, as a futile effort to relieve suffering, any more than can the vast proportion of medical and surgical work which does not radically cure the patient, in the sense of relieving him for the whole period of his life, from a malady which nevertheless physicians and surgeons profess to cure. Out of 300 cases of operation for the radical cure of inguinal hernia, then, 119 cases may be reckoned as having been kept under observation for vary- ing periods of time afterwards, while 48 have been actually proved to be failures in the strict scientific sense. 167 out of the 300 have then been ac- counted for, leaving 133 which have not been seen or heard of since the operation, either from not having been able, forgetting, or neglecting to do what all had been earnestly requested to do, viz., to report their condition from time to time afterwards. How, when we consider that patients who are not cured, are more likely to return on the hands of the surgeon for further aid, than those who are cured are to come and report their state, or express gratitude, we may fairly infer that the percentage of success in those who have not been seen or heard of, has been rather more than, or at least equal to, that among those who have been examined after the operation. How, rather more than half have been seen or heard from, and of these nearly three-fourths are cured- We are justified, then, in concluding that the percentage of success obtained by the subcutaneous-wire method for the radical cure of inguinal hernia is from 70 to 75 per cent, in selected cases, when the operation is properly performed. This percentage, however, drawn from all, including the early operations, well and ill selected alike, has been improved by another 5 per cent, in the latter more carefully selected cases. In some cases which have failed from various causes, such as the large size of the hernia, crying in a child, or carelessness just after the operation, a second operation, and in one case a third, has been performed with ultimate and complete success. Some were first operated on by my old methods with thread and compress, or with pins, and afterwards by the subcutaneous wire operation; of these there have been 12 cases, of which only one has failed utterly on both occasions. In two, no truss whatever has been worn since the last operation, viz., G. P., No. 11 in the table, a sailor, aged 15, last operated (second time), October, 1861 ; shown at King’s College Hospital, December, 1874; quite sound; no truss had been worn at all. M. A., aged 5, second operation, October, 1864; seen in 1877; had worn no truss and was an accomplished bicyclist. In an enormously sized scrotal hernia in a'sailor, F. H., aged 25 (No. 18), the operation was repeated three times, each time with improve- ment, and with ultimate complete success. Last operation, November, 1871. Shown to a large assemblage of surgeons at the operating theatre at King’s College, in May, 1881. INGUINAL HERNIA. 179 In 10 patients, both sides have been operated on, either at the same time, or with an interval:— In one of these, J. P., a male, aged 19, the operations were performed in March and May, 1878, and the patient was shown at King’s College Hospital in October, 1881, quite cured, no truss at all having been worn in the interval. In a boy, M. S., aged 8, the two sides were operated on at the same time in November, 1872. His medical attendant informed me, in 1877, that he was at school abroad, and quite cured. In one case, that of a child aged years, the operations on both sides failed entirely from the violent crying and struggles of the little patient, who made a good recovery from the operation, nevertheless. This was the only failure, with the exception of a slight bulge, if that can be called a failure, on one side only. In some instances, where a weak bulgy appearance of the groin has re- mained after the operation, and has given rise to apprehensions of a return of the rupture, the application of a horseshoe-shaped pad of vulcanite for a year or so has consolidated the parts and completed the cure. Wire Operation for the Radical Cure of Inguinal Hernia, with Removal of the Sac under Antiseptic Precautions.—This operation should be performed under the full use of the carbolic spray, and with the strictest antiseptic precautions. I accomplish the removal of the sac by a modification of the preliminary scrotal incision made in the subcutaneous method before described. Instead of a mere puncture three-fourths of an inch long through the skin and superficial fascia, an incision from two to three inches long, reaching as far upwards as the superficial abdominal ring, is made through the scrotal coverings right down to the sac itself, which is then detached from its investments, and lifted out and separated carefully from the spermatic vessels and vas deferens. This is best accomplished by a free use of the fingers and one or two pairs of forceps, or by the handle of the scalpel separating the sac from its coverings by tearing. Facility in this process, which in old truss cases may be found difficult, can only be obtained by frequent practice and experience. The greatest danger is to the spermatic duct and vessels, which are sometimes closely adherent to the inner and hinder surface of the sac, and covered by a dense fascia which appears to belong to, or to form, the sac itself. When the proper separation has been effected, and the operator has made sure of the return of the her- nial contents, if reducible, the sac should be drawn out of the incision and detached upwards and downwards. Its attachment to the tunica vaginalis is sometimes so close that the testis may be drawn out and the tunic itself opened by mistake. This connection having been detached, the fundus of the sac is firmly lifted up into a vertical position. The incision in the in- teguments is now glided up so as to be well opposite to the inguinal canal, and the sac is then followed and detached from the cord as high up as the deep ring. The handled hernia needle is next passed through the neck of the sac, close to the fascia transversalis, and a stout catgut ligature, which has been steeped in a solution of chromic acid, is connected with the eye of the needle and drawn through double in withdrawing it. The loop of the double liga- ture is then cut, and the ends tied firmly with a surgeon’s knot on each side. In doing this, great care must be taken not to include a loop of bowel, and to be the more certain of this, it is better to open the sac in front and pass the finger within it through the deep ring. If the hernia be a congenital one, the lower part or fundus of the sac which should have formed the normal sac of the tunica vaginalis, and which is adherent to the testicle, and forms its serous covering, should be separated from the rest, on a level with the upper end of the testicle and epididymis, and stitched up with fine catgut in a glover’s or continuous suture, to serve as the future tunica vaginalis. It will be found most convenient to place a 180 HERNIA. pair of straight dressing forceps across the sac at the place indicated, then to sew the sac with catgut, and afterwards to cut it straight off above the suture. If the hernia be irreducible, the sac must of course be first freely opened, the omentum drawn out and examined, any adhesion that may exist near the neck of the sac separated, and bowel carefully looked for. If a loop of bowel be found, but slightly adherent, the adhesions may be carefully separated, and the bowel returned. If the quantity of omentum in the sac be small, it may also be returned; but incase it is voluminous, diseased, or much ad- herent, it is better to tie its vessels carefully and separately with small catgut ligatures, and then to cut it off short with blunt scissors, afterwards securing any small bleeding points; care must be taken that the stump of omentum does not slip back into the abdomen before the process is completed. When the sac has been thoroughly examined, and the way cleared, its neck should be drawn out, separated, and tied in the way just described. The wire may now be applied to the conjoined tendon and Poupart’s liga- ment, as in the subcutaneous operation. Then there being no sac to be taken up in the scrotum, and the cord being sufficiently isolated and distinctly seen, the point of the needle may be passed across the lower part of the superficial ring, through the insertion of Poupart’s ligament at the spine of the pubis, and obliquely through the conjoined tendon and inner pillar, about half an inch above the pubic crest. The inner end of the wire may next be hooked on to the needle, and drawn across on the inner side of the vas deferens and twisted on to the outer end, in the way described in the account of the subcutaneous operation. The lower part of the scrotal incision must then be drawn together by sutures, closely applied, a drainage-tube of the size of a quill being placed along the bottom of the wound, from the superficial ring above, and out at the end of the wound below. The protective and gauze-dressing may then be applied, the large, outermost dressing being provided with an opening for the penis, and the lower border being tucked under close behind the scrotum, to serve as a suspensory bandage with a sufficient amount of padding under it. The elastic bandage should be carried across the perineum from one thigh to the other, in addition to the turns of double spica on the groins. It will be well to pin over all a square piece of Jacquinette mackintosh, with a hole in the centre for the penis, to keep the dressings unsoiled by the urine. The use of the catheter is sometimes required for a day or two. On the third or fourth day the scrotal wound may be found united, and the stitches may then be withdrawn, and the drainage-tube shortened. The condition of the parts then resembles that seen in the subcutaneous operation, and the wires may be withdrawn on or about the tenth day. There is rarely trouble from any effusion of blood if the veins of the cord have not been cut, and if the drain- age-tube is kept clear. A little swelling of the testicle, or effusion into the tunica vaginalis, if present, usually disappears without further treatment. The severity of this operation is, of course, greater than that described as the subcutaneous-wire operation. It is modified, however, in cases of reduci- ble hernia, where no omentum is removed, and where none of the abdominal viscera are involved in inflammatory complications. Its danger is increased by removal of any part of the omentum, adherent or non-adlierent, by the omentum being diseased, or by intestinal adhesions having been separated. We may then have some local or general peritonitis. These cases thus naturally fall, in respect to prognosis and fatality, into two divisions, viz., Those in which the operation is done for reducible hernia, and those in which it is done for irreducible hernia. If, however, great care be taken in the separation and ligature, by catgut, of all bleeding points in the omentum, mesentery, or adhesions of intestine, and if the antiseptic spray- INGUINAL HERNIA. 