They require a thorough knowledge of anatomy, often a more accurate knowledge than is required for the same operations under general anesthesia. We are forced to respect and preserve from injury all nerves encountered. While during the operation we are principally concerned with the sensory functions. of the nerves, we must not lose sight of the fact that most nerves are motor and trophic, as well as sensory. Division of an important nerve may be followed by muscular atony and relaxation of the parts and in the case of herniotomy, by a recurrence of the trouble, an unpleasant sagging of the scrotum, or a possible atrophy of the testicle.

One of the many advantages of local over general anesthesia, is the absence of post-operative. vomiting, which, if prolonged or severe, may compromise the results of the operation, particularly in large or complicated hernias, where often extensive plastic resections are necessary to secure a satisfactory closure. For this, if for no other reason, should the local method be preferred and I believe that a comparison of statistics will show a lesser percentage of recurrences following closure in this way.

The size of the hernia is no contraindication for this method, nor is the age of the patient, providing he is enjoying fairly good health. In fact, old age is particularly favorable to all local anesthetic procedures. Many of these old subjects may be refused operation by general anesthesia, when they can be safely and easily operated upon by local anesthesia. It is advisable that these old patients should be put to bed for a day or two before operation, to see how they stand confinement and to enable them to learn to empty the bladder and bowels in the recumbent position.

Another important consideration which applies to all cases, but more particularly to the aged, is that nutrition is not interfered with, as there is no disturbance of the gastro-intestinal tract. A light meal is always preferred just before operation, but nourishment should be restricted to liquids after operation, excluding milk for the first day or two. If the subject is very feeble, stimulating drinks, such as coffee, toddy or hot tea, can be administered during the progress of the operation. By handling feeble and aged subjects in this way, by local anesthesia, many can be safely carried through an operation for hernia, without any operative or post-operative disturbances whatever, who would most probably succumb otherwise, if not to the operation perhaps to the necessary post-operative disturbances following general anesthesia.

There are three nerves with which we are principally concerned in inguinal hernia-the ilio-hypogastric, ilio-inguinal and genito-crural. The skin over this region receives branches from several of the surrounding nerves, especially the last dorsal, but as it is infiltrated directly, these do not especially interest us.

The ilio-hypogastric perforates the transversalis muscle at its posterior part, near the crest of the ilium, and gives off its iliac branch, which descends; the hypogastric branch continues forward between the transversalis and internal oblique, perforating the internal oblique just above and a little to the outer side of the internal ring. It then runs transversely inward towards the middle line on the surface of the internal oblique and just above and a little to the outer side of the external ring, pierces the aponeurosis of the external oblique and is distributed to the skin of the hypogastric region.

The ilio-inguinal nerve appears in the field after perforating the internal oblique at or near the internal ring and descends along the lower part of the inguinal canal; it terminates by distributing fibres to the side of the scrotum and thigh. This nerve is not constant and occasionally is found joined to the genital branch of the genito-crural to form the external spermatic nerve.

The genito-crural nerve, its genital branch, appears at the internal ring and passes down the back part of the spermatic cord into the scrotum, where it supplies the cremaster muscle, testicle and other contents of the scrotum. The skin of the scrotum receives fibres from the inferior pudendal branch of the small sciatic and from the superficial perineal branch of the pudic, in addition to the ilio-inguinal nerve already mentioned.

It will be seen from a study of the above that after the skin is passed, all nerves entering the field emerge at or near the internal ring and it is consequently here that we inject most of our solutions.

Preparation for the Operation: Preliminary hypodermic of morphin, gr. 1/6, with scopolamine gr. 1/150, one hour beforehand.

Four ounces of solution No. 1 (novocain .25 per cent. sodium chloride .4 per cent.), to which add 15 drops of adrenalin solution 1 to 1,000. If the hernia is very large, it is well to have on hand more than the four ounces. Small hernias may not require this much, but it is well to have an ample supply. Two ordinary hypodermic syringes and one large syringe which will hold about 1/2 ounce, with long fine needles, or a Matas infiltration apparatus-all well tested beforehand, to be sure they are in good working order.

Some operators prefer to inject the solution about fifteen minutes to half an hour beforehand and allow time for the solution to diffuse and become fixed in the tissues. This practice, while advisable elsewhere, we do not find necessary here and proceed at once with the operation. Also, some prefer to use a 1 per cent. novocain solution to infiltrate the nerves as they are encountered, but as all the nerves are very small, it is unnecessary to use any but the ordinary solution (No. 1).

