MOVEMENTS AND INNERVATTON OF THE INTESTINES 1319 



which an inexperienced operator may mistake the fascia for the peritoneal sac and the contained 

 fat for omentum, as there is often a great excess of subperitoneal fatty tissue enclosed in the 

 "fascia propria." In many cases it resembles a fatty tumor, but on further dissection the true 

 hernial sac will be found in the centre of the mass of fat. The fascia propria is merely modified 

 extraperitoneal tissue which has been thickened to form a membranous sheet by the pressure of 

 the hernia. 



When the intestine descends along the femoral canal only as far as the saphenous opening the 

 condition is known as incomplete femoral hernia. The small size of the protrusion in this form 

 of hernia, on account of the firm and resisting nature of the canal in which it is contained, ren- 

 ders it an exceedingly dangerous variety of the disease from the extreme difficulty of detecting 

 the existence of the swelling, especially in corpulent subjects. The coverings of an incomplete 

 femoral hernia W 7 ould be, from without inward, integument, superficial fascia, superior falciform 

 process of fascia lata, femoral sheath, septum crurale, and peritoneum. 



The seat of stricture of a femoral hernia varies ; it may be in the peritoneum at the neck of the 

 hernial sac; in the greater number of cases it is at the point of junction of the superior falciform 

 process with the free edge of Gimbernat's ligament; or it may be at the margin of the saphenous 

 opening. The stricture should in every case be divided in a direction upward and inward for a 

 distance of about one-sixth to one-quarter of an inch. All vessels or other structures of impor- 

 tance in relation to the neck of the sac will thus be avoided. 



The spine of the pubis forms an important landmark in serving to differentiate the inguinal 

 from the femoral variety of hernia. The inguinal protrusion is above and to the inner side of 

 the spine, while the femoral is below and to its outer side. 



By the term internal hernia, we mean hernia into the foramen of Winslow, into the retro- 

 duodenal fossa, into the retrocecal fossa, or into the intersigmoid fossa. Such a hernia produces 

 the symptoms of acute strangulation of the intestine. 



In typhoid fever there is ulceration of Peyer's patches. One of these ulcers may perforate. 

 The only chance for life is immediate laparotomy and closure of the perforation. This saves 

 one-fifth, or possibly one-third, of the cases. The incision is made to expose the lower ileum, as 

 in the vast majority of cases the perforation is in this portion of the gut. 



The surgical anatomy of the rectum is of considerable importance. There may be congenital 

 malformation due to arrested or imperfect development. Thus, there may be no invagination of 

 the ectoderm, and consequently a complete absence of the anus; or the hind gut may be imper- 

 fectly developed, and there may be an absence of the rectum, though the anus is developed; 

 or the invagination of the ectoderm may not communicate with the termination of the hind gut 

 from want of solution of continuity in the septum which in early fetal life exists between the 

 two. The mucous membrane is thick and but loosely connected to the muscular coat beneath 

 and thus favors prolapse, especially in children. The vessels of the rectum are arranged as 

 mentioned above, longitudinally, and are contained in the loose cellular tissue between the 

 mucous and muscular coats, and receive no support from surrounding tissues, and this favors 

 varicosity. Moreover, the veins, after running upward in a longitudinal direction for about five 

 inches in the submucous tissue, pierce the muscular coats, and are liable to become constricted 

 at this point by the contraction of the muscular wall of the gut. In addition to this there are no 

 valves in the superior hemorrhoidal veins, and the vessels of the rectum are placed in a dependent 

 position, and are liable to be pressed upon and obstructed by hardened feces. The anatomical 

 arrangement, therefore, of the hemorrhoidal vessels explains the great tendency to the occurrence 

 of piles. The presence of the Sphincter ani is of surgical importance, since it is the constant 

 contraction of this muscle which prevents an ischiorectal abscess from healing and tends to 

 cause a fistula. Also, the reflex contraction of this muscle is the cause of the severe pain com- 

 plained of in fissure of the anus. The relations of the peritoneum to the rectum are of impor- 

 tance in connection with the operation of removal of the lower end of the rectum for malignant 

 disease. The membrane gradually leaves the rectum as it descends into the pelvis ; first leaving 

 its posterior surface, then the sides, and then the anterior surface, to become reflected in the 

 male on to the posterior wall of the bladder, forming the rectovesical pouch, and in the female 

 on to the posterior wall of the vagina, forming Douglas' pouch. The rectovesical pouch of 

 peritoneum extends to within three inches (7.5 cm.) from the anus, so that it is not desirable 

 to remove more than two and a half inches (6.25 cm.) of the entire circumference of the bowel, for 

 fear of the risk of opening the peritoneum. When, however, the disease is confined to the poste- 

 rior surface of the rectum, or extends farther in this direction, a greater amount of the posterior 

 wall of the gut may be removed, as the peritoneum does not extend on this surface to a lower 

 level than five inches from the margin of the anus. The rectovaginal or Douglas' pouch in the 

 female extends somewhat lower than the rectovesical pouch of the male, and therefore it is 

 advisable to remove a less length of the tube in this sex. Of recent years, however, much more 

 extensive operations have been done for the removal of cancer of the rectum, and in these the 

 peritoneal cavity has necessarily been opened. If, in these cases, the opening is plugged with 

 iodoform gauze until the operation is completed, and then the edges of the wound in the peri- 

 toneum are accurately brought together with sutures, no evil result appears to follow. For cases 