181 arid-gauze method is successfully and conscientiously carried out, the danger of the proceeding is very much lessened. The number of cases in which I have, up to the present time, performed the above operation is 18 ; of these, 10 have been for reducible hernia, with removal of sac only; and 8 for irre- ducible hernia, with removal of sac and portions of omentum, adherent or non-adherent. The first was done in July 13, 1878, for a large, right, scrotal, irreducible hernia, in a man, T. B., aged 26, admitted into King’s College Hospital for severe symptoms of strangulation. The hernia, after some difficulty, was reduced by the taxis. The opera- tion was done with antiseptic precautions, but not Listerism. There were no bad symp- toms, and no elevation of temperature after the operation, and the patient was dis- charged cured, and without wearing a truss, August 3. The second case was done April, 1879, in a boy, aged ten, for irreducible, large, right, scrotal hernia, in which a considerable portion of adherent omentum was removed with the sac. The result was very satisfactory, no bad symptoms ensued, and the patient was seen in November, 1881, perfectly well, having never worn a truss. Of the 18 patients, only one has died, and all the rest have been cured. The death occurred suddenly in a man, G. F., aged 45 (operated on January 11, 1881), from a clot in the heart and congestion of the lungs, three days after operation during the very severe snow-storm of that winter. Some signs of adhesive local perito- nitis about the cut omentum were found, but the state of the sac and other parts ope- rated on was all that could be desired. The operation had been undertaken at the patient’s earnest request, on account of the dragging pains and weight of an enormous left scrotal rupture, filled almost entirely by adherent omentum, which was removed with the sac, after the arteries had been carefully tied with small catgut. The bowel was not adherent, and remained untouched and scarcely seen, and there was little or no bleeding during or after the operation. The patient’s urine was free from sugar or albumen ; but he had been subject to a bad, chronic winter-cough, which had aggravated his sufferings very much. All the other cases have turned out satisfactory cures, some during nearly two years, and, what is still more encouraging, no dangerous or even trouble- some symptoms have occurred. All were operated on and dressed with very careful, antiseptic, Listerian precautions. Most of those operated on later than two years ago, have been seen or heard of, from time to time, and no evidence has been forthcoming to show that the operation has failed to pro- duce a radical cure in a single case. But, of course, the tests of number and duration have not been as extensively applied as in the case of the subcuta- neous-wire operation. From the statistics of the operation for the radical cure of rupture collected from various sources, different operators, and diverse methods—but all agree- ing in a free dissection of parts, ligature and complete or partial removal of the sac, and the use of catgut or other ligatures variously applied, both with and without the carbolic spray and Listerian appliances—given by M. Tilanus, of Amsterdam, the percentage of deaths is found to be eleven per cent. This is too high a fatality to render an operation generally acceptable, in a condition which does not immediately or directly endanger the patient’s life. The percentage of deaths after the use of my own method has been, as before said, at the rate of five and a half per cent, only, in sixteen cases. Further experience, and the careful employment of antiseptics, will still further reduce this percentage. Wire Operation for Radical Care of Inguinal Hernia after Strangulation.—• Of such operations I have performed seven, with one death from pneumonia and delirium tremens, no serious symptoms having occurred in any of the other cases. The essential particulars of each case are as follows:— 182 HERNIA. 1. M. W., aged 52. Large, right, scrotal hernia, of twenty-five years’ standing. April 24, 1872, strangulation violent; herniotomy; a quarter of a pound of omentum removed, but not the sac, which was tied up with ligature-threads and left. A slough in the scrotum, and abscess, followed ; no bad symptoms otherwise ; patient seen again, wearing light truss and quite comfortable ; no spray. 2. E. B., aged 21. Right scrotal hernia; taxis ineffectual; herniotomy; sac tied, but not removed ; no spray ; date of operation, March 23, 1873. Shown afterwards, in August, at a meeting of the British Medical Association, in London. Heard of seven years afterwards, as having had some return of the rupture, which was easily kept up by a truss. 3. W. M., aged 27. Right, scrotal, congenital hernia; strangulation ; herniotomy without spray, catgut ligature, sac removed, December 10, 1873; no bad symptoms; discharged January 24; seen again in April 19 ; no bulge or sign of weakness. 4. H. S., aged 19. Left, scrotal, strangulated hernia of two years’ standing; sac tied with catgut and removed, no spray, November 22, 1878; not seen since; a few months afterwards quite well. 5. T. B., aged 26. Large, right, scrotal hernia, irreducible from omental adhesion; strangulation of bowel reduced by taxis. Operation at once for radical cure under spray. July 13, 1878 ; sac and thickened omentum tied with catgut and removed ; stump of omentum fixed to internal ring ; progress very favorable ; no suppuration. Discharged cured, wearing no truss, August 3, 1878. Has not shown himself since; parts very hard and resisting when last seen. 6. L. S. L., aged 23. Right testicle in groin, with an irreducible omental hernia and occasional strangulation of bowel; violent strangulation requiring herniotomy, done under spray, with gauze dressing; testicle, sac, and omentum removed after catgut ligature, November 13, 1878; able to go out of doors, December 14, no bad symp- toms whatever, no suppuration. Examined in May, 1881 ; only a slight bulge appa- rent at site of deep ring. No trouble ; light truss. 7. J. G., aged 44. Left scrotal hernia, large, of twenty-eight years’ duration. A hard drinker, had had delirium tremens several times. No albumen or sugar in urine. Had had strangulation twice previously. Herniotomy, November 10, 1878; sac re- moved ; spray and gauze dressing. Directly after operation (in which very little blood was lost), symptoms of delirium tremens set in, and the day after, those of pneu- monia, followed by death, November 14. In this case, the radical cure was attempted at the patient’s earnest request, on account of the trouble and suffering which he endured with the truss, and the frequent recurrence of strangulation. There were no serious local com- plications in this case. The omentum was not removed, and the bowel was uninjured by the strangulation. The autopsy showed no signs whatever of local or general peritonitis. The neck of the sac was found to have been tied flush with the peritoneum, and all the parts concerned were unaltered by any morbid action; the serous membrane at the tied neck of the sac was slightly adherent. In Case 6, the strangulation was very severe and painful, and the steps of the operation very difficult, as they always are when an undescended testis is concerned. The progress of the case afterwards was absolutely free from bad symptoms. In the first four of the above cases, antiseptic carbolic precautions were carefully observed, but neither spray nor gauze was used. I have, however, from observation of abdominal surgery, little doubt that in these cases, as in all herniotomies, the Listerian method of dressing gives considerably increased security in preventing putrefaction and suppuration, and also in diminishing or entirely preventing surgical fever, and in lessening the period of conva- lescence. The amount of success in this procedure will depend in great measure upon a proper selection of cases. If after opening the sac in the necessary CRURAL OR FEMORAL HERNIA. 183 operation for the relief of strangulation, the intestine be found but little con- gested, and be not further injured; and if the omentum, though partly removed, be healthy as respects the stump; and if the patient be a healthy subject, with neither sugar nor albumen in the urine, of sober habits, and with a condition of solids neither flabby nor corpulent, and especially if he be young (under 30 years of age), the risks of the operation of herniotomy (rendered absolutely necessary by the irreducible strangulation) will be but little, if at all, increased by the steps taken to produce a radical cure. It cannot be too closely borne in mind that the risks in all such cases spring from disease or injury of the bowel and mesentery, and to a less degree oi the omentum. I have not met with a single case in which’pathological pro- cesses originating in the sac, except from erysipelas or pyaemia, have been the cause of death, or even of serious symptoms. It is absolutely necessary to make a very careful inspection of the bowel, mesentery, and omentum, which should always be drawn down and examined for several inches, after division of the strangulating tissue. The neck of the sac should be tied with stout carbolized and chromicized catgut at the place where the division of the stricture has taken place. Catgut, however, cannot be relied upon unaided for preventing the return of the rupture. It is not persistent enough when placed in contact with the living tissues, even with the carbolic dressing, to withstand the strain of the aponeurotic and muscular tension in connection with the inguinal canal. This is clearly seen after sutures of catgut have been applied to close apertures in the skin under the carbolic spray and dressing. After a day or two they become attenuated, thinned, frayed, and elongated, even under the simple elasticity of the skin- structures, and unless immediate union of the incision has taken place, the wound reopens. In one case of large scrotal hernia, in a child of 7 years, in which I used stout carbolized and chromicized catgut instead of wire for closing the canal, the catgut gave way and the hernia was reproduced, although much thickening of the tissues at the deep ring was the imme- diate result. Catgut ligature, however, serves best for tying the isolated neck of the sac, there being, by its use, no necessity for subsequent distur- bance of the parts, and it is eflicient if supported by the wire ligature in the canal until union has occurred. Even more satisfactory results, however, have been obtained by the use of the tendons of the reindeer and kangaroo’s tail, which are much more persistent than catgut. Crural or Femoral Hernia. From the greater width of the pelvis in the female, and from the increased length and diminished strength of Poupart’s ligament in that sex, this form of rupture, in women, is more common than the inguinal, in the proportion of about two to one. Anatomy of Crural Hernia.—In the lower half of the inguinal region, about half an inch below the inner third of Poupart’s ligament, is placed the opening through which a crural rupture passes out of the abdominal cavity. It is exposed by making an incision through the integuments along Poupart’s ligament, a second down the inside of the thigh, and a third from the lower end of the latter horizontally across the front of the thigh, at the junction of the upper and middle thirds. This corresponds to the area of Scarpa’s triangle. The first layer of the superficial fascia is composed of adipose tissue, and is continuous with that over the abdomen. The deep layer is denser and thinner, and is attached to Poupart’s ligament. 184 HERNIA. Between the two layers are found the saphena vein, to the inner side (see Fig. 1333, page 157), with several of its tributaries accompanying the ascending branches of the common femoral artery, viz., the superficial cir- cumflex iliac, passing upwards and outwards towards the iliac crest, and piercing the deep fascia at the outer third; the superficial epigastric, cours- ing upwards and inwards towards the umbilicus ; the superficial external pudic, passing also upwards and inwards, crossing the cord just below the superficial abdominal ring; the deep external pudic, perforating the fascia lata and crossing horizontally behind the spermatic cord towards the penis. Lying along the saphena vein, on both sides, are the lymphatics of the lower inguinal region, ducts and glands. The former receive tributaries which pass with the vessels just mentioned, and the latter, of an oval shape, with their long axes corresponding to the axis of the body, chiefly over a de- pression indicating the opening in the deep fascia which transmits the saphena vein, and through which the lymphatics make their way into the crural canal, and thence to the iliac glands in the abdominal cavity. A few nerve- twigs are also met with, viz., branches of the ilio-inguinal, which pass with the spermatic cord through the superficial abdominal ring, and turn down- ward and outward over the end of Poupart’s ligament, to be distributed over the adductor region of the thigh ; and a crural branch of the genito-crural nerve, which perforates the deep fascia about an inch below the middle of Poupart’s ligament, and joins with the middle cutaneous branches of the anterior crural which are distributed over the middle of Scarpa’s triangle. The internal and external cutaneous branches of the same nerve perforate the deep fascia much lower down in the thigh. The fasr.a lata of the thigh is thus exposed to view, thick, dense, and gray- ish white, with little or no fat except where the vessels and nerves pierce it, covering the femoral vessels and crural nerves, and inclosing