Begin the injection with the small hypodermic syringe at the highest point of the proposed incision, at the upper and outer part of the field. Make the injection intradermally. With the large syringe and long needle, enter at this point, directing the needle downward to the subcutaneous tissues and inject about 1/2 ounce in this position; another 11⁄2 ounce is injected subcutaneously along the proposed line of incision by advancing the needle in this direction, injecting as the needle is advanced. If the patient is very stout and there is much subcutaneous fatty tissue, more than this may be needed, but in the ordinary case the above is sufficient.

While we are waiting for these subcutaneous injections to diffuse the infiltration of the skin is finished, by starting at the already injected point on the skin and proceeding downward and inward intradermally the full length of the proposed incision. After this has been done, the incision can be made at once and carried down to the aponeurosis of the external oblique. Expose this freely over the site of the internal ring and with the large syringe inject about 1/2 ounce of solution just under the aponeurosis at this point. While waiting for this to act here secure and tie any superficial vessels that may be necessary, and

expose the rest of the field by gauze dissection. Now slit up the aponeurosis of the external oblique to above the internal ring, retract and you bring into view the ilio-hypogastric nerve. This has probably already been anesthetized by the last injection, but if there is any doubt, it can be injected intra-neurally or perineurally, with the small hypodermic syringe.

Retract upwards the internal oblique and transversalis to better expose the internal ring. If the ilioinguinal nerve is seen on the lower side of the cord, infiltrate it at once high up; if not seen, inject around the neck of the cord several small syringe fulls of solution. This will permit it to be freely handled and the ilio-inguinal and genito-crural nerve looked for, the ilio-inguinal on the lower side of the cord and the genito-crural behind. If any trouble is encountered in finding them, and it is likely that the cord or scrotal contents will be handled, then a free infiltration of about 1/2 ounce around the neck of the cord will suffice and will reach both nerves involved. If such an injection is made care should be exercised not to enter any veins. It is, of course, far preferable to locate the nerves. The sac is now picked up and opened and any contents replaced in the cavity. If they are adherent, their separation does not cause pain. Omentum may be resected, if necessary, without pain. A finger is now passed into the cavity through the neck of the sac and two or three small hypodermics of the solution distributed superitoneally around the neck. The sac can now be dealt with by any method preferred; if small, excised, if large and adherent, it can be divided, slit up and left in situ, to be eventually absorbed, or it may be entirely removed.

An existing varicocele or any other complication, should be dealt with now and requires no further infiltration. The testicle may also be exposed and handled, if necessary. It should be borne in mind, however, that any undue traction upon the cord by pulling upon the parts within the cavity, will cause pain; but none is otherwise experienced. The neck of the sac can now be closed, by crushing, if large and ligated, or sutured, if preferred.

The operation usually performed by Professor Matas and his staff is the Ferguson-Andrews. Here the cord is not disturbed and consequently may require less preliminary injection, as it is left in its bed. and all structures sutured over it, the aponeurosis of the external oblique being overlapped. However, the operation can now be completed by any of the accepted methods, the Bassini, or any of its modifications.

If the above technic is followed, absolutely no pain. should be felt by the patient; where pain is inflicted, the technic is at fault. In the hands of a skillful

operator, an ordinary hernia can be closed by using not over three ounces of solution (we often use much less) and the time consumed is not over five or ten minutes longer than would have been required with general anesthesia.

In case the hernial ring is very large it may be necessary to loosen the internal oblique and transversalis from the edge of the rectus, so as to enable the conjoined tendon to be brought down, in case this is necessary, and the dissection be carried very high. Some additional infiltration at this point may be needed and should be made directly into the tissues to be dissected.

Intraabdominal contents that cannot be replaced before operation can often be replaced after the sac is freely exposed and liberated and the internal ring

enlarged, by taking the sac up in the hands and resorting to manipulation. If the contents are not readily replaced, do not open the sac too freely at once, as the too long exposure of a large length of bowel may cause unpleasant intraabdominal discomfort and some complaint on the part of the patient. But make a small slit near the neck of the sac and explore its contents with the finger. The contents of these large hernia sacs are, as a rule, mostly omentum, with a small loop of bowel. If much bowel is encountered, it can be replaced in this way, usually without much. difficulty, unless adherent. If the omentum is found hard and fibrous from its long sojourn in the sac, it will require resection; but unless badly damaged, it should not be sacrificed, as it is an organ of many valuable functions. The exposure of the omentum never gives rise to any discomfort and its resection causes no complaint, as it has no sensation, unless inflamed.

In the case of very large hernias, where it is necessary to carry the skin incision well down over the scrotum, the skin must be infiltrated all the way.

In strangulated hernia, general anesthesia is contraindicated and should rarely, if ever, be used. In very severe and prostated cases, the general anesthetic may add sufficient additional depression to cause a fatal issue. In these cases the sac should be exposed and opened under infiltration. If the patient is very weak, a radical operation should not be attempted at the time, but the bowel opened and drainage permitted. It will frequently be found that the bowel is adherent around the ring and the general cavity walled off. If this is not the case, a few sutures and a little packing will close off the cavity and the bowel can at once be opened. The improvement permitted by this procedure revives the patient and after all gangrenous material has come away, the ends of the bowel can be approximated by Murphy button or

suture.

Reclus very justly refers to operations for strangulated hernia as "the triumph of cocain." In strangulation it is the anesthetic of election and it is only in special conditions, such as in hernias of unusually large size, with eventration of the abdominal contents and when extensive adhesions exist, that he would prefer a general anesthetic. In advanced strangulations, with vomiting of intestinal contents, the dangers of septic pneumonia and secondary renal complications. from chloroform and ether, are especially to be feared and more particularly in the aged. Then, again, colostomy for strangulation is an urgent operation which in country practice frequently compels the surgeon to depend upon unskilled assistants. Under these circumstances the value of a local anesthetic, entirely under the control of the operator, becomes especially apparent. It is not surprising, therefore, that Mehler enthusiastically asserts that he who has tried cocain in these conditions will never feel inclined to return to general anesthesia, unless compelled to by pressure of unusual circumstances.

THE RICHIE MORPHIN CURE.-The Richie Company was discussed in Collier's Great American Fraud series as one of the concerns which under the guise of mail-order "cures" for the morphin habit fosters the slavery of the drug habit by substituting for the morphin addiction an addiction to their villainous mixtures of opiates. More recently shipments of the "Richie cure" were seized by the Federal authorities and found on analysis to contain from 7.21 grains to 15.95 grains of morphin sulphate to the fluid ounce. (Jour. A. M. A., Jan. 10, 1914, p. 144.)

EMBRYOLOGY AND ANATOMY OF THE COLON.*

BY

O. L. NORSWORTHY, M. D.,

HOUSTON, TEXAS.

In order to say much on the embryology and anatomy of the colon and keep in mind the bearing of each on surgery, will require that I speak of "rotation," "prenatal fusion" and "fixation" of other portions of the digestive tract in conjunction with the large intestines.

In order to thoroughly understand these processes of rotation, prenatal fusion and fixation of the different portions of the digestive tract, it would be necessary to review embryology from conception, but to economize in time and to prevent my paper from appearing wholly without practical interest, I will omit as much of the early embryology as the nature of the paper will permit.

The primitive alimentary canal (Fig. 1) is a midline tube connected to the spine by a fold of peritoneum. Later the primitive stomach appears as a bulbous enlargement in the upper abdomen, while the lower portion of the tube retains its connection with the spine and becomes the descending colon, sigmoid and the left portion of the transverse colon. This

and the large intestine at the ileo-cecal valve; but functionally they maintain the rudimentary type, the small intestine beginning in the duodenum just below the opening of the common duct and the large intestine beginning near the splenic flexure of the colon.

The derivatives of the midgut are concerned in absorption and assimilation and functionally extend from the middle of the duodenum to the splenic flexby the superior mesenteric artery (Fig. 8). ure of the colon, and correspond to the area supplied

While it is generally accepted that the derivatives of the hindgut have some power of absorption, it is a fact that except during defecation the normal movement of the rectum, sigmoid and descending colon, is anti-peristaltic. Fluids introduced into the rectum, as in Murphy's proctoclysis, are carried backward to

A

IMA

Fig. 1.

SMA

SFC

IMA

Fig. 2.