externally the sartorius muscle in its sheath. Above, the fascia lata is blended firmly with that portion of the external oblique aponeurosis which forms Poupart’s ligament along its whole length. This is called the iliac portion of the fascia lata (see Fig. 1333, m, page 157). The inner portion, which covers the adductor muscles of the thigh (Fig. 1333, w), is attached above to the sym- physis pubis, the pubic spine, and the pectineal line, where it blends with the triangular offset of Poupart’s ligament which is called Gimbernafs liga- ment. Outside of this, the pubic portion of the fascia lata passes behind the femoral vessels and is blended with the capsular ligament of the hip- joint. The pubic portion thus dips deeply behind the iliac portion, which overlaps it at the inner third of the thigh, and between them is the saphe- nous opening. This is an oval opening, from an inch and a half to two inches in its longitudinal diameter and three-quarters of an inch transversely. When dissected, it is seen to present an external arched or curved border, the upper part of which (Hey’s, or the femoral ligament) curves inwards to the pubic spine and pectineal line, across the crural canal, where it is about half an inch wide, and so strong as sometimes to cause strangulation in a cru- ral hernia. At its lower part, the curved border of the saphenous opening arches under the saphena vein, forming a sharp curve, the falciform process of Burns. On the inner side, the opening is bounded by the sloping surface of the pubic portion of the fascia lata. The opening is covered in by a fascia which is closely adherent to the latter internally, and to the edge of the falciform process and Hey’s ligament externally. This covering is continuous with the deep layer of superficial fascia. It is perforated by numerous open- ings for the passage of the lymphatic ducts into the crural canal, and for the superficial epigastric and external pubic vessels, which curve upwards. It CRURAL OR FEMORAL HERNIA. 185 is closely adherent to these as well as to the coats of the saphena vein below, from which it cannot be separated. On turning aside the falciform margin of the iliac portion of the fascia lata by detaching it from Poupart’s ligament (Fig. 1349,/), the sheath of the femoral vessels is brought to view. It is a funnel-shaped in- vestment (/:), wider above than below. Its front wall is formed by a prolongation of the fascia trailsversalis behind Poupart’s liga- ment, to which it is closely attached, the union forming a band of fibres which arch over the crural opening (Cooper’s ligament), to be attached to Gimbernat’s ligament and the pectineal line internally. This forms the most usual seat of strangulation in crural hernia. The hinder wall of the femoral sheath is formed by a prolongation of the iliac fascia. It is continuous at the sides with the transversalis offset, and below, at the junction of the saphena vein with the femoral, it is intimately blended with the sheaths of those vessels respectively. On the inner side, the lymphatics can be seen to per- forate this sheath in numbers. The funnel- shaped process should be opened by three parallel longitudinal incisions, when it will be found that two septa in the interior separate the femoral vein (which is in the centre) from the femoral artery outside and the lymphatic canal inside. The latter is the channel through which crural hernia passes. It constitutes a section of an inverted cone, the base of which is formed by an interval between the septum of the femoral vein outside and the curved base of Gimbernat’s ligament inside. The apex is formed by the junction of the saphena vein with the femoral, at the lower part of the saphenous opening in the fascia lata. The sides of the canal are thus of unequal length. Superficially and internally the extreme width of the falciform or Hey’s ligament expresses it, viz., half to three- quarters of an inch. Behind and externally, the length is one and a half to two inches. The crural ring (Fig. 1350, c) is thus bounded in front by the inner end of Poupart’s ligament (a) with the fibrous band of Cooper’s ligament over-arching the canal; internally are the blended margins of the structures attached to the pectineal line, viz., Gimbernat’s ligament (5), with the conjoined tendons of the internal oblique-and transversalis muscles and the fascia transversalis behind it, and in front the extremity of Iley’s or the femoral ligament and the pubic portion of the fascia lata, joining at the upper edge of the saphenous opening. The area of the crural ring is placed nearly horizontally in the erect posture of the subject, with a slight slope upwards, outwards, and forwards; across it is stretched a curtain, derived from the subperitoneal connective tissue attached to its edges, perforated by the lymphatics, and usually con- taining a lymphatic gland enveloped in a sheath of the Fig. 1349. Deep dissection of the parts in crural rup- ture. The upper corner of the saphenous opening is separated from Gimbernat’s and Poupart’s ligaments and turned hack, show- ing the three compartments of the crural sheath opened by longitudinal slits. Fig. 1350. The crural ring. 186 HERNIA, same tissue. This horizontal fascia is called the septum crurale of Clo- quet. It offers no considerable opposition to the descent of a hernia, and is so indistinguishable from the fascia transversalis in a hernial condition, that it is of no practical use to the surgeon. On dissecting the crural ring from its peritoneal surface, it will be seen, on raising the serous membrane, that a slight dimple usually indicates the position of the ring, and that the deep epigastric vessels lie external and superior to the opening, arising from the external iliac. Sometimes these vessels are irregular. They may arise from the common femoral, as low down as the saphenous opening, or in common with the internal circumflex, in which case the epigastric will pass through the crural ring. (Fig. 1351) The epigastric artery may give Fig. 1351. Fig. 1352. Irregular course of obturator artery. Irregular arrangement of arteries concerned in femoral hernia. off the obturator, usually a branch of the internal iliac. When this is so, the obturator may either pass down into the pelvis, close to the external iliac vein, and therefore external to the crural opening (Fig. 1351.) or it may pass over the latter, behind Poupart’s ligament, and descend along its inner mar- gin, just behind Gimbernat’s ligament, (Fig. 1352.) It is" the latter rare position that concerns the surgeon in operating for strangulated crural hernia, since in dividing the ligaments freely the operator may divide the irregular artery. The arrangement, however, occurs so rarely that this seldom happens; one in five is about the proportion found in the dissecting-room, and not one in a thousand, perhaps, on the operating-table. It can be guarded against by not passing the hernia knife (which should not be too sharp) too far into the abdominal cavity, when its point will push off the elastic and yielding artery before it, without cutting it. The irregularity is produced by an enlarge- ment of the normally existing branch of communication between the epigas- tric and the obturator arteries. A crural hernia first makes its way by pushing before it from the perito- neal surface the sac and septum crurale on its surface, its direction being downwards and a little forwards; it then enters the crural canal, dilates CRURAL OR FEMORAL HERNIA. 187 the sheath, and bulges out the cribriform fascia; then, being prevented from passing down the thigh by the close union of the last-named fascia with the coats of the saphena vein (Fig. 1353 b), and fol lowing the line of least resistance, it turns over the outer edge of the saphenous opening («), and passes upwards and outwards under the integuments(c), lying upon the femoral vessels, and even passing above Pou- part’s ligament (d), so as to give the appearance of an inguinal bubonocele. It is thus exposed to severe pressure, first from Gimbernat’s ligament and its asso- ciated structures, and the band of Cooper at the crural ring, where the point of strangulation is most fre- quently found at or in the neck of the sac itself; and next, from the sharp, curved border of the saphenous opening (Hey’s ligament), where the direction of the axis of the sac is changed to one upwards and outwards. It follows that the direction of force in the taxis of a complete and large femoral hernia should be inwards and downwards upon the fundus of the sac, and directly backwards at the neck of the sac, so as to avoid pressing the bruised bowel against the sharp edges which lie above and outside it. It follows, also, that when an opera- tion is required, the hernia knife should be directed inwards and forwards, so as to divide Hey’s ligament and Gimbernat’s ligament together, in a line almost parallel with the superior ramus of the pubic bone. If this is not. sufficient to release the bowel, the deep fibres of Poupart’s (constituting Cooper’s) ligament should be further divided by directing the knife more forwards, care being taken, in the male subject, not to cut so far as to divide the spermatic cord in the canal which lies just above those structures. Fig. 1353. Diagram of crural hernia. Diagnosis of Strangulated Crural Hernia.—This condition may be mistaken for certain local diseases coincidently or causatively attended by constipation, vomiting, nausea, and other alvine symptoms. The most com- mon of these are enlarged femoral glands, which, when placed upon the saphe- nous opening, or within the crural canal, may resemble closely a small hernia. When not acutely inflamed, they are movable ; of the characteristic, oval, glandular shape; often multiple; and extending down with their long axes in the direction of the saphena vein. When inflamed, they are indurated and cedematous, the pain and tenderness extending down the thigh ; at the same time an examination of the feet will often reveal the cause of the glandular irritation. When suppurating, the fluctuation in the centre of the lobulated and indurated mass will, when punctured, explain the appearances. A varicose saphena vein, enlarged into a globular tumor at the saphenous opening, increasing in tenseness and size on standing, and disappearing almost entirely on lying down, feeling elastic, and yielding to the touch, may be mistaken for reducible crural hernia. The appearance of varicosit}7 in the same vein or in its branches lower down, a certain dusky complex color, characteristic of varicose veins, and a want of fulness over the crural canal in the groove over Poupart’s ligament, will help to diagnose this condition. The point of a finger placed firmly on the crural canal while the patient lies down, and the pressure kept up when he changes to the upright position, will keep back a hernia; but a varicose swelling will, under the same circumstances, immediately return. But, if in such a vari- cose condition the vein becomes plugged by a clot in the same position; and if the patient is affected with constipation or nausea at the same time (as lately occurred in a pregnant patient who was under my observation), the 188 hernia difficulty of distinguishing it from an irreducible, or even a strangulated crural hernia, becomes extreme, and may only be cleared up by careful obser- vation of the progress of the case, and of the effect of aperient remedies. A lipoma, may be found in the crural canal, so closely simulating omental hernia as to require an exploratory operation for its distinction and removal. A cystic formation in the crural canal may give rise to similar perplexity. Such cysts may arise from the sac of a small hernia, which has become cut off by adhesions from the peritoneal cavity, or from degeneration of the lymphatic ducts or glands. They are usually more movable than a real hernia. Other tumors, of an adenoid or sarcomatous nature, may exist in this situ- ation, and may be distinguished by the same criteria, viz., their hardness to the touch and lobulation, together with their persistent and steady growth. Psoas, or pelvic, or iliac abscess may simulate crural, as well as inguinal hernia, with or without abdominal complications, and may be distinguished by the means already pointed out in the remarks on inguinal hernia. When these means of distinction fail, and the complication of general and abdominal symptoms of a serious character still more perplexes the surgeon, an exploratory incision, under antiseptics, will alone clear up the matter; and this may be extended into an operation for the relief of strangulation, if re- quired. “When in intelligent doubt, skilfully operate,” is the proper maxim for safety. Operation for Strangulated Crural Hernia.