Fig. 1. Differentiating three stages of primitive digestive tract. A, at about three weeks; B, about four weeks; C, about five weeks. From human embryo (Modified from Huntington).

Fig. 3. Representing alimentary canal, umbilical loop and mesenteric attachments, after differentiation of large and small intestines and before beginning rotation. Human embryo of about six weeks (Modified from Huntington).

portion of the primitive tube, which remains connected with the spine, represents the hindgut and receives. its blood supply from the inferior mesenteric artery. In that portion of the primitive gut between this part and the stomach bulb, appears another bulbous enlargement to the left, near the central portion, which indicates the development of the cecum (Fig. 3). This middle section constitutes the midgut and receives its blood supply from the superior mesenteric artery.

Comparison of the physiology and embryology of the gastro-intestinal tract shows how much more permanent function is than structural formation. Anatomically the small intestine begins at the pylorus

*Read before the Section on Surgery, State Medical Association of Texas, San Antonio, May 6, 1913.

Fig. 7.

Fig. 8.

Fig. 7. Intestine and arteries of the canal in early stages of intestinal rotation. Note duodenum crossing under superior mesenteric artery; also, ileum entering cecum from the right and above. Human embryo of about three and a half months (Huntington).

Fig. 8. Final arrangement of arteries and alimentary canal, after rotation of intestine. Fetus at birth (Huntington). the splenic flexure and only a small amount is taken up by the derivatives of the hindgut. This antiperistaltic action is termed by some writers "reverse mucous currents." It has been shown that even small quantities of solid food will be carried from the rectum backwards.

Comparative physiology of the gastro-intestinal tract is interesting in that it shows digestion is praetically completed in the small intestine in carniverous animals, while in the herbiverous animals the colon is equally important-on account of the liquid nature of the plant and grass juices-upon which they depend for nourishment. The human species occupies an intermediate position. In the lower forms of animal life, notably in certain forms of fish, the alimentary canal is a straight tube. In the higher forms the alimentary canal becomes more complex. In man it becomes a succession of primitive canals, each of which performs an entirely different function and digests an entirely different kind of food. The mouth is alkaline, the stomach acid, the small intestine alkaline and the large intestine acid.

At the third week of intrauterine life the alimentary tract becomes a straight tube, and during the fourth week the stomach can be differentiated from the intestine (Fig. 1). By the fifth week the umbilical loop is distinct and the small and large intestine can be differentiated. At the sixth week the cecum is well

formed and during the seventh week there is evidence of the transverse and descending colon (Fig. 3). During the third month the cecum begins to rotate, and the intestinal villi and glands are formed. Also, during this period the lower end of the large herbiverous-like cecum rapidly contracts and the vermiform appendix is the result. During the fourth month the upper end of the ascending colon becomes fused with the posterior peritoneal wall in the region of the right kidney. During the fifth month the villi of the large intestine disappear. The descending colon continues

bands with sacculations between, and by fatty tags (appendices epiploica) suspended from its walls. The sacculations are greatest in the head of the colon and become less marked as the colon progresses toward the rectum. The longitudinal bands increase in strength and width until at the rectum they practically surround the tract and complete investment extends around the rectum. The act of defecation is partially accomplished by the use of this complete investment of longitudinal fibers (Fig. 8).

The head of the colon or cecum is about two and

At the twelfth week in embryo the cecum lies to the left of the midline and immediately under the liver and the ileum enters from the right. During the third month with the rapid growth of small intestine on the right and slower growth of the large intestine, a portion of which is fixed to the left, a rotary movement of the mesentery occurs and the colon rotates about the mesenteric axis. The cecum passes across the duodenum and is found in the right hepatic position at the fourth month. From this position it descends slowly until about the end of fetal life, at which time rotation is completed. The ileum now enters from the left (Fig. 8). As the colon rotates it carries with it its blood vessels, lymphatic and sympathetic ganglia; and when the normal situation is finally reached, the outer layer of mesenteric attachment is merely a peritoneal adhesion, the division of which at any situation enables the colon to be turned upon its mesenteric leaf which contains all the important structures (Fig. 8).

The colon is from five to six feet in length and is characterized by three longitudinal unstriated muscle

It diminishes in diameter towards the rectum and in the sigmoid it is less than half that of the cecum. As a rule the cecum is practically enveloped on all sides by peritoneum and possesses a short mesentery (the mesocecum-Fig. 8).