—The patient having been placed on the operating table, and an ansesthetic having been administered to its full effect, a final effort should be made with the taxis; in case of failure, the parts being shaved and the carbolic spray in action, a straight incision of a size proportionate to that of the tumor (averaging two inches long), should be made through the integuments a little to the inner side of the axis of the crural canal. The superficial external pudic, or epigastric, as the case may be, should be secured by twisting, or with a small catgut ligature. Then upon a director, the cribriform fascia and femoral sheath should be divided, and the subserous adipose tissue covering the sac carefully opened up to the femoral ligament. The curved hernia-director being carefully passed under this, it must be divided up as far as to the fibres of Poupart’s ligament, and then, in recent cases, an attempt should be made to reduce the contents of the sac by digital manipulation, as recommended by Mr. Luke. If this does not easily succeed in recent cases, and always in cases where long strangulation or symptoms of mortification have occurred, the sac should at once be opened by pinching up a portion at the centre, and dividing it with the point of the scalpel, placed horizontally ; the contents of the sac should then be examined by passing the finger up to the edge of Gimbernat’s liga- ment on the inside of the bowel. When the stricture is found, the point of the curved hernia-director should be insinuated under the edge of the deep crural ring and Gimbernat’s ligament, and the hernia-knife passed, not too deeply, and directed inwards, so as to divide the constricting fibres. The director should then be lifted so as to dilate the opening. The omentum and bowel are next drawn gently and carefully downward so as to examine the constricted parts. Any ulcerated point at the neck of the hernia, opposite the strangulation at Iley’s and Gimbernat’s ligaments,should be looked for; adhesions should be carefully separated; and the omentum and bowel should then be returned into the abdomen, or otherwise treated, as described in the case of inguinal hernia. The same rules as to sphacelated parts, and ulcera- tion or sloughing of the bowel, are to be followed in all cases of strangulated hernia. CRURAL OR FEMORAL HERNIA. 189 There is very rarely any trouble from an irregular course of the obturator artery. If profuse bleeding, whether arterial or venous, should occur at the crural opening after the return of the bowel, the aperture should be dilated —by division, if necessary, of Poupart’s ligament—and the bleeding point exposed and secured with a small catgut ligature. If the bowel is ulcerated through by the pressure of the aponeurotic fibres, the part above is commonly adherent to their edge. Under such circum- stances the gut should not be detached, nor the adhesions meddled with, after division of the stricture. The intestine should be left undisturbed, and not cut into unless clearly sphacelated. By this means, the formation of an artificial anus is often prevented, especially with the aid of the spray and gauze dressings. A small drainage-tube, or a bundle of horsehair or catgut, having been placed in the lower part of the wound, three or four points of suture should be applied, and then a small pad of gauze on each side over the protective oil skin; then the whole should be well padded with wet and dry gauze, especially towards the inner side. The entire dressing should be well secured by a spica bandage, and the patient placed in bed, with the knees bent over a bolster. Diagnosis of Unstrangulated Crural Hernia.—The most important point in these cases is to make sure whether the tumor in the groin is one which re- quires truss-pressure, or one which would be injured by it. The latter group includes the cases of enlarged glands, especially those acutely inflamed, and abscesses, which have already been considered. Obliterated hernial sacs and adipose tumors are often benefited by light truss-pressure. Cysts and vari- cose tumors in this situation are usually aggravated by it, unless, in the latter instances, the truss is soft, light, and accurately fitted. When the question of an operation for the radical cure is raised, the size of the neck of the sac and the nature of the contents are important. If the former is small and the latter omental, there is more chance of success than under opposite circumstances. The general diagnosis of the tumors which simulate crural hernia has been already discussed. Another important point is the distinction between crural and inguinal hernia, which in very stout persons is sometimes by no means easy. It has been treated of at length in the sec- tion on the diagnosis of inguinal hernia, at page 163. Operation for the Radical Cure of Crural Hernia.—The importance of, and necessity for, this operation, is generally by no means as great as in the case of inguinal hernia. In the first place, it is of much less frequent occurrence, and, in the next, it is by far most commonly found in females, whose less laborious employments and whose more flowing garments render the wearing of a truss more efficacious and less irksome than in the male sex. Still, there are instances wherein it is desirable, for both patient and surgeon, that a radical cure should be attempted before the operation for strangulation is needed ; and when the latter is required, a radical cure can be accomplished without increased risk, while the coverings of the hernia are divided. In the upper and middle classes, truss-pressure is always more or less irksome, and to some tender skins painful and wearisome; and in the working classes, women often have employments which require much mus- oular effort, as is the case with market-women, milk-women, etc. The exigencies of parturition also present conditions in which a rupture becomes a source of danger; and the desirability of a radical cure is further increased by the greater difficulty of getting a steady and unshifting bearing for the truss-pad, since the movements of the thigh are more felt in crural than in inguinal hernia. 190 HERNIA. Steps of the Subcutaneous-Wire Operation for the Radical Cure of Reducible Crural Hernia.—The patient being placed upon the table and anaesthetized, with the leg of the affected side slightly flexed and turned a little outwards, the parts should be shaved and purified with 1-20 carbolic solution, in which the instruments and wire should also be laid. The hernia should be reduced and the finger passed into the crural ring to make sure that nothing is irre- ducible. An oblique incision, three-quarters of an inch or an long, is made through the integuments and fascia covering the sac of the hernia, which is then invaginated upon the finger into the crural ring. The finger is to be pressed firmly outwards against the femoral vein, so as to empty it and push it out of the way of danger; the pulsation of the femoral artery will be plainly felt in doing so. The same needle as that used in the like operation for inguinal hernia, but rather smaller in ordinary cases, is now passed along the finger till its point reaches Poupart’s ligament, through which it is to be passed at a point opposite the inner margin of the femoral vein. When the point raises the skin, this is to be drawn outwards for about an inch before the point of the needle is pushed through. The wire (about fourteen inches long, and bent at each end into a hook) is next hooked on to the needle’s eye, drawn down into the incision, and then de- tached. The finger must now again be invaginated and pressed firmly against the edge of Gimbernat’s and Hey’s ligaments ; the needle is then to be pushed through the fascia lata, which covers the adductor and pectineus muscles, and then carried along through Gimbernat’s ligament and the in- sertion of Poupart’s ligament into the pubic spine. (See Fig. 1354.) The skin is now to be drawn inwards until the point of the needle appears at the upper puncture, through which the wfire already passes. It is then pushed through the same puncture, and the hook at the other end of the wire at- tached and drawn down through the incision. When the sac is large, it may now be transfixed or wholly in- cluded by the needle being passed across or behind it, pinching it up between the finger and thumb. The two ends of the wire are then to be twisted twice around each other, and the upper loop pulled so as to invagi- nate the sac into the ring (Fig. 1355), and then twisted down into the punc- ture, as in the inguinal operation. The ends of the wire are then to be cut off* to a convenient length, bent over towards the bent-down loop, passed through the loop, and fast- ened by a bend. A pad of carbolized lint is then passed under the loop and made to cover the wound (see Fig. 1355, B); over this is placed a little oiled silk, and then a spica bandage, with a little carbolized tow to catch any drainage that may occur. The last should be so placed as to be removable and replaceable without disturbing the pad of lint. The patient should be placed in bed, with the upper part of the trunk raised and the knees bent over a bolster. The wire may remain a Fig. 1354. Subcutaneous-wire operation for crural hernia. CRURAL OR FEMORAL HERNIA. 191 week or ten days, when it can be removed, after being untwisted, without difficulty, as the wires by this time will have ulcerated through the tissues, so as to be in close proximity, and will often lie in the same track. The drainage is kept free by the lower end of the twisted wire while it is in place. When it is withdrawn, the dressings should be so arranged as to allow the pus free exit. Fig. 1355 Mode of securing the wire, When cicatrization has been completed, a soft truss-pad of an oval shape (as described in the section on trusses) should he applied over cotton wool and dusting powder, and subsequently replaced by a vulcanite pad. Operation after Herniotomy for Strangulation.—When under the spray the sac has been opened, the stricture divided, the bowel and omentum drawn down and examined carefully, and the former found not essentially injured, with no ulceration at the strangulated part, and no appearance of sphacelus, the ope- ration should be concluded by tying up the neck of the sac by strong catgut, at the level of the crural ring, and cutting off the sac just below. If the sac be large, the catgut should be made to transfix it, and should be tied tightly on each side. Then after passing the needle through Poupart’s ligament on the one hand, and through the pubic fascia lata and Gimbernat’s ligament on the other, as above described, the needle should again be passed horizontally through the pubic fascia lata, just below its insertion into the pectineal line, and the inner end of the wire hooked on and drawn through. Then the two ends of the wire should be twisted together, and the loop drawn up and twisted firmly down into the upper skin puncture. A drainage-tube should next be placed in the lower part of the wound, reaching as high as the closed crural ring, and two or three points of suture applied. Upon the protective, a double pad of wet, carbolized gauze should be placed, so arranged that a groove is left to lodge the end of the drainage-tube, and to give free exit for any discharge. Then the rest of the antiseptic dressing is to be applied, with plenty of loose padding, especially on the inner side, to absorb the discharge, and a 192 HERNIA. spica bandage above all. If the discharge does not soak through, the dress- ing may be left for three days, when, if primary union has occurred, as is most likely, the stitches may be removed and the drainage-tube cleansed and reapplied, shortened by about half an inch. In another three days the dressing should be changed, and the wire removed, the tube, again shortened, being kept in till the next dressing in three or four days more. The tube will then generally require removal. I have operated for the radical cure of crural hernia by the wire operation, directly after the operation of herniotomy for strangulation, in four cases, all in women. In the first two the spray was not used, but all the other antiseptic precautions were employed. In the last two, the spray and Lister’s dressing were used. All the patients recovered without a bad symptom, each having a good, firm, resisting cicatrix; no return of the rupture has occurred, as far as known, up to the present time. 1. H. S., aged 50, a woman, bedridden from paralysis, with a chronic cough which caused the bowel to come down under the truss, when it often became strangulated. Left crural hernia; a large part of the tumor was irreducible. The truss gave her much pain and trouble, from slipping down and causing excoriations, of which the marks were very visible. Strangulation symptoms severe for thirty-six hours. Operated on October 28, 1879. A considerable portion of omentum, ecchymosed and congested, was removed after being tied in sections with thin catgut. The sac was then tied and removed, the ligature (of stronger catgut) being made to lay hold of the stump of the omentum. Stitches, drainage-tube, and dressing of carbolized lint, covered with a large pad of carbolized tow, and secured by a spica bandage. She made a good and rapid recovery; never wore a truss, and, when last heard of, was more comfortable than she had been since she had had the hernia. 