The ascending colon, seven to eight inches in length, is covered with peritoneum anteriorly and laterally only (Fig. 26). Posteriorly it is fused with the parietal peritoneum and has an insecure attachment of loose areolar connective tissue to the posterior muscles. The ascending colon like the transverse and sigmoid colons, originally possessed an independent mesentery, but between the fourth and fifth months of embryonic life it became adherent to the primary peritoneum over the lower third of the right kidney (Figs. 19-20). Later it becomes fixed to the posterior abdominal wall to a point where the psoas magnus muscle crosses diagonally from the spine to the iliac fossa (Fig. 26).

Anatomists have called attention to the fact that in one case of every five human anatomical subjects the ascending colon has not rotated completely, and an improper fusion of the ascending colon and cecum with the parietal peritoneum is present.

If not properly rotated the cecum and ascending

colon hang by a mesentery, as is the case with the large intestine in the quadruped. The cecum serving as a reservoir for fluids is very heavy and has a tendency to prolapse. In certain cases the hepatic flexure remains fixed to the duodenum and right kidney. The kidney remains in place and the cecum becomes elongated and moveable ("cecum mobile"). In other cases the appendix and mesentery adhering to the parietal peritoneum causes obstruction in the ileum, known as "Lane's Kink." Mr. Lane has failed to differentiate between prenatal fusion and postnatal adhesions. He laid great stress on ptosis of the colon and to the effect of the erect posture of man in producing this condition. The most important factor he believes to be the effects of bands of adhesions. Postnatal adhesions never form in the absence of pressure or inflammatory action.

In case of complete non-rotation the cecum would not reach the right iliac fossa and the ileum would enter the cecum from the right. The duodenum would be free and not fixed posteriorly. The transverse colon would not be evenly supported by its attachment through the gastro-colic omentum to the stomach.

The transverse colon is about twenty inches in length. It extends transversely across and ascends from the hepatic to the splenic flexure. The transverse colon is completely covered with peritoneum, has a long mesocolon and is the most movable portion of the colon (Figs. 8-26). Due to its anatomical relation the transverse colon is not included in prenatal fusion to any part of the parietal peritoneum, except through the mesentery. Hence, the great tendency for it to prolapse and assume many shapes, resembling the letters "S," "M" and "U."

The transverse colon is suspended by its mesentery and the gastro-colic omentum, which becomes a suspensory ligament only after the different peritoneal layers have fused (Figs. 15-16-17). Lack of fusion

Fig. 19

Fig. 20.

Fig. 19. Normal relation of colon to the right kidney after intestine has passed over duodenum and completely rotated. Colon is fused with broad surface entirely across lower pole of kidney and well to its outer side (Huntington).

Fig. 20. Relation of colon to right kidney after incomplete rotation of intestine. The colon after crossing to the duodenum fuses with a small area of the lower and inner side of the kidney, consequently hangs directly from the bottom and inner border of the kidney (Coffey).

of the walls of the gastro-colic omentum and of the greater omentum, is the chief underlying factor in mid-ptosis of the transverse colon, as well as ptosis of the middle stomach. A chronically loaded colon or an overdistended stomach and such occupations as require prolonged standing postures in an individual,

finds a midline ptosis to exist, which is often associated with ptosis of the middle of the stomach.

The descending colon, eight to nine inches in length, is covered with peritoneum anteriorly and laterally only. It has no mesentery. It has retained its primitive attachment to the posterior abdominal wall, which attachment shortens during embryonical life and then is in immediate contact with and securely united to the posterior abdominal wall for its entire length (Fig. 26).

Improper fusion is not likely to occur on the left side, owing to early formation and fixation of the splenic flexure of the colon. This portion of the primitive intestinal tube, as will be remembered, retains its connection with the spine, becoming more securely fixed during the entire nine months of embryonic life.

Should it occur, there are sufficient anatomical reasons why left sided ptosis does not so often follow. In embryo the omentum furnishes a reduplication of the peritoneum, which securely fixes the splenic flexure to the vault of the diaphragm, recognized as the costo-colic ligament. The gastro-colic ligament furnishes an additional support to this angle of the gut. The descending colon, acting only as a passageway, is never loaded and propels its contents downward with no angle of resistance.