2. A. S. H., aged 35. Strangulated left crural rupture; for forty-eight hours, vomiting of fecal matter; herniotomy operation, May 9, 1879. Patient had bronchitis at the time of operation; sac removed, and operation done without spray; good recovery. Discharged June 8 ; wore no truss after a few months; seen December 5, 1880, one year and three-quarters after operation, quite well. 3. F. D., aged 30. Right crural strangulation for twenty-four hours; severe pain and vomiting; herniotomy under spray, September 28, 1880 ; no omentum ; bowel chocolate-colored; sac removed after ligature by catgut wires applied as above; no symptoms afterwards. Discharged cured, October 15 ; seen in January, 1881, quite well. 4. E. O. N., aged 56. Right crural strangulated hernia, irreducible omentum. Strangulation forty-eight hours; bowel chocolate-color; omentum adherent. Omen- tum removed with sac; operation with wires as above, May 26, 1881. Discharged cured, June 21, 1881. Heard of afterwards as quite well. We should no doubt be prepared to expect a higher rate of mortality in this operation than in that upon unstrangulated hern he. Very much will depend upon the care and judgment of the surgeon as to the condition of the bowel and omentum, before venturing to return them into the abdomen, and upon his choice of cases in which strangulation is recent. With due caution we may expect confidently that no higher rate of mortality than is met with in ordinary crural herniotomy, will be experienced. And if so, it certainly seems to be a shortcoming in surgery not to take advantage of the open wound, to cure, if possible, the hernia, by the same operation as that which is necessary to relieve strangulation. It is well known that by not doing so, the hernia is left to become" larger and more troublesome to retain, because of the crural ring being cut so as to be more open and unprotected than before the operation. To be successful, as a rule, cases must be operated on as soon as possible after a fair trial of the taxis, aided by inversion and anaes- UMBILICAL HERNIA. 193 thesia, has been made. But this rule, also, operates favorably in an operation which is usually successful in saving the patient in inverse proportion to the amount of damage done, chances lost, and time misemployed by ill- directed and unskilful use of the taxis or other futile methods of treatment; and this especially in thin, feeble, female patients after the middle period of life. Umbilical Hernia. Anatomy of Umbilical Hernia.—Two varieties of umbilical hernia pre- sent themselves to the surgeon. One is congenital, and is seen in infants and children at or soon after birth (Fig. 1356), and the other (probably also de- Fig 1356. Umbilical hernia. pendent in some measure upon the same original weakness) is found in adults: in women whose abdominal walls have become distended from pregnancy— especially from multiple births, from a large child, with a narrow pelvis in a small woman, or from a large quantity of liquor amnii—or, in both sexes, from corpulence consequent upon adipose deposit in the omentum, or from dropsy in the peritoneal cavity. Congenital umbilical hernia is so common in both sexes as to be consid- ered by Sir Astley Cooper to come next in frequency to inguinal hernia. In the development of the foetus, the last part of the peritoneal cavity to close into a shut sac is at the navel. The aperture through which the omphalo-enteric duct of the yelk sac or umbilical vesicle passes to the intes- tine with its omphalo-mesenteric vessels, is occupied in its upper part by these structures bound together by the reflected tube of amnion, while the lower part is occupied by the urachus, or tube of communication of the allantois sac with the bladder, and with it, passing upwards from the pelvis in front of the peritoneum, by the placental (afterwards the hypogastric branches of the internal iliac arteries), and, passing downwards from the liver, by the umbilical or placental vein. About the third month of intra- uterine life, the umbilical vesicle and the omphalo-enteric duct, with its vessels, 194 HERNIA. begin to shrink, and finally disappear. In cases of slow and late develop- ment, a thread-like pedicle can be seen even at the full period of gestation. Soon afterwards, the tubes of the urachus, occupying the lower part of the umbilical opening, shrivel and close up. And here again we occasionally find a delay in development, and at birth there may be a patulous opening at the navel, through which a little urine may trickle. In more decided cases of very early arrest of development in this region, we may have produced the deformities known as ectopia vesicse and epispadias. The hypogastric arteries and umbilical vein persist until birth is fairly accomplished. Some- times the reflected tube of the amnion, the vagina funiculi urnbilicalis, is found to pass into the umbilical cord and to contain a portion of small intes- tine even at birth. In such cases the navel-string is of unusual diameter close to the foetus, and compressible, dilating when the child cries. Care must be taken not to include the intestine by tying the cord too close to the body of the child in such cases. Here is an intra-uterine formation of um- bilical hernia, rendered more decided and kept open by the struggles and crying of the newly born infant. And at this point is the original weakness of the navel, in cases of congenital umbilical hernia, to be looked for. When this condition is detected at birth, it is best, after the ordinary liga- ture and division of the navel-string at about an inch and a half from the abdomen of the infant, to squeeze out of the persistent sac all traces of the presence of intestine or omentum, and then to tie the cord again firmly close to the surface of the abdomen. By this means the occurrence of an umbili- cal rupture may be prevented during the cries of the child soon after birth. The developmental tendency to close up the navel-opening is very strong, and requires only a little aid from art to secure its accomplishment. On each side of the opening is one of the broad, expanded recti abdominis muscles, inclosed in the split sheath of the internal oblique, fortified on its posterior part by the tendon of the transversalis, and on the anterior by that of the external oblique muscle. Opposite to the navel is found one of the linear, tendinous intersections of the recti muscles, pursuing an irregu- larly horizontal course, and closely adherent to the enveloping tendinous sheath. On the inner side, the sheaths of the two recti muscles are united in the median line by crossing and interlacing fibres, forming the linea alba, so that those of one side pass over by a decussation to the opposite side of the abdomen. At the navel, the linea alba is at its widest part, and a close dis- section will show that some of the fibres at this point are arranged so as to surround, in a parabolic curve, the opening for the umbilical vessels. These curves, arranged in different directions, give the effect of a circular arrange- ment to the investing fibres, which by this contraction tend powerfully to close up the umbilical opening. The closure is aided also by the contraction and consequent widening of the bellies of the recti muscles in expiratory and expulsive efforts. The contraction of the oblique muscles also aids, by the cross pull which it exercises upon the decussating fibres at the navel. To some extent the traction of the pyramidales muscles, which are proportion- ately largely developed in the infant, and are also attached to decussating and more or less longitudinal fibres, contributes to close up the umbilical opening. It may easily, therefore, be inferred that, up to the period of puberty, exercise of the abdominal muscles by proper gymnastics will aid in the cure of congenital umbilical hernia. The fascia transversalis in the umbilical region is thin, but tougher and with closer fibres than in other parts of the abdominal wall, and it is here blended closely with the decussating fibres of the linea alba. The serous peritoneum is also thinner, tougher, arid more closely adherent than else- where. In congenital hernia the sac is usually very thin, and its covering UMBILICAL HERNIA. 195 often consists only of the transformed cutaneous investment of the umbilical cord itself. The umbilical hevnice of adults, unless they are a continuation of the infantile, differ somewhat in their origin and anatomy. They sometimes pass through the true navel-aperture, but more frequently through an aperture close above, or below, or on one side of it. After some distension, the umbilical cicatrix becomes involved, and it and a part of the skin cover the tumor, which is not quite in the centre, but usually below it. An examination of the anatomy of the front abdominal wall, will show that there are numerous small openings near the linea alba, through which pass small branches of the intercostal arteries and nerves. Usually these openings (some of which are also found in the sheaths of the recti proper) are tilled up with small nodules of con- nective or adipose tissue. When the person gets corpulent, these nodules increase in size, while the openings in the fibrous network become larger by stretching, and then, if the individual gets thinner, from any cause, the open- ings become more patulous, and are imperfectly tilled by adipose processes from the sub-peritoneal fat joining on to the subcutaneous adipose structures. Under a violent expiratory exertion—such as a cough, or straining or forcing effort—a portion of peritoneum is driven into the opening, and a small sac is formed. These sacs are not uncommonly found in subjects in the dissect- ing room before a regular hernia has been the result. They may also be seen near the inguinal region, and in several cases a rupture has been found to pass into the inguinal canal, simulating an oblique inguinal hernia, but not covered by the infundibuliform or cremasteric fascia. They may occur at various parts of the abdomen, and form ultimately true ventral hernise. Umbilical hernia in the adult has a thin and closely adherent sac, some- times so attenuated by distension as not to be recognizable by the surgeon, who may in operating come suddenly upon the contents of the rupture. The contents of an umbilical hernia in adults are almost always omentum, usually loaded with fat, and often thickened and hardened by inflammatory effusion from external pressure, to which its situation exposes it in an unusual degree. In children, umbilical hernia usually contains small intestine, with a thin covering of omentum, or entirely without it. In adults, the colon is often contained in the sac; sometimes in its whole diameter, sometimes one of its cells pinched up into a pouch. In rarer and larger cases a part of the stomach, duodenum, liver, gall-bladder, csecum, sigmoid flexure—or even the uterus, ovaries, or bladder—may be found in the sac. The proximity of the hernia to the stomach, and its hold of the omentum high up, usually causes a great amount of dragging pain, nausea, and sickness, while its implication of the colon causes frequent constipation, flatulence, colic, and distress. Sometimes a double opening is found in the interior of the hernia, either with two distinct sacs, or with two necks to the same sac. The latter arrange- ment often results from the remains of the urachus and hypogastric arteries at the upper part of the superior false ligament of the bladder, traversing the interior of the sac to the navel-cicatrix, with adhesions to the neck and with a pouch on each side, one of which may contain omentum, and the other large or small intestine. The suspensory ligament of the liver has been seen to form a similar division of the sac. The point of strangulation in an adult umbilical hernia is most frequently at the lower part of the neck of the sac, where the action of gravity, the dragging weight of the contents and the super-incumbent fat, together with the pressure and weight of the dress or of an abdominal belt, combine to press downwards upon the sharp edge of the abdominal opening. It is here that adhesions and ulceration of the bowel are most frequently found, and here the surgeon must search for the constriction in cases of strangulation. The coverings of the hernia consist chiefly of the 196 HERNIA. integument, often attenuated by stretching, and under it a thin prolonga- tion of the deep fascia, with fibres from the aponeurosis of the linea alba. These are usually blended intimately with the serous peritoneal sac, with but little subserous connective tissue. Diagnosis of Umbilical Hernia.—Umbilical hernia in the child may be mistaken for dropsy of the funis, or for a sarcoma or carcinoma growing from or near the navel, or for a cyst. It may be distinguished by its dilating impulse on crying, and by its compressibility and total disappearance on con- tinued, gentle pressure. In the adult, it is most likely to be mistaken for a fatty or other tumor; it is also distinguishable by the above signs, and by its getting larger or smaller as the patient stands or sits up, or lies down; by its tympanic sound on percussion when it contains bowel; by its yielding on being kneaded when it contains feces, and by its flatulent croaking and bor- borygmus when it contains air. Impacted feces, causing obstruction of the bowels, give a peculiar, lumpy feel, and may be sometimes distinguished from hardened masses of omentum by assuming different shapes under pres' sure. In one case, seen by myself, rounded masses were felt, which were found to be intra-peritoneal concretions of coagulated albumen, like billiard- balls, which had found their way into the sac. I have also found like con- cretions in inguinal and crural liernise of old standing. They seem to be formed by deposits of coagulable lymph upon nuclei of fat, in shape and structure resembling the “ appendices epiploicse” which have afterwards be- come detached, leaving a mark indicating their former connection. In ascitic patients, an umbilical sac may be filled with fluid and contain no viscera. Treatment of Umbilical Hernia.—Congenital umbilical hernia in children under puberty is rarely, if ever, strangulated. It tends naturally towards a cure, and requires only the aid of proper and efficient pressure to accomplish it. For very young infants, nothing is better than a penny-piece wrapped up in adhesive plaster, with the sticky side outward, placed on the opening after carefully pressing the contents into the abdomen, with the point of the finger. Over this pad, transverse straps of soap plaster, one inch wide, and long enough to reach well over the sides of the abdomen, should be firmly applied, and a light flannel belt over all. This should be changed whenever it begins to curl ofl‘ or to slip down, and the skin in the neighborhood should be well cleansed and dried, and then dusted with starch-powder to prevent exco- riation. The common practice of putting on a conical pad of cork cannot be too much deprecated and condemned. Any plug passing into the umbilical opening, although apparently making it more secure against slipping, tends powerfully to prevent, instead of aiding, in the closure of the aperture. In the section on Trusses will be found a description of the pads which I employ to produce a radical cure of umbilical hernia, and from the use of which, in older cases, many cures have resulted. They should be employed when- ever the adhesive plaster makes the child’s skin sore and excoriated. The truss which I use for reducible umbilical hernia, in adults, will be found described in the section on Trusses. That for irreducible hernia should be an air-pad, in the hollow of a concave, thin, German-metal plate, fitted on to the tumor, the edge of which is protected by a rounded air-pad, to pre- vent it from chafing the skin around. This should be held in place by a laced belt coming down to the groins, with elastic side-pieces. The thin plate protects the rupture from injuries or violent pressure in front. In the application of the taxis to the umbilical hernia of children, simple pressure between the finger and thumb, the child being in the recumbent posture, will, in most cases, suffice, if persevered in gently and persistently. 197 UMBILICAL hernia. In large hernise, and in fat women with obstructed or complicated hernke of long standing, the fundus of the tumor, if large enough, should be first lifted up so as to avoid pressing its neck against the lower edge of the constricting opening. Then the whole tumor should be gently kneaded and compressed (as directed heretofore), so as to press out any flatus and feces that may be present. The occurrence of borborygmus is a favorable sign. Then any inclosed bowel may pass into the abdominal cavity with a sudden flop, and the omentum, very often adherent, will remain as a soft doughy mass, which will usually give little trouble, unless the inflammation of the sac end in suppurative action, as it sometimes does. Too much pressure should not be used, and if the tumor be very tender, or the symptoms of sickness, etc., very severe, or if the obstruction persist after the use of oil and turpentine enemata, and fomentations, an operation for the relief of strangulation should be had recourse to. This operation, on account of the frequency of morbid changes in the contents of the rupture, and the nearness of its site to the sympathetic ganglia, stomach, and liver, is of a more dangerous character than in other cases of hernia. The continued application of ice to the hernia is also to be avoided, for the same reasons, and also because of the thinness and abnormal congestion of the hernial coverings, and the close proximity of the enfeebled bowel to the cold ice-bag, endangering mortification. Operation for Strangulated Umbilical Hernia.—An anaesthetic having been administered, and the patient placed on the back, with the shoulders raised, and a last effort at the taxis having been made, the tumor, if large, should be lifted up from the abdomen below, and, under the carbolic spray, an incision from two to three inches long, in the median line, should be care- fully made, the thinness of the walls being borne in mind. The incision should extend below the navel-cicatrix, down to the lower border of the her- nial opening, in order to obtain good drainage after the operation, as well as to bring into good, open view, the lower edge of the strangulating ring and the viscera in contact with it. The sac should be carefully opened on a direc- tor ; but before doing so a towel, wet with warm 1-40 carbolic lotion, should be spread on the abdomen on each side of the hernia, to receive and inclose any intestines that might fall or be forced out. The amestlietic should be regu- lated at this time, so as to prevent cough-straining as much as possible. The sac should be pinched up with forceps, and opened, with the scalpel held hori- zontally. Into the opening thus formed, after being enlarged by the fingers, the broad hernia-director should be passed downwards, and upon it the sac slit up in the median line, carefully avoiding the bowel. The loop of stran- gulated gut should now be gently lifted up, and the curved director passed over the lower constricting edge of the hernial opening into the abdomen, and this edge cautiously divided with the hernia-knife sufficiently far to relieve the strangulation. The bowel and omentum should then be examined closely. If the former be ulcerated by the edge of the opening, the soft adhesions should be separated, and the injured part of the bowel placed opposite the opening in the skin, the gut being drawn a little out of the abdominal cavity to pre- vent any danger of fecal extravasation into the peritoneal cavity. If the bowel be fairly sphacelated, as indicated by its loss of lustre, deep black color, and putrefactive smell, an opening should be made in it, and the sides should be stitched with thick, soft silk, steeped in carbolized oil, to the edges of the cutaneous incision. One or two stitches may be put in on each side, before the bowel is opened, to prevent retraction, and a vessel, or large warm sponges, should be held ready to receive the fecal outpour. If the bowel be intact, and only congested, of a chocolate color, it may be returned. The omentum, which should at first be turned up over the upper edge of the hernial open- 198 HERNIA. ing, may now be examined. If diseased or sphacelated, the vessels should be tied where they are evident, with tine catgut, carried around them with a common sewing-needle, and then the mass should be cut off with blunt scis- sors ; all bleeding points should be carefully tied. Ho haste should be used, unless urgently needed at this part of the operation, so as to be sure that all bleeding is permanently stopped; the edge of the omentum may now be so arranged as to meet the lower, cut edge of the hernial opening, and become adherent thereto, so as to prevent, if possible, any future protrusion. The omentum should not, if possible, be tied “ en masse,” or in a puckered bundle. It sometimes happens that adhesions of the omentum form the strangulat- ing agency, and not the hernial aperture. If this be so, the adhesions must be cut or separated, and the bowel released. All bleeding points are to be carefully tied with small catgut ligatures. In corpulent persons, in whom the operation has been delayed until peri- tonitis has begun, the operator has frequently to contend with a gush of bowels out of the abdomen. This should be restrained by receiving them in the warm wet towels, and applying pressure by the hands of assistants. If it can be managed, all the operative proceedings within the sac should be done before such a rush occurs; but if a cough, or vomiting, or anaesthetic difficulty occurs at this juncture, this is sometimes impossible, and the sur- geon is compelled to do the best he can. In such cases the operation becomes a formidable one indeed, and is comparable only to laparotomy under condi- tions of inflammatory distension of the intestines. The bowels and omen- tum should always, if possible, be kept in the warm wet towels, and not indiscriminately handled by the assistants, whose arms should be bared, and well purified with carbolized lotion. The intestines should be always returned before the omentum, which should, if possible, be spread out over them before the stitches are applied. These should be put in very closely and numerously, taking up the serous membrane as well as the skin. A drainage-tube should be placed in the lowest part of the wound. If it be small, and with no distension of the abdomen present, the sac may be entirely removed, with a portion of the thin skin over it, and the wound may be then brought together with thick silver-wire sutures and leaden buttons, taking a good hold of the recti muscles and sheath, the skin being united by close points of silk suture, and the whole covered by gauze dressing and a broad flannel bandage. If an artificial anus is unavoidable, the sutures should be closely applied to the living edges of the bowel, uniting them to the skin so as to prevent subsequent extravasation. In this case further use of the spray is unnecessary and inconvenient. The opening, after free evacuation of the contents of the bowel, should be lightly covered by carbolized lint, over which a quantity of loose carbolized tow should be laid, and the whole secured by a broad flannel bandage lightly applied. The apartment should be kept at a temperature of 60° F.,1 and a “bronchitis- kettle” should furnish steam while the operation is going on. Sickness may be allayed by sucking small lumps of ice; aud a grain of opium, in the solid form, may be given every four hours, unless albumen or sugar be present in the urine, when the effects of each dose should be closely watched before another is given. If the stomach reject all medicines, the sedative may be administered by hypodermic injection. Ho enemata should be given for a week after the operation. The wire and buttons, when used, should not be removed before this time has elapsed, and before the median wound has be- come well united. In cases of artificial anus, the bed may be deluged with the contents of the bowels. This complication is best met by placing large quantities of carbolized or marine tow under and on each side of the patient. [* A temperature of 70° F. would be preferable in America.] UMBILICAL HERNIA. 199 Radical Cure of Umbilical Hernia.—In congenital cases, properly treated, a radical cure by the use of truss-pressure may be confidently looked for. In early infancy, the condition of the navel should be carefully examined. If a tendency to swelling at the root of the funis be observed at birth, when the infant cries and struggles, the stump of the navel-string should be pressed firmly between the finger and thumb, and a thick silk ligature, or a very narrow piece of tape, should be tied firmly around it at the level of the skin, and kept on until it ulcerates through, so as to produce adhesion of the persistent vagina funiculi umbilicalis. Afterwards the penny-piece should be applied, and if the parts get excoriated by the plaster, an India- rubber belt, with a pocket to receive the coin, or a fiat piece of lead, oppo- site the rupture, is the best application. If this be carefully attended to, the weak place will be closed before the age of puberty. If it persist be- yond this, or if it prove unmanageable at an earlier period, as is often the case among the children of the poor, a subcutaneous operation by wire may properly be had recourse to. Subcutaneous Operation by Wire.—For this proceeding, a copper wire silvered, thin enough to be pliant, and made warm and pliable by brisk rubbing, with a hook at each end; a handled needle, with a medium curve, and stout and sharp enough to pierce the very tough structures concerned (or a stout, strong, common suture needle (see Fig. 1357 (/), in default of this), are needed. A spoon-shaped director (see Fig. 1357 a, b, c,), to guide the needle, will be found Fig. 1357. Instruments used in operation for umbilical hernia, also serviceable to guard the bowel from possible injury. The child being laid upon its back, and thoroughly under the effect of an anaesthetic, any pro- trusion should be carefully returned into the abdomen, and the director, well oiled, should then be pressed into the hernial opening, and its edge pushed a little upward, and laterally, well under the tendinous margin of the umbilical ring. Then, its handle being firmly depressed and steadily held by an assist- ant, the needle should be passed through the invaginated skin, the tendinous aponeurosis, and the skin at the side of the navel, a little above the centre, the latter being drawn up before the needle pierces it by traction with the fore-finger (see Fig. 1358). If a handled needle is used, one hook of the wire should now be attached and drawn through. Then tbe director should be pushed well downwards and laterally, and the needle should be passed again through the hernial coverings and through the aponeurosis, so as to take a good hold, when its point should be directed so as to come through the same aperture in the skin as before (see Fig. 1359), a manoeuvre which is aided by drawing the skin down a little with the point of the finger. The other end- hook of the wire is then to be attached and drawn through, so as to leave a loop of wire projecting through the skin-puncture. The same manoeuvres are next to be effected on the opposite side of the hernial opening, the needle being passed through the same punctures in the hernial covering, and the 200 HERNIA. ends of the wires being drawn upon until the middle portions have sunk through the punctures in the hernial coats. The ends are then to be twisted down into the side puncture by two twists, and brought over so as to hook into the loop. If a common suture-needle be used, two wires must be em- Fig. 1358. Fig. 1359. Introduction of the first wire. Introduction of the second wire. ployed, and both ends twisted. (See Fig. 1360.) A firm pad of lint, bent so as to fit over the projecting and crumpled-up sac, is now placed under the bridge of wire (see Fig. 1361); a padding of lint is put at the sides, and a light bandage is applied around the body to keep all steady. The wires may Fig. 1360. Fig. 1361. be kept in until they ulcerate through the inclosed tissues (in about a week or ten days), and the newly united parts must be carefully supported by pad and bandage, and dressed with simple cerate, until cicatrized. An elastic body-belt, and a flat., hard, circular pad, of three inches in diameter, placed in a pocket of the belt in front, should be worn for six or twelve months to support the union. I have performed this operation in six cases of hernia in children, which had baffled all contrivances for truss-pressure. In one case, a lad, F. M., aged 14, the hernia was about the size of a walnut, and the patient had been refused admission to the navy in consequence. He was operated on with wires, December 6, 1867 ; and in the year following the cicatrix wras found, on examination, to be hard, firm, and resisting, with no cough-impulse whatever, and with much retraction of the navel. In none of the cases were any serious symptoms observed, and none of the ruptures are reported as having returned, although the patient’s friends were earnestly requested to inform me if any recurrence should take place. The ring closed by twisting the wire. Diagram showing closure of ring. 201 OBTURATOR OR THYROID HERNIA. In two cases, in which the sac of an umbilical hernia of considerable size was removed during the operation of ovarian laparotomy, the sides of the hernial opening were united by wires and leaden buttons in sewing up the abdominal wound, and the cases did very well, the removal of the sac not having had the smallest apparent influence upon the progress of the case. In one, however, apparently from the general lax and stretched condition of the abdominal walls about the linea alba, the resulting cicatrix, both at the site of the umbilical hernia and below it, where no hernial sac had existed, remained in a weak condition, necessitating the wearing of a belt. In .the most common cases of umbilical hernia, attended with corpulence, a fatty condition of the omentum, and general constitutional debility, these circumstances, as well as the age and habits of the patient, preclude any attempt at a radical cure of the rupture by operation, and the best thing that the surgeon can do is to tit ou a hollow truss-pad and abdominal belt. The pad should have a large, hollow plate or disk of thin German silver, moulded to the shape of the rupture, when so far reduced by taxis as to be comfortable to the patient. In the hollow should be fitted an air-pad of India rubber, with an India-rubber tube placed on the rim, to prevent its cutting in or chafing when the belt is tightened up; the belt should fit well down into the groins, should have elastic side-pieces, and should lace up behind. Ventral Hernia. Ventral hernise, near the usual site of umbilical hernia, rarely allow of inter- ference for a radical cure, from the causes just explained regarding the latter. When small, and placed near the inguinal region, however, they may some- times be dealt with on the same principles as inguinal Itemise, especially if passing partly through the inguinal canal or external ring. Sometimes they make their appearance in one of the lineae semilunares, with an aponeurotic sac, especially after distension from pregnancy; or they may arise after a wound, or after an operation such as laparotomy. An abdominal belt and pad, as just described for umbilical hernia, is the best application in most cases. If they become subject to strangulation, which is rare, the operation should be conducted in the same manner as that already described for umbili- cal hernia. Obturator or Thyroid Hernia. This is a rare form of hernia. Covered by a sac derived from the pelvic pouch of peritoneum, it dilates and passes through the opening formed by the passage of the obturator vessels and nerves below the superior pubic ramus. In a case of this kind, fatal from strangulation, great pain was felt passing down the thigh in the course of the obturator nerve. In another case, how- ever, in which the late Mr. Hilton opened the abdomen unsuccessfully in search of an internal obstruction, and found a small knuckle of bowel strangu- lated in the obturator opening, this important symptom was not observed. In a patient with symptoms of internal strangulation, there was a. slight degree of fulness in the upper and inner part of Scarpa’s triangle, inside the femoral artery and the saphenous opening. The surgeon, Mr. Obre, made a straight, exploratory incision over this tumor, down to the saphenous opening, where a hardness was observed under the adductor portion of the fascia lata. On dividing this fascia and the pectineus muscle below it, a hernial sac was exposed, rising into the wound to the size of a pigeon’s egg. The sac was opened, and some small intestine exposed; the strangulating edge of the obturator 202 HERNIA. opening was divided, and the intestine returned. This bold and thoroughly scientific proceeding was fortunately successful in saving the patient. The saphena vein was wrounded accidentally, and tied. For a hernia of this kind, a truss like that for crural hernia, but with a longer and more depressed spring, should be tried. In a case giving great trouble and endangering strangulation, an operation for the radical cure— removing the sac, and closing its neck and the hernial opening by the appli- cation of a strong, carbolized tendon-ligature—would be admissible on the principles already laid down. Ischiatic Hernia. This variety of hernia is still more rare. An obscure and small tumor felt under the gluteus muscle, with local pain, tenderness, and symptoms of intestinal obstruction or strangulation, would justify an exploratory operation under antiseptic precautions, division of the strangulation, ablation of the sac, and closure of the opening by tying its neck in the way above described. From the position of such a hernia, it is not likely that any form of truss- pressure could be successfully maintained. Perineal, Vaginal, and Pudendal Hernial Perineal hernia comes down between the bladder and rectum, with a sac of peritoneum, through an opening in the pelvic fascia and the fibres of the levator ani, forming a tumor with the characteristics of hernia, in front or to the side of the anus. A truss may be adapted for this on the same principle as that made by the instrument-makers for supporting piles or pro- lapsus of the rectum. Vaginal and pudendal hernias are varieties of the preceding, projecting into the vagina or pudendum in females. The pudendal must he distinguished from the labial variety of inguinal hernia, in females, which is the liomologue of the scrotal variety in the male, and which is more commonly found than the one under consideration. The absence of any protrusion in the inguinal canal, or in the upper part of the labium, in the latter, affords an easy means of diagnosis between the two, taken together with the presence of a tumor at the side of the vagina. When strangulated, these forms of hernia will be made more detectable by local tenderness and pain, as well as by the general symptoms. They should be reduced by pressure with the fingers on the vulva, and also, if necessary, through the vagina and rectum, with the patient in the recumbent position, and the pelvis elevated on pillows. They may be kept up by the use of a vaginal, elastic-ball pessary, combined, if necessary, with a spring perineal truss. Diaphragmatic Hernia. Diaphragmatic hernia may occur from a wound by a lance, spear, sabre, or gunshot-missile, passing obliquely through the peritoneal cavity into the pericardium or pleura; or by separation of the fibres of the diaphragm, or dilatation of the oesophageal opening, by violent pressure, such as that of a cart-wheel passing over the abdomen, or a heavy body falling upon it. The latter accidents usually result in rupture of the liver, spleen, or other TRUSSES. 203 abdominal viscera, and prove speedily fatal. The .liver powerfully protects the diaphragmatic openings against any hernial results of undue pressure of the intestines. The occurrence of strangulation from such a rupture gives rise to the symptoms which characterize internal strangulation, but the deter- mination of the position of such internal constriction will be helped by the local pain, by impaired action of the heart or lung respectively, and by tym- panic resonance over the pericardium or pleura, as the case may be; while, perhaps, in cases which are not strangulated, gurgling may be heard through the stethoscope in the same situations. In one case recorded by Copeman, of Norwich, the hernia was pleural, and gave rise to pain in the shoulder. Guthrie proposed, in such cases, to make an opening into the abdominal cavity, and to introduce the hand in order to withdraw the bowel from the hernial opening; and, no doubt, this ought to be done when the history and symptoms of the case are sufficiently clear. Trusses. On the proper construction and exact adaptation of trusses, depends a vast amount of comfort or of suffering in the numerous patients who are affected with hernia. And the proper choice and application of trusses should be made a subject of study and experience by every one practising surgery, nor should the patient be left (as is too often the case) to the mechanical mercies, and rough and ready adaptations, of the instrument-makers and chemists who sell these appliances. Space will not permit more, in this place, than a descrip- tion of the kinds of trusses and belts which I have found most successful in practice, and will allow of no reference to the great variety of articles which their inventors and makers offer, by advertisement, to that portion of the public which needs this kind of surgical relief. Trusses may be classified most usefully under two heads, viz., those which are intended to afford the greatest possibility of the chance of an ultimate radical cure (a possibility which is usually small and uncertain), and those which are intended to make the patient comfortable by giving support, and to avoid the dangers of strangulation. For the former purpose, the patient must be content to endure some inconvenience from the more firm and effec- tive pressure required for the sake of the full chances of a cure by this means. For the latter object, the efforts of the maker should be to make the patient comfortable, as far as may be compatible with keeping the rupture in the abdomen, or preventing its increase and further descent. In all cases, however, the practice which is too commonly followed, of rendering easier the adaptation of the truss and aiding the pad to keep its place by making it so conical as to press into the hernial opening like a cork into the neck of a bottle, should be carefully avoided. The introduction of such a plug from without, acting upon yielding and distensible structures, is unscientific, and instead of counteracting the dilating influence of the viscera from within, is calculated to increase ultimately, instead of diminishing, the size of the rupture. The constant boring movement produced by the motion of the side-spring in walking or any other form of exercise, has invariably this effect when kept up long, as is demonstrated by the deep, pit-like depres- sion left in the integument when the truss is removed. The investing struc- tures are pushed into the hernial apertures, and produce the same dilating effect from without as the protruding viscera do from within. A bubonocele is thus met half way in the canal, and is assisted, by the dilatation of the superficial aperture, to become a complete hernia. The more complete the 204 HERNIA. adaptation, and the better the fit of this kind of truss, the more speedily are its mischievous effects made evident. The truss-pad should have its surface as nearly flat as its adaptation to the body will permit, should be shaped according to the form and outline of the rupture, and should be as large as can be conveniently worn. It should press upon the walls and sides of the hernial canal quite as much as upon its centre, and should be so inclined as to face a little in the direction of the hernial canal. In a corpulent patient, it should be so inclined as to lie flat upon the sloping integuments. The spring should be of sufficient strength to resist protrusion in ordinary expiratory efforts, such as coughing. For the purpose of measuring the force required, before the truss is fitted, an instrument made for me some years ago by Matthews, is very useful. (See Fig. 1362. Pressure-gauge, for ascertaining the amount of hernial impulse, and consequent strength required for truss-spring. Fig. 1362.) By placing the piston-pad (a) of this instrument, in truss fashion, upon the rupture, and the plate (6) upon the sacrum, then closing the lever arms by the screw (c) until some supporting resistance is felt by the patient, a cough-impulse will be imparted to the spiral spring placed within the pro- jecting cylinder, and can be read oft* on the indicator (d), wdiich shows in pounds the amount of pressure necessary to restrain the hernial protrusion. Violent and extraordinary efforts in coughing or straining cannot be effectu- ally resisted by any amount of truss-pressure which can be continuously borne by the patient. The truss-spring, under such circumstances, should be helped by pressure with the hand upon the pad, during the continuance of the cough or straining. No contrivance which has hitherto been employed to substitute the steel side or hip spring is effective in giving real support to the rupture in cases of inguinal or crural hernia. Straps and belts are yielding, and inca- pable of such a degree of lateral resistance, when passed in a circle round the body, as to be effective at the point required. TRUSSES. 205 Trusses for Inguinal Hernia.—One of the first essentials in the truss-pad for this kind of rupture, is that it should not press upon, or interfere with, the circulation or other functions of the spermatic cord. Not uncommonly the cord becomes jammed by the downward pressure of the truss-pad upon the crest of the pubic bone below. The consequences are pain and uneasiness along the cord and in the testicle. The latter slowly enlarges if the pressure be continued ; etfusion takes place in the tunica vaginalis,- and a hydrocele or a hydro-sarcocele is gradually formed. In other cases, the pressure upon the spermatic veins of the cord gives rise to varicocele. This condition is some- times the result of the continual pressure of a rupture alone, but more fre- quently it results from the combined pressure of the rupture and of an imper- fectly adjusted truss. It is more likely to occur in cases where a radical cure is attempted by means of firm truss-pressure with a hard pad. In order to avoid the two dangers of increasing the size of the hernial aperture by using a too conical pad, and of making undue pressure upon the cord, I devised, some years ago, a horseshoe-shaped truss-pad for the treat- ment of inguinal rupture. In cases where a radical cure without operation is sought, the pad is made of vulcanite or of compressed gun-cotton. Both these substances have a firm, perfectly smooth, and unirritating surface, which is capable of being washed clean every morning, and of being thus freed from the irritating and acrid accumulation of the decomposing secre- tions of the skin, which give such an unpleasant odor, and produce such an irritating effect upon the skin, in the leather-covered trusses in common use. When perfectly cleansed, and dusted with powdered starch, these pads can be very comfortably worn when properly adjusted. The pad for oblique inguinal hernia is made with a flat surface, rounded off smoothly at the borders, and of the shape of an oblique horseshoe, with the outer or inferior limb shorter than the inner or superior. A cleft about three- fourths of an inch long and half an inch wide, intervenes between the ends of the horseshoe (Fig. 1363); this is for the lodgment of the spermatic cord as it Fig. 1363. Horseshoe-pad for inguinal hernia, lies upon the groove of the outer pillar of the superficial ring, external to the pubic spine, which is also placed, when the truss is properly fitted, in the cleft or groove. The mobility of the healthy spermatic cord is so great, that, when the pad is placed upon the inguinal canal so that the cleft is opposite to the pubic spine, looking downwards and inwards towards the testicle, the cord slips into its proper place under the pressure of the ends of the pad, while the upper, rounded border presses upon and prevents protrusion through the deep or internal abdominal ring. The spring is fixed by a screw upon the geometric centre of the oval pad, so as to bear equally in its pressure upon the deep and superficial rings. It is held by a screw, which, when slackened, allows of 206 HERNIA. rotation of the pad until the proper obliquity and right bearing upon the inguinal canal are obtained, when it can be fixed by tightening the screw with a small screw-driver. The studs on the ends of the horseshoe are for the attachment of the under strap, when this is needed. This strap, however, can in most cases be dispensed with after wearing the truss for a little while, till it adjusts itself under the heat of the body and settles into its proper place. In all cases, the side spring should lie in the slight depression below the crest of the ilium, between it and the projection of the trochanter major. At the back it should lie evenly upon the sloping posterior surface of the sacrum, just avoiding the projecting posterior superior iliac spines. In a single truss, the free end of the spring may be connected by means of an eyed cross-strap with the stud on the centre of the pad. In a double truss the cross-strap is attached to both the central studs of the pad; in many cases, however, the cross-strap may be entirely dispensed with after a few months’ wear. For use in hot countries, as in India, and also for bathing, the spring and pad may be entirely uncovered, no leather or soft material being necessary, except a linen or silken bag or covering for the truss, which may be removed at intervals for change and cleanlines's. These trusses have been worn for years by scores of patients in the East and West Indies, with the greatest comfort and effect. Truss for Direct Inguinal Hernia.—In some large cases of direct hernia, the cord becomes displaced so much to the outer side of the opening that it lies fairly across Poupart’s ligament, and is out of the way of pressure by the truss-pad on the pubis. Under such conditions, the rupture can often be better controlled by a circular or ring gad of the same material as the former (Fig. 1364). In these pads the spring is attached by a screw to a cross-piece placed Fig. 1364. Ring-pad for direct hernia. over the hole (b). The pressure in both these kinds of pad falls chiefty on the margins of the superficial ring. In the horseshoe form, it resembles the pressure of the fingers upon the rupture. There is no conical or plug-like pressure in the axis of the hernial opening. At the same time, it is more difficult for the rupture to escape by the sides of the pad. The sides of the ring and canal are thus pressed together instead of asunder, as by the action of the conical or convex pads, and the closure of the opening is promoted instead of being retarded. Both these forms of truss-pad may be used after the ope- ration for the radical cure has been performed. They promote the gradual closure of the aperture and the contraction of the cicatrix, upon which the cure depends. They may be made of soft material in cases where ease and comfort are more to be looked for than a radical cure, or where the hard TRUSSES. 207 pressure cannot be borne. Frequently they are made of an India-rubber, air or water cushion, supported by a thin steel plate of the required shape; or they may be stuffed with horse-hair, or with the material of the “ moc-main” pad. Trusses for Crural Hernia.—The conditions of effective truss-pressure in crural hernia are somewhat different from those in the inguinal variety. The hernial canal is a section of a tube placed nearly vertically (Fig. 1365 A), with its deeper (